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.

Revolution of the Soul

In the past several days, through the lens of my profession, I have been given a rather stark and disturbing vision of our current cultural revolution. It is, it seems, a revolution every bit as pervasive and transformational — and destructive — as China’s Cultural Revolution of the 60s — and indeed may be but a different manifestation of a global transformation which transpired in those very same decades in the West. Ideas have consequences, as they say, and we are watching them bear fruit before our very eyes in a slow-motion train wreck which seems now to be accelerating at a disturbing rate.

Exhibit 1: Phyllis Chesler’s recent piece, “Every hospital patient has a story“, at PajamasMedia. It is a piece to be read to completion, including its lengthy comment section. Therein she details a recent experience during a hospital stay for a hip replacement, with a rather remarkable litany of rudeness, neglect, indifference, and suffering sustained at the hands of her healers, at an upscale New York hospital. Her story is shocking enough, and revelatory; the comments provide even further insight, running the expected gamut of such a piece in the New Media. There are those simply shocked; those sharing similar horror stories; those relaying far better experiences in contrast; those defending doctors and nurses, those attacking them. There is the obligate wackjob who blames the AMA, and the usual finger-pointing: not enough nurses, too much paperwork, inadequate pay scales to draw quality; the evil insurance companies and the government. All mostly true, to greater or lesser degree — but all missing the core dysfunction by a wide mark. At the final period of her post, one comes away with a sense of hopeless, feeling out of control and angry, despairing that such a situation may be even a part of our reality (and not knowing how large a part it may be), yet at a loss to prevent its malignant progression through our remaining hospitals which may have been spared to date, the encroachment of such a toxic stew of callousness, indifference, and coldness. There seems, in the end, little cause for optimism.

Exhibit 2: It is late, nearly 9 P.M., seeing a final consult at the end of a punishing call day, in the ICU. The patient, chronologically young yet physiologically Methuselan, lies in his bed, oxygen mask affixed to his face by heavy straps, bleeding, as he has for months, from a tumor in his kidney. He would not survive surgery, nor even radiological intervention to stem the hemorrhage by strangling its arterial lifeline. He is, furthermore, in the parlance of modern medicine, “non-compliant”: refusing treatments and diagnostic studies; rude and abusive to nurses and physicians alike; demanding to go home though unlikely to survive there for any significant length of time.

The nurse — young, competent, smart, hard-working, the very best of the modern nursing profession — apprises me of his situation, closing with this knockout punch: “You know, we just passed that initiative — you know, the suicide one. He’d be an excellent candidate.”

She wasn’t joking.

Taken a bit off guard, I responded that it is most unwise to give physicians the power to kill you, for we will become very good at it, and impossible to stop once we are.

She continued: “No, I would love to work for a Dr. Kevorkian. Be an Angel of Death, you know?”

“I know”, I muttered under my breath, as she ran off to another bedside, competently and with great efficiency, to adjust some ventilator or fine-tune some dopamine drip. And hopefully do nothing more.

These vignettes in modern medicine are really not about medicine at all. They are in truth about a culture which has lost its compassion. Our calloused and cynical society has become a raging river fed by a thousand foul and fetid streams. We have, by turns, taught our children that ethics are situational and values neutral; taught our women that compassion and service are signs of weakness, that they must become hard and heartless like the men they hate; taught our men that success and the respect of others comes not through character and integrity but through callousness, cynicism, and greed; and taught ourselves that we are a law unto ourselves, the sole and final arbiter of what is right and what is good.

We have, in our post-modern and post-Christian culture, inexorably and irrevocably turned from our roots in Christian morality and worldview, which was the foundation and font of that which we now know — or used to know — as Western Civilization. Yes, we have preserved the tinsel and the trappings, the gilded and glittering exterior of a decaying sarcophagus, where we speak self-righteously of rights while denying their origin in the divine spark within the human spirit, made in the image of God; where we bray about liberty, but are enslaved to its bejeweled impostor, the damsel of decadence and libertinism; where compassion is naught but another government program to address the consequences of our own aberrant and irresponsible behavior, duly justified, rationalized, and denied. Others must pay so that I may play, you know.

