Deep Waters

The following essay was originally posted in June 2005. The story is a true one, although the names have been changed.

 
Lake ClarkThey say that hell is hot. Sometimes, however, it is very, very cold.

Jim loved Alaska — it had been his home since birth. God’s country: wild, unpredictable, spectacular in beauty–there was no place like it on earth. Cities were a necessary evil, with their services and surliness, but out in the wild was where life could be found. Out among the glaciers, the ragged mountains framing the endless blue sky like jagged, broken glass, out where grizzlies snatched salmon from raging rapids, shortening their march to death as they fought wild currents to reach their spawning grounds. Out where eagles graced the sky, soaring above green fir spires and spotless snow fields. Out where God lived, where a man could see His hand, and hear His voice.

Jim lived a simple life of simple faith. He loved his wife as he loved the land, and together they were blessed with six children–three older girls, the twin boys, and a baby son their most recent gift. Each was a treasure greater than the next. Their lives were story book: The lodge they owned nestled near the shores of Lake Clark, a large inland glacial sea, mirroring the snow-peaked mountains surrounding it. Summers were busy–hunting and fishing tours, visitors from afar seeking trophies and photographs, decked in newly-purchased gear from REI in the lower 48. Jim loved to fly–the float planes lifted gracefully from the lake, carrying their awestruck passengers over endless miles of breathtaking beauty to some far-away stream where tied flies touched water and fish broke airborne for their last meal.

Out in the bush, relationships were few in number but rich and deep. Church was more than a Sunday obligation–it was a place where life was shared, joys celebrated, suffering comforted–a place where faith begot works, where love put on snowshoes and helped stack the winter’s wood. Family life was alive, ripe with blueberries picked, hikes to the falls, and quiet nights beside campfires. Summers passed quickly at Bible camp, concentric ripples of cannonballs and giggles of joy rolling across the lake from the old dock. Dates with dad and high tea with mom found no competition from mindless cartoons, and bedtime prayers thanked Jesus for His goodness and God for His gifts.

Winter was time for quiet reflection, as the short days and deep snows kept sportsmen far away, and school and indoor chores made the time pass slowly but with purpose. The plane was their lifeline: what few roads there were became impassible in deep snow, and flights to Anchorage a necessity for supplies and health care. The girls came along often, although the younger boys stayed with friends and relatives for lack of space.

Jim had tens of thousands of hours of flying experience, a skill which paid rich dividends in the harsh, capricious winters of south Alaska–there was little in the way of flying conditions he had not challenged and mastered. So this flight to Anchorage in February was a pleasant surprise: the low gray skies broke open to display the rare winter glory of sunshine on pristine snowfields, the glorious tinted rim of Alaska Range peaks and deep seas of Cook Inlet. The supplies garnered and the girls’ dental care completed, they took off for the return flight to home and hearth.

The storm struck without warning, a white she-devil blown in from the Gulf, the Cessna buffeted by sharp, hard winds as visibility and ceiling dropped precipitously. The instruments held true, and countless hours of difficult flying forged Jim’s nerves steely and his focus intent. Mom held the girls’ hands, distracting them from natural fears with songs and stories and heads held to breast, her own pounding heart betraying her calm demeanor. “Will we be OK, mommy?” “Jesus will bring us home, honey.”

The GPS told Jim they were indeed near home–the lighthouse in space beaconing safety and rest. By reckoning they should be near the lake, just a few miles out from the landing strip. But Nature had not finished yet, her rage reserved for one final blow.

A whiteout in a small plane is dreadful beyond imagining. Suspended between earth and sky, with no point of reference, no sense of up or down, sensory deprivation in a aluminum rocket. Your training trusts your instruments, but instinct and eyes scream for visual confirmation. There! On the right! Through a brief window in the suffocating white blindfold, a dark line: the outline of the lake shore. Jim banked the plane toward this beacon of hope. “Are we home yet, daddy?” “Almost there, honey.”

But wild Nature held one last vengeance: an atypical winter thaw had opened a long dark crack in the ice, normally frozen solid in February. The line Jim saw was not the shore. The plane hit water at airspeed.

The prop and windshield exploded. The cabin filled instantly with icy water, as Jim craned his neck to reach the fast-retreating air, still restrained by his harness. Years of wilderness training sprung to life, as without a thought he grabbed his Bowie and cut free the webbing. He struggled with the girls’ restraints, hopelessly locked between seats crumpled by the impact. His wife was nowhere to be seen. Time was up–the air was gone. He broke from the cabin, gasping for air at the surface, hoping to dive and try again to free his treasures. It was not to be: the plane sank like a millstone, 600 feet to the bottom of the frozen fjord, entombing the family he worshiped.

In shock, he looked around. His wife, by some miracle, thrown from the plane at impact, had struggled to the surface and clung to a floating berg. Spared from a frigid tomb, they stood on a fragile shelf of thin and breaking ice. Over two miles from the shore, clothing soaked through in sub-zero temperatures, their survival was still a loser’s bet. Slowly they worked their way shoreward, breaking through the ice at times, body temperatures dropping despite their exhausting physical efforts. Guided by some hand unseen, they finally fell exhausted on shore, finding shelter in an empty lodge. Blinded by cold and head trauma sustained in the crash, Jim was led into the cabin by his wife, who cut off his frozen clothes and started a fire.

