Category Archives: healing

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Fraud in medicine: why “help” won’t help

This article:  Doctors wasting over two thirds of their time doing paperwork showed up on Facebook yesterday.

The problem is that “hiring people to help with paperwork” will not help.

Why? We’ve already done that and it’s a huge mess.

For example: I was referred to an Ear Nose and Throat Specialist at one of the Seattle Mecca hospitals. I had to travel two hours and then in the waiting room I was given a four page patient history to fill out. I filled it out. I had been referred by a Neurologist, who sent a letter and note. After I filled out the forms, HIPAA and “you will pay if your stupid insurance won’t” and address and consent to be treated and yada yada…. I waited.

At last I was shown to a very luxurious room. There a medical assistant asked me many of the same questions that I’d filled out on the form and which were already in the letter and note from the neurologist. She typed these into the EMR- electronic medical record. Then she left. And I waited.

At last the distinguished otolaryngologist entered the room. He said, “I see that you are here for chronic sinus infections.”

“No.” I said. “I am not.”

Silence.

“I see that you did not read anything I filled out and I am a physician and I drove two hours to see you.”

Silence. “Um.” he said. “Uh, why are you here?”

“Strep A sepsis twice and we want to know if my tonsils should be removed.”

Right. So… all that paper you fill out before the physician saw you? Yeah, like, my impression is that physicians don’t read it until after you leave. And maybe mostly don’t EVER read it.

I plan to find out the next time I have to see a specialist. I will write “you don’t read this anyhow, so I am not filling this shit out” on page 2 and see if the specialist notices. Bet you money they don’t. Though when they yell at their staff for not entering my medication allergies or the review of systems, they might notice.

So… I am a primary care physician. What do I do?

A new patient has one form: name, address, insurance information, hipaa and “you pay if your insurance doesn’t”.

I do the health history myself in the room entering it in the first visit, which takes 45 minutes to an hour. WHOA! INEFFICIENT! Nope. Actually it is brutally efficient. For four reasons:

One — I enter it myself and ask the questions myself and I am really fast at it.

Two — now I know the person, because I went over all of it: complaint, history of present illness, past medical history, social history, allergies, review of systems, and I ask people to bring all their pills including supplements to the first visit and I enter them too. And I look at the bottles. I don’t like vitamins with 6667% of the Recommended Dietary Allowance of any vitamin, lots of vitamins now have herbs in them too and I would not recommend taking cow thymus, labeled as bovine thymus.

Three — Now I don’t have to spend time reading forms filled out in the waiting room or a history entered by someone else, because I don’t have time to do that anyhow. I did it all in the visit. I will still have to read old records and any labs or xray results or consult notes or pathology reports and hey, where do you think the waiting room paperwork falls in that priority list? Yeah, like never.

Four — I hand people a copy of the note as they leave and ask them to read it and to bring corrections if I got it wrong. They go from thinking that I am a drone staring at the laptop to saying, “Hey, she typed nearly everything I said (and she has three spelling errors).”

Because the truth is that medicine is really complicated now and it just doesn’t help to have more people “do the paperwork”. I have to read the notes and labs and reports myself, because I am the physician.

There are three things that WOULD help:

1. One set of rules. Hello, the insurance companies, all 500ish of them send us postcards and emails every week saying “Hey, we’ve changed what we cover, meaning we cover less and we have new improved and more complicated prior authorization rules! Go to our website to read all about it.” Guess how often I have time to do that. NEVER NEVER NEVER. I read medicare’s rules. So medicare for all, single payer is partly to have ONE SET OF RULES. I can memorize miles of rules, but not if they are changing in 500 companies every week. Shell game. Also, prior authorization means “your insurance company is making your doctor fill out paperwork in hopes that they can delay or refuse the care your doctor thinks is best for you.”

2. One electronic medical record. Right now there are about 500 of them too and none of them talk to each other so we are all “paperless”. Ha. It’s worse than ever, because we get 100 pages or 200 or 300 of printed out electronic medical record for every single new patient. I need two more big file cabinets for my “paperless” office. Hong Kong did it in 9 months. What, are we wimps? Make a decision.