This toxic stew of self-centered callousness has percolated into every pore of our society. In health care, the effects are universal and pernicious. Patients demand perfection, trusting the wisdom of a web browser over the experience of a physician — then running to their attorney to redress every poor outcome which their disease or their destructive lifestyles have helped bring about. Physicians, hardened and cynical from countless battles with corrupt insurance companies, lawyers, and Stalinist government regulation, forget that they exist solely to serve the patient with compassion and self-sacrifice, and that financial recompense is secondary to healing and empathy. Nurses have in large measure become administrators, made ever more remote from their patients by mountains of paperwork and impossible nurse-to-patient ratios, their patient-critical tasks delegated to underlings poorly trained and ill-treated. Hospital administrators are MBAs, with no interest or clue about what constitutes good health care, and are indifferent so long as their departments are profitable and their marketing wizards successful as they trumpet “Care with Compassion” in TV ads, radio, and muzac on hold.

The list could go on far longer, but the theme is clear: we have as a culture become utterly self-focused, trusting no one, demanding our rights while neglecting our responsibilities, seeking to be profitable rather than professional. We have abandoned the responsibility to be patient and caring of others, forgiving of human shortcomings and humble about the limits of our abilities — a responsibility not merely of those in health care but of human beings in civil society. We have, through the dubious gift of extraordinary technological advances, industrialized our profession, and replaced a sacred covenant of commitment to the patient’s best — and its corollary of the patient’s trust in the integrity and motives of physicians and nurses — with the cold legality of contract medicine. Small wonder we are treated as fungible commodities in doctors’ offices and hospital beds. Small wonder we will be euthanized when we have exhausted our compassion quotient, dispatched by highly efficient providers delivering “Death with Dignity.”

This utter self-obsession and cynical callousness is by no means limited to health care. We long for “bipartisanship” in government (by which we hope for reasoned men of principle to come together for the good of those they represent), but get instead the blood-lust of modern politics, where power trumps principle, money is king, and votes are bought and sold like chattel. Lawyers sue everything that breathes — and much that doesn’t — raking in billions while their “victimized clients” get pocket change they can believe in. Airlines pack in passengers like cattle, lose your bags, and toss you a bag of peanuts for your trouble. Road rage is rampant, rudeness rules, rip-offs too common to count. The coarseness in culture is extraordinary — in language, art, media, fashion, and behavior. It is revealing how shocked we find ourselves when encounter someone — regardless of the venue — who is actually pleasant, helpful, courteous, and kind; we have come to expect and tolerate far worse as a matter of course.

The revolution which started in the 60s with the “me” generation is bearing its bitter fruit — though its aging proponents will never admit it. And sadly, there’s no going back: the changes which have infiltrated and infected the culture, inoculated through education, media, entertainment, scientific rationalism, and a relentless and highly successful assault on reason and tradition, are permanent, and their consequences will only grow in magnitude.

So it’s time for a counter-revolution.

There is an alternative to our current cultural narcissism with its corrosive, calloused, destructive bent. It is not a new government program, nor a political movement; no demonstrations in the street, no marches on Washington. Its core ideology is over 2000 years old, and the foot soldiers of the revolution are already widely dispersed throughout the culture.

This revolutionary force is called Christianity, and it’s long past time to raise the banner and spring into action.

The true antidote to the nihilism and corruption of the age will be found, as it has always been, in the church. It has since its inception been a revolutionary force, transforming the hopeless and purposeless anarchy of the pagan world of its infancy by bringing light, hope and joy where there was none before.

It can happen again.

The church, of course, has to no small degree been co-opted by the culture it should have transformed. From TV evangelists preaching God-ordained health and wealth to liberal denominations rejecting the core truths of their foundation and worshiping instead the god of government and humanistic socialism; from pederast priests to episcopal sodomy, Christianity in the West has whored itself to a prosperous but decadent culture. Its salt has lost its saltiness, and it has, not surprisingly, been trampled underfoot by men.

It is time to return to our First Love. It is time once again to become light to an dark and stygian world. It is time for a revolution of the soul.

We must, first and foremost, be about grace and truth. We must begin with the truth of our calling: to be holy, transformed by the power of Christ and the work of the Spirit. We are, by nature of our new birth in Christ, His ambassadors: we are to be the face, the hands, the heart, the words, the compassion of Him who saved us.

The task is enormous, yet for each of us, the steps are small, easily achievable yet enormously powerful.