Friends awaiting their arrival grew anxious, and the Air National Guard was called. A Pavehawk helicopter–battling the same merciless weather–located the crash site, and ultimately reached them at the cabin. Even then, they could not be evacuated, as conditions grounded the rescue helicopter until morning. A friend flew a Piper cub–braving the same horrendous storm–to bring arctic sleeping bags and warm food. Bravery, love, and duty had spared their lives.

Months passed. Physical healing came quickly, but the rawness of heart wept like an open sore, gently salved by friends and faith, prayers and potlucks, tears and thankfulness. The boys were precious as never before, but the emptiness of heart left by a lost child cannot be filled. The rage at God passes–slowly–as strength flows from trust born of countless old decisions to set aside self and act in faith. But the memories remain–the laughter lost, the peace of a sleeping child, the love of a flower picked, the unexpected hug. There is no answer to “why?“–only time, and trust, and talk, and the tender whispering of a gentle Spirit. Yet one haunting regret refused to die: the vasectomy Jim had undergone after their last son–expeditious at the time, financially prudent–was now a self-imposed prison in a home filled with people, yet achingly empty.

And so they sat in my office, seeking my skills to restore what no man should be asked to provide–hope and happiness. And they told their story, my heart aching with each small detail disclosed. Jim was a man of enormous character and strength, his wife still bearing the unspeakable pain on her face–yet there was no shame in the tears that welled up in their eyes. As I gently probed deeper with almost unseemly curiosity, I was drawn in by the most remarkable revelation: these two would stand. Theirs was a strength not merely of hardiness, or training, or steely denial hiding a dying heart, but of power beyond the means of any mortal. They had faced the hell that men fear even to consider, and conquered it. There was glory in their weeping, victory in their agony. They would never be alone, and never be defeated. I, the proud expert, felt strangely insignificant in their presence.

The surgery went well, and early recovery smoothly. As I spoke with Jim before he left for home, he talked about the girls who had loved their daddy and whom he still loved so deeply. “You know, if I could fly to heaven and bring them back, they would not want to come. Their happiness is complete, ours still unfulfilled. Jesus has indeed brought them home.”

Confessions of a Health Care Rationer


 
Over at First Things, you will find an excellent article on the topic of rationing in health care, written by a clinical oncologist now working for the insurance industry in evaluating claims for medical necessity. Despite what would at first glance raise concerns about being an apologetic for the private insurance industry, this proves to be a well-balanced essay on the difficult choices in allocating scarce health care resources wisely. It is well worth your time to read in its entirety: Confessions of a Health Care Rationer

It’s a mistake to think of health care as a right. It is not a right; it is a good. Freedom of speech, by contrast, is a right, as is freedom of religious belief. They are privileges that inure to individuals as a consequence of the primordial right, free will. That is why we see them as inalienable. The exercise of these rights does not depend on any action of government, but rather on its inaction. Government may not legitimately interfere with their exercise, but nothing mandates that the government provide us with printing press or chapel.

All modern societies ration health care. A wise society considers the options and chooses a method of doing so which best conforms to its values and capabilities. Thus we come to the terrible question we would so very much like to avoid: How shall we ration health care? How shall we explicitly ration it? So noxious a question is this, so offensive in its tacit assumptions and implications, that most politicians and wishful thinkers will deny that we need to address it at all. They will argue that the fundamental problem is one of distribution, not one of unmeetable demand. They will argue, with more enthusiasm than evidence, that an emphasis on preventive care would substantially reduce aggregate demand. Some will say we must reduce the role of government; others will argue that we should augment it. If only we will adopt their plan—they’ll say—waste, fraud, and abuse will be abolished. There will be chicken—or at least chicken soup—in every pot, and a vaccine in every arm. People love honesty, but they hate the truth. To frankly acknowledge and address the ineluctable reality of healthcare rationing is not merely to touch the proverbial third rail of American politics; it is to lie across the tracks in front of the onrushing train.

Check it out.

Texas Tort Reform

Over at the Belmont Club, Richard Ramirez has a post citing a proposal by a physician for reform of the health care system. The proposal is thoughtful, with some excellent suggestions (which will never get implemented in today’s environment, sadly).

