fraud in medicine: navigating your failing healthcare system

Navigating health care in the United States is challenging and challenged. Currently the 800+ insurance companies, each with multiple “products”, the 500+ electronic medical records that don’t talk to each other, the increasing volume of information and the decreasing number of physicians make getting care very challenging. Here are some steps to help you navigate.

1. Get your records and keep copies.

Get the disc of any radiology studies: MRI, xray, CT scan, echocardiogram. Keep them. Hand carry to your visit with the specialist. Yes, I know your doctor said they’d be sent and I know the specialist’s office said they’d get them, but I have two friends so far this week in two days who traveled 2 hours or more to a specialist who DID NOT HAVE THE STUDIES. Do NOT give your only copy to the specialist. Demand two. Either get them on different days or just pay for the second disc.

A clinic closed in our area a year ago. It was in three counties, 3400+ patients. The physician owner was not paying the bills, including the electronic medical record. We couldn’t get records, the emr company wouldn’t release them. Gone. Thirteen people called to be new patients with me the day the clinic closed and we took five new patients a week for 6 months. You need a copy of your records.

2. In the specialist’s office or ER, do NOT give your records to the receptionist.

Hand them to the physician only. Hand them copies, you keep copies. “When will you be getting back to me?” That is, if it’s two hundred pages of complicated records, when does the physician think they can read (some) of them? The real truth is that WE CANNOT READ ALL OF THE OLD RECORDS. We don’t have time. We have to sleep. We read what we can and there are MOUNTAINS of old records that we haven’t read. I have files of old records and I pull them for visits so we can look up specific things. I have asked patients to go through and find specific things: find me the MRI report of your back.

Because what is really happening in many offices is that the information is being scanned but not read. Truly. I think this is dangerous. I had a patient who had five specialists and me. I was sending updates to his rheumatologist, with letters, asking questions and not getting a word back. Finally the patient went for the two hour trip to see the specialist, who called me: “I had not read any of your notes! I didn’t know what was happening!” I saw RED. Oh, so my letters and the ER notes and the other specialist notes that I faxed to you MYSELF about a very sick, very complicated medicine WERE NOT READ? I wanted to scream at her, but I didn’t. I just said, “We really need your help and I have been trying to keep you informed.” Through gritted teeth. Then later I kick and hit my heavy bag. And at that point the specialist was finally helpful. It still makes me furious just to think about it, so I have to work on forgiveness once again.

In my office, if a physician (me) has not read it, it has not been scanned. There will NOT be surprises in the scanned chart. The unread old records are filed alphabetically and when I have a time turner, I will have time to read them all, right? And then in a visit, the person asks if I got their mammogram report. I have to LOOK, because I sign off on about a billion different pieces of paper a day and I really don’t remember the names of all the people who had normal mammograms. I don’t try to remember that: I know who has an abnormal one, because I am worrying about them.

3. Make a record trail that you can quote.

When you call the physicians office, get the name of each person you speak to. Write it down. Have them spell it. Ask how soon you will be called back. Ask what you should do if you do not get a call back. (That being said, every physician has to prioritize the calls. It’s sickest first, not first come first served. If your call really is an emergency, then you should be in an ambulance, not calling your doctor.)Our local mental health was in such disarray, understaffed, underfunded, that my instructions to non-suicidal patients were: “Call every day, be polite, and call until they make you an appointment. Do not wait for the call back. Call daily, they just don’t have enough staff.”

If you fax them the missing notes, keep a copy of the fax proof. Call after your fax the missing records. Ask if they received them and then write down the name of the person you spoke to, date and time. I put a computer message in the chart for 99% of the phone calls I have with patients. I may miss 1% because I get interrupted or a really sick patient arrives or another phone call or whatever. Ask when the physician or his assistant will be calling you back about the records or better yet, make an appointment: “He did not have the records, so I would like an appointment as soon as possible now that he has them.” This forces your physician to look at the old records, because the patient is coming in. I do not read old records before a new patient shows up. I used to, but then people no show for a one hour new patient visit and I feel used, abused and grumpy. So I don’t touch the old records until you show up. After two one hour new patient no shows we tell the person they need to find another physician. Two strikes on the new patient visit and they are out.

4. Hospital.

If a person is really really sick, family or friends should be there. Ask questions. Who is each person who comes in the room? Do they have the clinic notes? Don’t assume they do, I am not on our hospital’s EMR because it costs 2 million dollars. The inpatient hospitalist doctors almost never call for my notes. I fax my notes anyhow and call them, but the information gap is BIG ENOUGH TO DRIVE THE MOON THROUGH. Really. I am sorry to burst the electronic medical record bubble, but we have 500ish different EMRs in the US right now and they do not talk to each other, so every patient arrives accompanied by 2 years of paper records (or more), 200 pages or more. I joke that they need a bigger doctor because the paper is too heavy for my 130 pounds. And many many times, the hospital medicine list is wrong. It is old. It’s out of date. The person is sick as hell in the emergency room and they don’t remember that their lisinopril dose was changed three weeks ago. One person in the room with the sick person and keep a notebook and write down what the physicians and nurses say, time, date. Then if they start contradicting each other, ASK.

5. In clinic

Give your doctor the whole list right away: my foot hurts, my chest is really bad when I try to run up the stairs, there’s this thing on my arm and is my cholesterol too high? Don’t discuss one thing in detail and then bring up the next. I have long visits, but I can’t do justice to that list in one visit and I have to prioritize. This requires negotiation: the chest pain has my attention. You may be focused on your foot, but the number one killer is heart, so your doctor will worry about your heart first.

If the doctor asks you to bring in all your pills, bring them all in. There are three different types of metoprolol and five strengths of each. Do you know the type and strength of every drug? I want to see your vitamin bottles because vitamin B1 can cause neuropathy from too high doses and yes, they can sell high doses. I want to see the supplements: why are you taking bovine thymus/testicle pills? By the way, if the doctor actually looks at the supplements, keep that doctor. Most don’t.

6. Be careful out there. Good luck.

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.