3. Standardization of lab and xray and home health and physical therapy and nursing home and rehab and hospital order forms. Because every stupid lab form is different: not only arranged differently but also the lab panels are different, the requirements for what that lab wants to fill the order is different and the results are arranged differently on the page. Hello. Stupid, right? Any efficiency expert would laugh.

And that’s how we could really help doctors help patients.

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G is for gluttonous

Welcome to 7 sins and friends, where I am writing about a feeling for every letter of the alphabet…. including the 7 sins.

I spelled gluttonous “glutinous” first…. a quite different feeling. I had to look up the spelling of gluttonous.

  1. marked by or given to gluttony<a gluttonous appetite>

Now I need a definition of glutton:

a :  one given habitually to greedy and voracious eating and drinking
b :  one that has a great capacity for accepting or enduring something <a glutton for punishment>

When I started this topic for the A to Z challenge, I had to look up the 7 sins. I could only name four and I always want to include murder. I get the ten commandments a bit conflated with the 7 sins.

Gluttony is an interesting sin and I did not think of the second definition. I have only seen it used in “glutton for punishment”, but the way the definition is written, I wonder if Nelson Mandala could be seen as a glutton ….. his courage in enduring imprisonment for so long. That meaning would not be a sin, would it?

G

When my daughter was in grade school, her sitter’s family hosted an exchange student from Uzbekistan. He was a teenager, very thin, and he seemed appalled by the US. He showed us slides from home. They had electric power for an hour or two a day at most. The cooking facilities were out door stone ovens burning wood. I think that he considered us to be gluttons because not only did we demand more than one meal a day and snacks, but also we demanded different food at each meal and always look for something new! And we ate until we are obese and then obsess about losing weight!

I spent a year as an exchange student in Denmark in high school. I continued with the language in college and got a scholarship to translate a book one summer. The book is Livsens Ondskab, by Gustav Wied, written in 1899. It is fascinating and very dark and funny. It is about a small town, fictional, but this town has a “Glutton’s Club” where the richest men get together and have fabulous rich meals. The meal descriptions are glorious. But their goal is to eat as much as possible and more…..

I am in the Rotary and love it. The Rotary helps 9000 exchange students world wide: I think that going to another country, another place, and trying to understand and be understood is one of our biggest hopes for peace.

My daughter made the cake for my birthday last month!!! mmmmmmm

 

 

 
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Under the camillia

My mother had many of her copies of Louisa May Alcott’s books, including the odd moral fairy tales. One is Under the Lilacs. I loved slipping into that world that was quite different from my own, in so many small details.

Thursday I was coughing and had no voice. I cancelled clinic and lay on the couch. In the warmest part of the day I lay bundled in the sun, under the camillia.

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Fraud in medicine: prior authorization II

The insurance corporations and the culture of business fraud is destroying the United States economy and allopathic medicine.

I am a US physician who calls for prior authorizations myself, with the patient in the room, and bills the insurance company for the time “counseling and coordination of care” by the minute.

I called with patient X, to get authorization for a medicine, last week. We had already tried by me filling out on line forms, twice, and faxing paperwork to the insurance company. Now I was calling them. His insurance card has a separate number for “Rx”, that is, prescriptions. I call the number.

Call 1 takes me through a phone tree, puts me on hold and then hangs up on me.
Call 2 takes me through the same phone tree: enter my national provider identification number, my tax id number, the patient id number, etc. I reach a human. She asks for my number in case we are cut off. I give it to her. I also confirm my clinic address, national provider number, tax id, fax number, patient id number, date of birth, patient name. She will call back if we are cut off. We are cut off. No call back.
Call 3 takes me through the same phone tree. It hangs up on me before we reach a human.
Call 4 takes me…….we reach a human. He takes my number. He promises to call back if we are cut off. Repeat previous information. We are cut off.

No. Call. Back.