What caught my eye in the comments was a summary of the changes which tort reform has brought about in Texas by a commenter, Leo Linbeck:

I’m pretty familiar with tort reform in Texas, as my dad was the founding Chairman of Texans for Lawsuit Reform. TLR started in the mid-1990s after forty years of steadily increasing tilting of the civil justice playing field in favor of plaintiffs. There were two major inflection points in this fight:

The 1995 session (with George W. Bush was Governor)

Limited punitive damages
Reformed joint and several liability
Restricted venue shopping
Restored the Deceptive Trade Practices Act to its original purpose of protecting consumers in ordinary consumer transactions
Enacted a half dozen other reforms to curtail specific lawsuit abuses

The 2003 session (with George W. Bush was Governor)

Enacted comprehensive reforms governing medical liability litigation, including a $750,000 limit on non-economic damages
Initiated product liability reforms
Made the burden of proving punitive damages similar to criminal law, requiring a unanimous jury verdict
Comprehensively reformed the statutes governing joint and several liability and class action lawsuits
Imposed limits on appeal bonds, enabling defendants to appeal their lawsuits and not be forced into settlements (this is what pushed Texaco into bankruptcy in its famous lawsuit against Pennzoil)
Further limited the filing of lawsuits that should have been brought in other states or countries

The changes to medical liability in 2003 were extraordinary, and had a very substantial impact, including:

1. In August 2004, the Texas Hospital Association reported a 70% reduction in the number of lawsuits filed against the state’s hospitals.
2. Medical liability insurance rates declined. Many doctors saw average rate reductions of over 21%, with some doctors seeing almost 50% decreases. (Recent information provided to The Perryman Group during the course of this study suggests that premiums are declining even further in 2008.)
3. Beginning in 2003, physicians started returning to Texas. The Texas Medical Board reports licensing 10,878 new physicians since 2003, up from 8,391 in the prior four years. Perryman has determined that at least 1,887 of those physicians are specifically the result of lawsuit reform.
4. In May 2006, the American Medical Association removed Texas from its list of states experiencing a liability crisis, marking the first time it has removed any state from the list. A recent survey by the Texas Medical Association also found a dramatic increase in physicians’ willingness to resume certain procedures they had stopped performing, including obstetrics, neurosurgical, radiation and oncological procedures.

Last year, TLR commissioned a study by The Perryman Group to figure out the impact of these reforms (the above are excerpted from that report). Here are the economic impact findings of that study:

$112.5 billion increase in annual spending
$51.2 billion increase in annual output – goods and services produced in Texas
$2.6 billion increase in annual state tax revenue
$468.9 million in annual benefits from safer products
$15.2 billion in annual net benefits of enhanced innovation
499,000 permanent jobs
430,000 additional Texans have health insurance today as a result of the medical liability reforms

The complete Perryman Group report is here.

As these numbers show, tort reform can have a substantial impact on economic growth and wealth creation, and a huge impact on the healthcare system in particular. Any serious national healthcare reform must include comprehensive tort reform to reduce the practice of defensive medicine and other perverse incentives.

Which is why I do not consider the current proposals from the Obama Administration to be serious (other than being seriously flawed).

Our current re-invention of the health care system, for all its complexity, completely ignores the problem of runaway malpractice lawyers and the costs of defensive medicine. While not surprising, given the huge contributions to the Dems from attorneys, this deficit alone virtually guarantees a disastrous outcome should it be implemented.

The Crush of Covenant

Well, I finally did it: I quit.

Walked into the boss’s office, gave him a piece of my mind, tossed my resignation letter on the desk, and told him exactly what he do with his stinkin’ job. “Take this job and shove it”, as the country song goes.

Felt great. Been wantin’ to do this for a loooong time.

What led me to such a drastic, disgruntled display of ill-demeanor?

Here’s just a few vignettes from the past few days:

Monday 7 A.M: It’s Monday, my regular ER on call day. Full office scheduled. The ER calls — at exactly 7 A.M. Which means the weekend call guy, who goes off at 7:00, hasn’t answered his pages for the last 2 hours. Bastard. There’s a term for this: it’s called “dumping.”

The patient: a 90-something man with Alzheimer’s dementia, from a nursing home. Not any nursing home, mind you: one specializing in the care of Alzheimer’s patients. Ads on the radio about how caring and compassionate they are — you’ve heard ’em. Creme’ d’ la creme, and all that. Chronic Foley (urinary) catheter for incontinence. Despite their fawning attention, he somehow managed to grab his Foley and pull it out — with the balloon inflated, of course. He’s bleeding. A lot. The caring, attentive staff at the home has also neglected routine catheter care, so it has basically eaten its way through his penis. He now pees (if he could) through a hole just over the scrotum.

The ER staff can’t get the catheter back in. Not just because the anatomy ain’t quite normal (the P.A. is still trying to insert the catheter into the end of the penis, and can’t figure out why it won’t go in) — but he’s agitated. Really agitated. 4 nurses and counting to hold him down, still throwing punches. (great left hook!). Clearly this isn’t going to work — he’ll need to go to surgery ASAP, so this can be done under anesthesia — putting in a more permanent bladder catheter through a small hole in the low abdomen. With a big-ass balloon he can’t pull out. Hopefully.

Monday 9 A.M.: Inform my office staff that most of my busy morning office has to be rescheduled, the rest will have to wait. They are not happy. The patients rescheduled will not be happy – most have waited over 6 weeks for their appointment, and probably another 6 for their new one. C’est la vie. They will likely think my “medical emergency” means I’m on the 1st tee with my golfing buddies. Whatever. The more urgent ones will get squeezed into another day, already overbooked. Then they can be even more unhappy because the doctor is running late, and “Their appointment was at 10:00 A.M., dammit, and their time is valuable.”