It must begin with a renewed commitment to obedience and submission to Christ, a willingness to fully subject ourselves to His will, rather than trying to bend His will to ours. It means getting serious about church attendance — not merely as a consumer but as an active participant. We need to renew our devotion to prayer, to Scripture reading, study, and memorization, to fellowship with other Christians. These are simple steps which ground us in truth, and give us access to that power which can first of all transform us, then radiate out to all around us.

Then we must act like the counter-culturists we claim to be. Be patient with those who are difficult; be generous in time and money; express gratitude to those around us (when was the last time you wrote a thank you note to your doctor, your contractor, your attorney, to the manager of the store employee who helped you?). Lose the profanity; guard your tongue. Repair broken relationships, as best you can. Be joyful in difficult times, knowing that God is at work in your life despite your difficulties. Be compassionate rather than judgmental to those whose life choices are destructive or misguided. The tattoos and piercings we ridicule are cries of desperation from those hungering for purpose and meaning.

These things will not come easily to many of us who claim to be Christians, as we have become complacent in our self-gratification and comfortable compromises, fearful of being viewed as extremist or weird, rejected and ridiculed.

Get over it.

You may just find that such renewed passion for Christ and love for others might, just might, transform your life.

And you might just find that it will change the world.

Got a better idea? Good, I didn’t think so.

Let’s get started.

Thank You for Your Prayers …

Just a word of deepest-felt gratitude for those of you who offered your support and prayers regarding my deposition yesterday. The strength of your prayers were felt and experienced in a deep way, one which I consider in many ways to be miraculous.

The deposition itself went well, as best I can judge. My attorney was very pleased (and quite relieved, I suspect) with the way it progressed, and believes I made a very strong case for my defense, neither ceding any ground to the plaintiff’s attorney nor making any grievous missteps which might come back to haunt you later in the courtroom.

That it seemed to proceed so well is no small miracle in and of itself — my attorney was present at the deposition of one of the other physicians being sued, and felt it went very poorly indeed for the defendant, with lots of bad body language, evasiveness, fidgeting, and argumentativeness by the physician with the plaintiff’s attorney. My attorney’s preparation on such matters had been excellent, which was of course a great asset.

The real miracle — as is so often the case with prayer — came within the heart. After my prep last week I was nearly hysterical, panicking about the need the prepare for a hostile interrogation in the midst of of very busy schedule, which included a weekend on call last week. All sorts of calamities were imagined, immediately becoming in my mind an inevitable reality, with much resulting anxiety, depression, anger, resentments, and sleeplessness. The world looked very black indeed.

As Thursday drew near, all this changed, rather dramatically. My work schedule was nowhere near as frantic as anticipated; the call weekend was busy but I had a long sustained period on Sunday to focus on the litigant’s chart and clarify the events of my care in detail — including several things in my defense which I had previously overlooked.

The cavalry, meanwhile, came charging over the hill, leaving a cloud of dust in their wake: my wife and her prayer ministry partners were recruited; my dear office nurse, a devout believer and prayer warrior prayed and fasted with her partners. Many other friends — and strangers — volunteered their calls to the Almighty. Psalm 27 became my own prayer:

The LORD is my light and my salvation—
whom shall I fear?
The LORD is the stronghold of my life—
of whom shall I be afraid?

Though an army besiege me,
my heart will not fear;
though war break out against me,
even then will I be confident.

Wait for the LORD;
be strong and take heart
and wait for the LORD.

By Tuesday most of the insanity had left, although I was still quite anxious. By Wednesday, I was actually looking forward to the opportunity to present my case. By Thursday, there was — astoundingly — no anxiety whatsoever. When I walked into the conference room, I had no anger, no resentment against the attorney who was questioning me and challenging me, was able to see him as someone doing his best to defend an unfortunate child with a serious illness, and was entirely comfortable with where I was and what I had done, and actually enjoyed much of it, with some humor and a real sense of ease. Best exchange of the morning:

Plaintiff’s attorney: “Doctor, did you know what was causing this patient’s urinary tract infections?”

Me: [pause] “Bacteria.”

Plaintiff’s attorney: [shaking his head] “Umm, I guess I walked into that one, didn’t I?”

Me: [smiling, nodding] “Yeah.”

All caught on videotape. Sweet.