Ok. I call the insurance company main number and explain. Meanwhile I am documenting each call in my patient’s chart. The insurance company explains that the patient is in a Union and the Union has it’s own prescription program which has NOTHING TO DO WITH THE INSURANCE COMPANY. I insist that as the patient’s insurance company, they must help. They give me the number of the Union headquarters and put me on hold to transfer me. We wait five minutes. Then we hang up.

I call the Union. I reach a person. I explain that my patient needs prior authorization and we can’t reach the Rx company and we called the insurance company. The Union person kicks it upstairs and swears someone will call me. Tomorrow.

I apologize to my patient for the continued delay. I document in the chart: billing by time one hour face to face counseling and coordination of care making SIX PHONE CALLS TO TRY TO GET PRIOR AUTHORIZATION AND UNABLE TO. I express frustration in my note. I hope the company reviews the clinic note regarding the high bill, because I would be very happy to think that the insurance company might get upset at the Rx company for costing them money.

This is fraud. This costs United States citizens $82,000.00 per provider per year to have people sitting on the phone, on the computer, trying to get prior authorization approval from the insurance companies. The contract that I sign with an insurance corporation to be a “preferred provider” basically says that the insurance company can change their policy whenever they want. There are 500 plus insurance policies. Do you think you could keep up with every policy’s changing rules? I can’t. Nor can my patients. It is in the interest of the insurance corporation to make it difficult and incomprehensible.

I am told that Donald Trump knows how to run a business. I think he does, by US corporate standards, which means that the business is dishonest. I am not in the land of the free and the brave and the independent. I am in the land of corporate dishonesty and lies and I am angry.

I like my patients and I like medicine. But I hate United States business practice: rob from the poor and the sick to enrich the rich.

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practical medicine

This week I see a patient that I sent to a specialist that I don’t know well.

“How is he?” I like to get feedback on the specialists.

Q grimaces. “He knows his stuff. But…. he’s by the book. I complained about a side effect. He says it is not listed. But I go on line and there are lots of people complaining about that side effect.”

“Hmmm.” I say.

“He doesn’t really listen if it doesn’t fit…. if it’s not in the book.” Q brightens. “But I am going to call the nurse line for the drug and see what they say.”

“Cool.” I say. “Some doctors are very by the book. I’m into practical medicine: use it if it works. Don’t care if it’s witchcraft.”

Q giggles.

“What about the rash?” I say.

Q pulls up a pant leg. There is almost no rash. “He said it wasn’t related to the problem.”

We both look at Q’s leg. “Looks better to me.” I say. “Looks a lot better.”

“Yeah,” says Q. “It does. It looks nearly gone.” The rash was what initially triggered the testing that led to the diagnosis that led to the specialist.

“I use whatever I can figure out for people.”

Once I had an elderly woman with an intestinal bleed. She is transferred to Virginia Mason and goes through every possible test to localize the bleed. Upper endoscopy, lower endoscopy, swallow the camera, CT scan, probably pet scan and bone scan. Can’t find it. It is too slow a leak to use radioactive tagged red blood cells. She comes back.

I transfuse her every three weeks. This is not good. She will develop antibodies eventually.

She goes back to Virginia Mason. They do it all again. The surgeons discuss opening her up. “No.” they say. “Too frail at 88. She will die on the vent.” They send her back.

I am still transfusing her every three weeks. I am grumpy as hell.

Her daughter says, “I have a friend in Canada who knows a scientist. He is studying aloe vera. They said take aloe vera twice a day. What do you think?”

“Well I don’t have anything! Try it! We will test a chem panel in two weeks and watch the blood count!”

She takes aloe vera twice a day. Her blood count stabilizes. No more transfusion. Happy dance. Not absorbed or at least doesn’t bother her kidneys or liver tests….

After a year she says, “Can I try stopping it?”

“Sure,” I say. “We will check a blood count in 2 weeks.”

It drops. She goes back on aloe vera.

Practical medicine. If the book has nothing, try something else…..