Monday 1 P.M.: Back from surgery, the few longsuffering and surly patients from the morning clinic seen and (somewhat) assuaged. Short conference with my billing specialist, a soft-spoken pit bull with lipstick who daily does battle with the forces of evil and corruption (a.k.a., insurance carriers and Medicare), and wins an amazing number of battles. But not today.

Mr. Jones, you see, had a prostate problem. So he needed a fairly simple test to check for obstruction, called a uroflow, to evaluate whether his prostate was causing blockage. Charges for this procedure? About $325.

Sounds like a lot of money to pee in a jug. But it’s a very special jug. The equipment which measures and records his urinary efforts cost over 6 figures (it has a number of other highly specialized functions as well, lest you think it’s too extravagant for such a lowly task). The specialized catheters used to measure pressures for the more sophisticated tests cost well over $100 each — and are single-use disposables. Setup, cleanup, patient instruction and assistance by my back-office nurse, about 20 minutes of her salary, benefits, health insurance, 401(k) contributions. Overhead to keep the office open (rent, supplies, maintenance, malpractice insurance, licenses, etc., etc.), about $200 an hour. Oh, and my interpretation of the test and conclusions about how best to treat the patient is included in the fee.

What the insurance usually pays for the procedure: about $125.

What Mr.Jones’ insurance company paid: $0.

The reason? Mr. Jones’ policy doesn’t cover in-office surgery. “But peeing in a jug isn’t surgery!”, you protest. As did I. But the CPT service code has been incorrectly categorized as surgery by our friends at the AMA, in their massive annual tome used by insurers and federal payors to determine payments for medical services.

So I sat down and wrote a detailed appeal letter, explaining in a clear, courteous, and detailed manner that peeing in a jug is not surgery. Dictated, proof-read, sent off. My time? About 20 minutes. My reimbursement for that time? $0 (Called your attorney lately and chatted for 20 minutes, for free? Didn’t think so).

One month later, the response arrived: Appeal denied. The letter explained how the medical situation had been carefully reviewed: first, by their highly-trained Resource and Review Nurse; then by a panel of esteemed physicians and other health care providers; and finally, because of the seriousness of the matter, by their Medical Director (whose 7-figure income reflects the gravity and burden of such decisions). The verdict?

Peeing in a jug is surgery.

Of course, it is never prudent to take the last shred of hope from the hopeless, so they politely inform me that I may submit a Level II appeal — which requires pleading to the AMA that the categorization of peeing in a jug as surgery, in their massive annual CPT coding tome, is an error. And, of course, they will be more than happy to reconsider the matter once the AMA has agreed, and changed their rules.

Oh, and have a wonderful day! We cannot tell you how much we appreciate your outstanding care for our insured clients!

Monday, 1:10 P.M:: Billing conference, part II. Mr. Smith, another nursing home patient, had blood in the urine. Came to our office for a cystoscopy, a visual inspection of the bladder. Found he had a small bladder cancer, and was scheduled for surgery in a few weeks. Went back to the nursing home until then.

In the past, billing for such a procedure was simple: submit the claim to Medicare, get paid (about 40% of my billed fee, about 10-20% less than my overhead to perform the procedure) by Medicare a few weeks later.

Then Medicare changed the rules. Since Mr. Smith is in a nursing home, the nursing home must now bill for my cystoscopy, get paid by them — and then pay me, if and when they get around to it. But, of course, they have no motivation to do so — since I have no recourse against them if they fail to bill it, or bill it incompetently and get denied, or refuse to pay me.

So the executive summary: I get nada for Mr. Smith’s procedure.

The unintended consequence of this little change in Medicare regulations? Urologists and other specialists now refuse to do procedures in the office on nursing home patients, since they don’t get paid. The procedures either don’t get done — or the patient has to be admitted to the hospital when his bleeding gets bad enough, where his cystoscopy will be performed at a cost to Medicare of, oh, about 500-fold what it would have been if I did it in the office.

Medicare, of course, will be ecstatic: their payments for office procedures will plummet, after their careful review of regulations helped trim “wasteful and unnecessary medical spending” from their budget. The jump in costs for hospital procedures which results from this shell game are, of course, because of greedy health care providers, fraud and abuse, and more wasteful medical spending — and come out of a different pocket, so’ll they’ll never make the connection. The politicians are sure to trim those frivolous expenses as well, by carefully reviewing the regulations and implementing more “fraud and abuse” abuse, as they seek high quality, affordable health care coverage for all.

Tuesday, 1: P.M: Mr. Smith’s nurse from the Alzheimer’s Home calls, and says he has some blood in the urine from his new bladder catheter (which is expected). “How much?” “Dark pink, no clots.” “Have you irrigated it?” “Yes, and we’re sending him back to the hospital.” “Is the catheter draining well?” “Yes, but we’re going to send him back.” “Is he stable, blood pressure OK, any pain, blood count OK?” “Yes, do you want him to go by ambulance or do we call 911?” “He doesn’t need to go back to the hospital.” “Well, he’s going anyway. We can’t handle this.” Yeah, I guess that’s why they call it a nursing facility. God forbid you should deliver, you know, nursing care.