The point here is that I was not myself. I could not, in my own ability, have been so comfortable, at ease, so at peace, so joyful even, as I was yesterday morning. That was a gift — and I am indebted ever so deeply to those of you who made that gift possible.

Thank you again from the very bottom of my heart.

Trial by Tort

As some of you may have noticed, my rate of posting has been relatively slow for the past few months. There has been, as you might imagine, quite a few things competing for my time, some of which I hope to discuss forthwith.

My most immediate focus is a legal one. As I mentioned some time ago, I have been involved in a medical malpractice lawsuit for the past year. The wheels of justice — if you can call it that — turn slowly, and many months have passed with little more than an extraordinary plethora of paper which accompanies such a legal adventure. I have, quite literally, no less than 3-4 feet of paper accrued, including countless pages of chart notes, hospital records, court records, and communications from both attorneys. Keep in mind that this is in addition to the daily avalanche of paper accumulated through the normal running of a medical practice. Despite this torrent of tort-related tree products, the actual lawsuit itself has generally been a background matter for me for months, predominantly handled by my attorney.

Last week, however, in preparation for my upcoming deposition by the plaintiff’s attorney, and I had a several-hour prep session with my attorney. While very helpful, it significantly raised my anxiety level by putting this lawsuit front and center. Keep in mind that one cannot simply shut down a medical practice to focus on such things, so the cumulative stress is significant.

Of course, I cannot disclose any of the details of this case — a mistake imprudently made by another physician blogger. We believe our case to be very strong in defense, but of course the legal system can be something of a crapshoot, and the chess game of an interrogation by a plaintiff’s attorney is enough to give even the most steely-nerved defendant a serious case of the butterflies.

These are the matters which also challenge one’s faith, and all of the easy spiritual bromides and Bible verses about trusting God and His protection and provision are put to the test in the crucible of such a confrontation. As you can imagine, the knees on my trousers are getting significantly more wear of late. This road is far from easy; I cannot imagine enduring it without the pillar of my faith — shaky as it may be — and the love and support of those of like mind and belief.

So if you are of the praying sort, and feel inclined to do so, I would be most grateful for any whispered intercession on my behalf before our Creator.

My deposition is this coming Thursday.

God bless, and back soon.

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.

Crossing That Dark River

Often in the sturm und drang of a world gone mad, there comes, through the chaos and insanity, some brief moment of clarity. Such times pass by quickly, and are quickly forgotten — as this brief instance might have been, courtesy of my neighboring bellweather state of Oregon: (HT: Hot Air)

Last month her lung cancer, in remission for about two years, was back. After her oncologist prescribed a cancer drug that could slow the cancer growth and extend her life, [Barbara] Wagner was notified that the Oregon Health Plan wouldn \'t cover it.
 
It would cover comfort and care, including, if she chose, doctor-assisted suicide.
 
… Treatment of advanced cancer meant to prolong life, or change the course of this disease, is not covered by the Oregon Health Plan, said the unsigned letter Wagner received from LIPA, the Eugene company that administers the plan in Lane County.

Officials of LIPA and the state policy-making Health Services Commission say they \'ve not changed how they cover treatment of recurrent cancer.

But local oncologists say they \'ve seen a change and that their Oregon Health Plan patients with advanced cancer no longer get coverage for chemotherapy if it is considered comfort care.

It doesn \'t adhere to the standards of care set out in the oncology community, said Dr. John Caton, an oncologist at Willamette Valley Cancer Center.

Studies have found that chemotherapy can decrease pain and time spent in the hospital and increases quality of life, Caton said.

The Oregon Health Plan started out rationing health care in 1994.

We have, at last, arrived. The destination was never much in doubt — once the threshold of medical manslaughter had been breached, wrapped as always in comforting words of compassion and dignity, it was only a matter of time before our pragmatism trumped our principles. Once the absolute that physicians should be healers not hangmen was heaved overboard, it was inevitable that the relentless march of relativism would reach its logical port of call.

Death, after all, is expensive — the most expensive thing in life. It was not always so. In remote pasts, it was the very currency of life, short and brutal, with man’s primitive intellect sufficient solely to deal out death, not to defer it. There followed upon this time some glimmer of light and hope, wherein death’s timetable remained unfettered, but its stranglehold and certainty were tempered by a new hope and vision of humanity. We became in that time something more than mortal creatures, something extraordinary, an unspeakable treasure entombed within a fragile and decomposing frame. We became, something more than our mortal bodies; we became, something greater than our pain; we became, something whose beauty shown through even the ghastly horrors of the hour of our demise. Our prophets — then heeded — triumphantly thrust their swords through the dark heart of death: “Death, where is your victory? Death, where is your sting?” We became, in that moment, something more than the physical, something greater than our short and brutish mortality. We became, indeed, truly human, for the very first time.