14 hours later he returns to the nursing home after an ER visit, perfectly stable medically, just as he was when he left the nursing home. About an $8-10,000 medical junket, because a nurse couldn’t, or wouldn’t, handle basic nursing care.

Wednesday 9:00 A.M.: Mr. Johnson is waiting when the office opens. His is a sad story: prostate cancer, had successful surgery to remove it, and is cured. Developed scar tissue afterward and couldn’t pee. Opened it up and he couldn’t not pee — bad incontinence. Had a prosthetic device placed, an artificial urinary sphincter, nine months ago. Worked beautifully, Mr. Johnson is happy. 8 months later, leaking again: Mr. Johnson is not happy.

Took him to surgery yesterday to repair it. A tiny leak had developed, and the pressure on the sphincter cuffs was lost — an uncommon but known problem with these devices. Replaced the components, hooked it up, tested it thoroughly, worked great. The device has a control valve located in the scrotal area to open the cuffs when you need to pee, which was one of the components replaced. It has a locking button, which holds the cuffs open, as things are too swollen and tender for the patient to use it for a while. Locked the cuffs open, tested it again several times, everything’s perfect.

He goes home, and can’t urinate. Somehow the lock released on its own — which isn’t supposed to happen. Goes to the ER, where they try to put a catheter in, rather indelicately, and left it in — which greatly increases the risk his sphincter prosthesis will get infected, and have to be removed. And he needs to go back to surgery, since it is far too painful to try to lock the cuffs open now, and he will need a temporary bladder drain through the skin until the swelling goes down.

Mr. Johnson is not happy. I am not happy.

Not to be too whiny, but the responsibility of this profession at times can be crushing. At the risk of seeming hyperbolic, you really do, to a greater or lesser degree, take patient’s lives in your hands when you assume their care. Not just the life-and-death stuff, although that’s sometimes part of it too. No, it’s the rest of their lives which come under your responsibility. It’s the drug to treat a serious disease, which causes serious side effects or unintended adverse effects on their other diseases. It’s the surgery to cure cancer which can have painful, disruptive, frustrating complications, even when the cancer is cured — and even when the surgery is competently and expertly performed. You are, in the end, responsible. When the side effects happen, you are responsible. When the patient fails to follow treatment advice, or has unrealistic expectations despite your best efforts to temper them, you are responsible. When the pharmacist sends the wrong drug; when the nurse fails to notice an important problem; when the technician doesn’t properly clean and sterilize the instrument; when the prosthesis fails to operate as designed: you are responsible.

Perhaps in some alternate universe, where Gucci-loafered lawyers with fat cigars parse guilt in mahogany-gilded chambers, the responsibility would be meted out in scrupulous fairness to all involved. But as a physician, where our relationship with the patient is one of covenant, not contract, those responsibilities become ours, because we commit to the patient’s best interest, no matter what, while orchestrating the complexities and complications of this enormous technological beast we call 21st century medicine. This gleaming beast can accomplish enormous good — or ghastly harm. And much of the behemoth we seek to command is not under our control — yet we remain responsible nevertheless. So we lash, kick, prod, and goad the monster, trying to reign in the mind-numbing complexity and tie up the endless loose ends, as the monster snarls back and snaps at your head or pummels you with its tail. And never forget your own frailty: perfection is unattainable despite your most obsessive, strenuous efforts. The country doc with his black bag could do little good and cause little harm; small errors today, even unrecognized, can multiply and spiral into disaster at frightening speed. This fact alone crushes many a doctor with its gravity, as witnessed by the high rates of physician burnout, suicide, divorce, and drug and alcohol problems.

The feeling is like a punch in the gut, only worse. I am not happy. I am depressed, and angry, and fearful, and discouraged — and convinced that with my level of competence I should be flipping burgers at McDonalds. Self-condemnation is a narcotic, savored and craved by perfectionists: noxious in flavor, but oddly salutary in the self-pitying comfort of its dark and fetid euphoria.

It does not pass easily.

Wednesday, Noon: Mr. Smith, with the Alzheimer’s, is back in the ER, and they are calling me. No preliminary call to me this time from his nursing home — they just sent him back. His 4-by-4 inch gauze dressing around his new bladder catheter is bloody — about a silver-dollar sized area. The ER doc sees and evaluates him: still demented, still medically stable as a rock, blood count unchanged. The ER doc changes his dressing, and sends him back to the nursing home. So, here we are, some $20-25,000 spent on this poor man, because his nurses are inept, lazy, incompetent, and can’t change a g*d-damned dressing. No one at the nursing home will have their pay docked because of this travesty; no one will be fired or fined. Medicare will pay its fractional part of the costs, oblivious to the incompetence which triggered it. The hospital will eat the difference.

And life in the circus of 21st century medicine will go on.

And so, enough is enough: the camel’s back has snapped. I quit. It’s not the first time, by any means; likely won’t be the last. My boss is very understanding, and he’s been through this all before. That’s one of the skills you need when you’re a self-employed, solo physician.

He knows I’ll be back at my desk tomorrow, as if nothing happened. Ready to start it all over again.

* All names are, of course, fictional.

The Bounty Hunter


I’ve been feeling a bit remiss (but only a bit) about my light posting of late — but hey, it’s summertime, and if Vanderleun can take a vacation, well, why not me?

But of course there’s always something which comes up, which demands some comment — such as this little blurb in the Wall Street Journal today:

Medicare Auditors Recover $700 Million in Overpayments

 
Auditors have recovered nearly $700 million in Medicare overpayments to hospitals and other medical providers in a half-dozen states under a controversial program that pays the auditing firms a portion of amounts they identify.

The program has drawn fire from health-care providers, and hospitals in particular, who call it overly aggressive and too confrontational. But the federal Centers for Medicare and Medicaid Services has supported the move and is in the process of expanding it nationally.

In all, the agency’s recovery audit contractor program caught $1.03 billion of improper payments over about three years, primarily in New York, California and Florida, about $992.7 million of which was overpayments by Medicare. The audits also identified about $38 million that providers should have received but didn’t. (Three states were added toward the end of the trial program, but accounted for only a small part of the recoveries, Medicare officials said.)

The program’s expenses amounted to about 20 cents on the dollar, including $187.2 million paid to the audit firms, and medical providers successfully challenged about $60 million of overpayments identified by the auditors. In the end, about $694 million has been returned to the Medicare trust funds, the Medicare agency said. The auditors reviewed a total of $317 billion in claims.

“All in all, we’re very happy with the results,” said Tim Hill, the agency’s chief financial officer and director of its office of financial management. “It returned a lot of money to the trust fund, particularly when you think that we’re talking about three states.”

I’ll bet you’re very happy, Mr. Hill.

Now, at first glance, this would appear to one of Medicare’s already notorious fraud and abuse investigations, carried out by OIG, but no — there’s no accusation of fraud involved here, although the government is more than happy to let this implication stand.

What this involves is demanding refunds based on different interpretations of Medicare’s mind-boggling regulations. So you provide a health care service, and bill Medicare based on your best understanding of its Byzantine regulations, and get paid. Then, at some future date, a third-party auditor, hired by the Feds, reviews the claim and decides — with no input from clinicians or other health care experts — that you were paid in error. Out goes the notice, pay up or else. Of course, this is always a highly objective, impartial review — the fact that the auditor gets a hefty cut of the refund has absolutely no influence on their judgment, none whatsoever.

Of course, you have a right to appeal — on your own dime and time, hiring your lawyers and taking time off from your practice to prove to the bounty hunter that your interpretation of the regulations is the correct one, and his is wrong. If you win, you get to keep the cash you already earned — minus a small stipend for lost time and lawyers fees. So, on that disputed $35 you got for an office call, you might come out, oh, $20,000 short, give or take a few thousand. But hey: You won!! Ain’t it grand?

Of course the low rate of appeals, entirely predictable based on the above freakonomics, is seen as proof that the audits are finding real problems:

Mr. Hill pointed to the low appeal rate — about 14% of overcharges were appealed, and 4.6% of the total were overturned — as evidence that the audits succeeded. “We know that we got the right answer,” he said.

If an 800-pound gorilla wants to make love to you, it’s always best to fake an orgasm. And the luvin’ ain’t over ’till the gorilla says it’s over…

Of course, these auditors also expend large amounts of time and energy looking for cases where you were underpaid:

RACs [Recovery Audit Contracts] are authorized to review payments for the previous 4 years. The software they use is more capable of picking up overpayments than it is underpayments. This discrepancy is borne out by a CMS report showing that 97% of improper payments in fiscal year 2006 were overpayments, and only 3% were underpayments. No money has been reported as having been returned to physicians because of underpayment.

At this point, the program has been primarily focused on hospitals in a few states, but is being rolled out nationwide, and will quickly be auditing physicians and other health care providers.

I have spoken a considerable length about the maze which is our current reimbursement system. It makes perfect sense, in a way, for the Feds to do exactly this: use bounty hunters to exploit the system’s complexity and inscrutability. They will no doubt recover a bundle of money, keeping the band playing on the Titanic for a few more years.

But sooner or later there’ll be a price to be paid — and that price is access. Repeated pay cuts such as the currently stalled 10.4% Medicare fee reduction being bantered around Congress, combined with heavy-handed recovery audits such as these, will drive physicians to the exits in droves. It is already nearly impossible in our area to find a primary care physician who accepts Medicare patients; a few more years of this B.S. and you’ll likely get a pretty clean sweep: best of luck finding anyone who will see you if you have Medicare or any other Federal health insurance.

Happy hunting on your audits, Mr. Hill.

Cinnamon Boy

cinammon

I wanna live
with a cinnamon girl
I could be happy
the rest of my life
With my cinnamon girl.