That humanity transcended and transformed all that we were and were to become, making us unique among creation not only in the foreknowledge of our death, but our transcendence of death itself. Life had meaning beyond the grave — and therefore had far more weight at the threshold of the tomb. Suffering became more than mere fate, but rather sacrifice and purification, preparation and salvation. The wholeness of the soul trumped the health of the body; death was transformed from hopeless certainty to triumphant transition.

But we knew better. We pursued the good, only to destroy the best. We set our minds to conquer death, to destroy disease, to end all pain, to become pure and perfect and permanent. We succeeded beyond our wildest dreams. The diseases which slaughtered us were themselves slayed; the illnesses which tortured and tormented us fell before us. Our lives grew long, and healthier, more comfortable, and more productive. Our newfound longevity and greater health gave rise to ever more miracles, allowing us to pour out our intemperate and precipitous riches with drunken abandon upon dreams of death defeated.

Yet on the flanks of our salient there lay waiting the forces which would strangle and surround our triumphant advance. Our supply lines grew thin; the very lifeblood of our armies of science and medicine, that which made our soldiers not machines but men, grew emaciated and hoary, flaccid and frail. We neglected the soul which sustained our science; the spirit which brought healing to medicine grew cachectic and cold.

So here we stand. We have squandered great wealth to defeat death — only to find ourselves impoverished, and turning to death itself for our answers. The succubus we sought to defeat now dominates us, for she is a lusty and insatiable whore. We have sacrificed our humanity, our compassion, our empathy, our humility in the face of a force far greater than ourselves, while forgetting the power and grace and the vision which first led us and empowered us on this grand crusade. Our weapons are now turned upon us; let the slaughter begin.

We will, no doubt, congratulate ourselves on the wealth we save. We will no doubt develop ever more ingenious and efficient means to facilitate our self-immolation while comforting ourselves with our vast knowledge and perceived compassion. Those who treasure life at its end, who find in and through its suffering and debilitation the joy of relationships, and meaning, and mercy, and grace, will become our enemies, for they will siphon off mammon much needed to mitigate the consequences of our madness.

It has been said, once, that where our treasure is, there will our heart be also. We have poured our treasure in untold measure into conquering death — finding succor in our victories, while forgetting how to die. The boatman now awaits us to carry us across that dark river — and we have insufficient moral currency to ignore his call.

Drinking the Kool-AIDS

Threat of world Aids pandemic among heterosexuals is over, report admits:

A quarter of a century after the outbreak of AIDS, the World Health Organization (WHO) has accepted that the threat of a global heterosexual pandemic has disappeared.

In the first official admission that the universal prevention strategy promoted by the major Aids organizations may have been misdirected, Kevin de Cock, the head of the WHO’s department of HIV/AIDS said there will be no generalized epidemic of AIDS in the heterosexual population outside Africa.

Dr. de Cock, an epidemiologist who has spent much of his career leading the battle against the disease, said understanding of the threat posed by the virus had changed. Whereas once it was seen as a risk to populations everywhere, it was now recognized that, outside sub-Saharan Africa, it was confined to high-risk groups including men who have sex with men, injecting drug users, and sex workers and their clients.

There was never very much evidence of the threat of AIDS to low-risk, heterosexual populations — a threat which was nevertheless widely hyped to drum up massive research and public education funding for a disease whose risk has always been extremely low in heterosexuals who did not use IV drugs or visit prostitutes.

While medical treatment of AIDS has advanced greatly — mostly through the breakthrough of protease inhibitor therapy (enormously expensive drugs with a host of serious side effects) — prevention efforts designed to change high-risk behavior have failed dismally. No surprise there — you can’t cure addictions — sexual, drug, or otherwise — with education.

But, hey, our schools taught several generations of kids to use condoms rather than study math, so it was worth it, no?

And Dr. de Cock?? Sometimes life is funnier than fiction …

Cinnamon Boy

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