    — Neil Young
 
You can’t make this stuff up, really…

Joe is an old patient, been seein’ him since I started practice some 25 years ago. Nice guy, but a little — shall we say? — quirky. Big into herbs and alternative medicine, sees a naturopath who performs prostate massage on him until it stops hurting (or death, whichever comes first). Has some chronic prostatitis, and his love life leaves much to be desired — especially since his Asian concubine left him hanging, taking all of her magic potions with her.

“The thrill is gone,” as B.B. King would say.

So he comes in for his annual checkup.

“How ya’ doin’, Joe?”

“Pretty well, although my prostate still burns at times.”

“Been on any antibiotics for that?”

“Naw, don’t take those things, you know. Too toxic. But I did try another treatment.”

“Do tell.”

“Well, you know that cinnamon has healing powers.”

“Didn’t know that.”

“Yeah, I had a stubborn rash on my leg, and it cleared up after using cinnamon on it.”

“Interesting.”

“So I decided to try it for my prostate.”

Gulp. “How’d … you do that?”

“Well, I filled up a condom with it, and put it on, and worked it into the opening.”

Reflexly, I cross my legs, holding his chart tightly on my lap.

“How’d that go?”

“Hurt like hell!”

Ya think?

“Did it help any?”

“No — and I don’t think I’m gonna try it again. But I’ve got some other ideas…”

Perhaps next time he should blend it with sugar and berries, and make a tart…

The Call

cancer crab

Damn!, I hate these calls…

Lying on my desk, clipped to a yellow manila binder, is a single sheet of paper. Its pleasant color format and sampled photomicrograph belie the gravity of its content:

Adenocarcinoma, Gleason grade 9, involving 60% of the specimen.

How do you deliver a death sentence?

Your first impression of Charlie is his sheer mass: 50 years young, healthy as a horse, built like a tank, a former football player turned popular coach at a local high school. He arrived at my office after seeing his family physician for an acute illness, with fever, chills, and problems urinating. His doctor had diagnosed a urinary tract infection, placed him on an antibiotic, and drew a PSA–a screening test for prostate cancer. It was markedly elevated: over 100, with normal being less than 4. I grumbled to myself as I reviewed his chart: Those damned primary care docs shouldn’t draw PSAs when patients have prostate infections — it just muddies the waters.

PSA (prostate specific antigen) is a test which measures a protein in the blood stream released by prostate tissue. It has greatly improved early detection of prostate cancer in the 20 years it has been in widespread use — but it is not, strictly speaking, a cancer test. It is noisy — often abnormal in other conditions, including benign prostate enlargement (BPH), inflammation, and prostate infection. It is virtually always elevated in the presence of an acute prostate infection — often markedly so — and can take months to return to normal. The high PSA alarms the patient, however, who is told he may have cancer. But most do not — and Charlie looked like a classic case of infection.

His history was typical, and his response to antibiotics appropriate, so this seemed at first glance like so many other similar cases I had seen. His prostate exam was alarming, however: rock-hard and irregular, unlike the typical soft, boggy texture of an infected gland. Experience and training kicked in, and I knew exactly what we were dealing with: a relatively uncommon form of prostate infection called granulomatous prostatitis. I had seen dozens of cases — always alarming on first exam, with very high PSA values — and always responding to long-term antibiotics. Charlie was started on a one-month course of high-powered, high-priced bug exterminator, and came back for follow-up after its completion.

He was feeling better, and his PSA had dropped markedly, to 45. His prostate exam also seemed improved, but still quite abnormal. I remained quite confident in my diagnosis — after all, cancer doesn’t get better on antibiotics — but was unwilling to wait much longer to know for sure. I scheduled a prostate biopsy, reassuring him after its completion of my optimism that the results would show only infection.

The report was a blow to the gut. I sat silently, staring at it, in stunned disbelief.

In the age of PSA screening, most prostate cancers are detected at an early, curable stage — although their slow-growing nature makes treatment less important in very elderly patients. The chances for cure at diagnosis are determined by an estimate of the size and aggressiveness of the tumor. Size is determined by exam, ultrasound findings, and total PSA values; aggressiveness by the Gleason score — a value indicator (between 2 and 10) of the aggressive appearance of the cancer cells under the microscope. Higher is not better: Gleason scores of 9 and 10 indicate rapidly growing cancers which tend to spread early and are difficult — if not impossible — to cure. Charlie had drawn a pair of deuces in a high-stakes poker game: large volume, high-Gleason score cancer. The statistics were dismal: he would likely be dead of cancer in 5 years, regardless of treatment. And as cancer deaths go, this one’s not pretty: pain is a huge management problem in many, as the cancer infests and erodes the spine and long bones, breaking even the strongest of men. One learns to hate this disease before very many such cases have been seen.

And now I had to call him with his biopsy results.

The actual call will be brief: I will inform him that, unfortunately, the biopsy has shown cancer, that additional tests will be needed to determine its extent and the best way to manage it, and arrange for a follow-up visit in the office. The real bad news will be transmitted then, face-to-face, with more than enough information for its gravity to sink in. To do this — without robbing hope — will require more inner strength than is readily at hand.

But for now, I simply need to tell him he has cancer.

The word cancer encapsulates the deepest fears and anxieties of man, embodying in one small word pain, suffering, loss of control, hopelessness, dependency, death, the fragility of our dreams and hopes, and our uncertainty about the hereafter. To inform a patient that he has cancer is to shatter the illusion, the daily denial that death may yet be outmaneuvered, forestalled, kept on hold for some future date of our own determining. It is an illusion which dies hard — surprisingly so, as we alone among all creation are cognizant of its inevitability and certainty.

Perhaps the cruelest wish a man might be granted — were there some bottled genie passing out such favors — is knowledge of his own future. Yet, in some small measure, that power has been granted to me, and others of my profession. Not in any specific manner, of course — not of days or years, details or circumstances — but in knowledge deep enough to see the broad strokes: shadowy figures through rippled glass, of pain, and loss, and shattered dreams, of desperate grasping at the frail straws of fading hope, as the drumbeat of mortality pounds ever louder toward its dark crescendo.

Patients receive the call in different ways. Most accept it with seeming stoicism, and little expressed emotion — yet it is not hard to imagine — and sometimes to sense — the tight grasp of fear that grabs the throat and grips the heart. When wives are listening, the fear is more immediate, more palpable, as voices tremble with panic despite every effort to control it. A million questions will arise — but almost never on the initial call. On rare occasion, there is a casual indifference to the news — prompting reflection on what strength of spirit — or dense denial — such men possess.

I often wonder how I would receive the call. As a Christian, I am confident of a life hereafter, eternal, spent in the presence of Him who loves me. Some call that arrogance, or self-righteous; it is not. God alone knows better than I the darkness of my heart, the depravity that makes me uniquely unsuited to be in the presence of the Holy One but for one moment, much less eternity. But I have been adopted — an unworthy child by an unspeakably loving and merciful Father, who only asks submission to His tender guidance and direction, and transforms a lost fool into something useful, something cherished, someone with purposes aligned — though poorly so — with His own.

But the call of death — so confidently faced from the comfortable vantage of good health and cheap grace — will strike fear into my heart when it arrives, for far smaller challenges have brought dread in larger measure. There will be the fear of the ordeal, the journey of suffering, the loss of things now treasured but instantly made worthless. There will be the pain of watching the loss of those close to me, struggling to make sense of a relationship, undervalued while unthreatened, yet now more precious while counting down inexorably to its end. I know – -by the tutor of past and bitter experience — that faith will sustain me and mine through it all. But one cannot know what that day will be like — nor should we wish to ever know.

But for Charlie, the battle will now be enjoined — the weapons and wherewithal of modern medicine in all-out war against its implacable foe. Perhaps by some miracle or unexpected grace he will be given a reprieve, a window to revalue and reassess life’s course, its priorities, its purpose. For even when we are cured, we are healed to face death again: Lazarus, once risen, will revisit the stony crypt. Yet the Voice which called him forth calls us also, beckoning toward a painful light from the cold terrors of death.

How difficult to be the herald of another’s mortality — it is a burden no man should have to bear. Some will deliver it through the steely detachment hammered hard by years of training; some avoid it altogether where possible, through choice of profession or abdication of responsibility. But for those who must speak this hard truth, may there be grace and wisdom, empathy and compassion.

May it be also for me.

CAT Scams

cat scan cartoonThe Wall Street Journal reports on a recent New England Journal of Medicine study which concludes that doctors are over-utilizing CT scans, exposing their patients to excessive, and potentially harmful, radiation doses:

Doctors are ordering too many unnecessary diagnostic CT scans, exposing their patients to potentially dangerous levels of radiation that could increase their risk of cancer, according to Columbia University researchers.

The researchers, writing in this week’s New England Journal of Medicine, conclude that in the coming decades up to 2% of all cancers in the United States may be caused by radiation from computed tomography scans performed now. Children face the most danger, they said.

In ordering CT scans, doctors are underestimating the radiation danger … In many cases, the researchers say, older technologies like X-rays and ultrasound that expose patients to lower radiation doses or no radiation at all would work just as well.

Since CT scans were introduced in the 1970s, their use has grown to an estimated 62 million annually. An estimated four million to five million scans are ordered for children, Mr. Brenner said. Adults receive scans for diseases of the stomach, colon, breast and other areas. Children most often are scanned for appendicitis. It has become a favored technology because it provides detailed information about patients’ bodies, is noninvasive and typically is covered by health insurance.

While the scans save lives, the authors say, doctors are leaning on them over safer diagnostic tools because they underestimate the levels of radiation people receive from the scans.

The authors measured typical levels of radiation that CT scans emit. They found levels they say were comparable to that received by some people miles from the epicenters of the 1945 atomic blasts over Hiroshima and Nagasaki, Japan.

There can be little doubt that CAT scans, as well as other expensive medical imaging studies, are overutilized in medicine today. There is also no doubt that the overutilization of CAT scans in particular, with their ionizing radiation, does expose patients to significantly more radiation. It may be worthwhile to pause and think about why so many CAT scans are being performed.

Hint: It’s not because doctors don’t know that CAT scans deliver more radiation.
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