Sunday, February 18, 2018

Overuse of Colonoscopy - Scoping out the Reasons

In our practice we have an open endoscopy system, as do most gastroenterologists. This means that other physicians – or patients themselves – can schedule a procedure with us without seeing us in advance for a consultation.  Of course, we are always pleased to see any of these patients for an office visit in advance, but many patients prefer the convenience of accomplishing the mission in one stop.  This is reasonable for patients who truly need our technical skill more than our medical advice.

Our office screens these procedure requests in advance to verify that no office visit is necessary.  While this process works very well, it is not infallible.  There have been times when a patient arrives to our office poised for a colonoscopy with accompanying medical issues more complex than we had expected.

No vetting procedure is failsafe.  Have you seen the TSA statistics when they are tested in identifying dangerous items hidden in luggage?  Even though our trained personnel vet the procedure candidates, no process can capture every issue.  Also, sometimes patients forget about a medical condition or risk factor or medication, even when questioned about them. 

In addition, there have been occasions when patients arrive prepared for an endoscopic intrusion into their alimentary canal, when the procedure may not be truly indicated.  Keep in mind that the timing of a medical test often depends upon medical judgement.  For example, capable gastroenterologists may have differing opinions on whether a colonoscopy for a particular patient makes sense.


Colonoscopy - It's Alimentary!

Recently, a patient whom I had never met arrived for me to do a colonoscopy.   He had enthusiastically swallowed the liquid dynamite which had the desired cleansing effect.  I presume he took a day off of work and had a driver with him.   My review of his records demonstrated that he was about 2 years too soon for this procedure.  The reason he scheduled the exam is because his prior gastroenterologist’s office sent him a computer-generated letter that he was due for a colonic violation.  In other words, the patient was following his doctor’s advice.  

I speculate that the reason that the computer issued a Notice to Appear was that the prior gastroenterologist experienced a ‘click malfunction’ and clicked Return in 3 Years by error, rather than have correctly requested a Return in 5 Year recall.  While this may sound egregious, ask your doctor how many screw ups he has committed on electronic medical record (EMR) systems.   Indeed, EMR has created a new niche for medical malpractice attorneys to sue physicians and hospitals.

So, I have a patient before me who endured a night of purging, who has missed work and has a driver with him.  But, he is 2 years early.  What should I do?

Sunday, February 11, 2018

Why Did CMS Contact My Office? Medicare Fraud?


In our society, there are absurdities that simply defy reason.  In the past week or so, I have read about an individual who was denied the ‘right’ to bring a peacock on board a plane for comfort.  Just this morning, I read of a women who was cruelly denied to fly with her comfort animal – a hamster.  Readers are invited, if they dare, to use their preferred search engine to discover the tragic denouement regarding this hapless hamster.


'Let me comfort you.' *


If a person needs a peacock, a snake, a pig, a kangaroo or a pterodactyl for airborne support and comfort, then perhaps flying is not for you.  The rest of us have some rights also.  Rent a car.
The medical world has its own exhibits in the Theater of the Absurd.  Here’s our latest performance.
Our medical practice received notice last week from The Centers for Medicare & Medicaid (CMS) that we owed the federal government money.  Apparently, according to federal brain trusts, we had billed a patient under Medicare when we were not entitled to do so.   I’ll let readers choose from the following explanations for the government’s accusation.
  • A random audit demonstrated that we had never seen the patient.
  • The patient was dead at the time we claimed we had treated him.
  • A whistleblower (love that term!) had contacted CMS regarding our fraudulent billing practices.
  • CMS routinely sends out letters like this knowing that some medical practices will simply pay on demand rather than take on the Mother of All Bureaucracies and risk an audit of their billings over the past century.
  • There was an unconscionable error in our electronic claims submission to CMS.   We used the abbreviation Ave. in the patient’s street address in direct violation of CMS policy that dictates that acceptable abbreviations for streets include Dr., Blvd., and Rd, but that Avenue must be spelled out.
Have you made your choice?  I’ll be you are incorrect.  Sure, you may have accumulated a decent measure of knowledge and wisdom in your life, but this is no match against the brainiac feds.  They asserted that we were wrongly paid for medical services because when we claimed to have seen the patient he was already stone cold dead. 

While actual facts support that the patient was quite alive on the encounter date, try explaining that to a federal bureaucrat who believes otherwise.  The patient did, in fact, pass away a couple of weeks ago, months after we saw him.   However, when his death certificate was prepared, the incorrect year of 2017 was inserted instead of the correct year.  The scientific term for this event is call a typographical error.  The government now believed that this patient entered the hereafter a year ago.  Therefore, all social security and Medicare payments made on his behalf last year must be returned to the government.  We should support such fiscal responsibility by our government knowing how wisely they spend our money.

Of course, this will all get straightened out by his poor family, who are still mourning his loss.  They will have fun with lots of phone calls, long wait times, maddening phone menus, letters, forms and maybe even an attorney.  The whole affair has stressed me out.  Where’s my hamster?




Sunday, February 4, 2018

Top CEOs Aim to Disrupt Health Care Market.

Since the infamous memo released this week by the chairman of the House Intelligence Committee has taken up so much oxygen, other newsworthy events were relegated to a lower priority by the media.  In my view, many of these second tier issues deserve Page 1 coverage, but our media in general has decided that potential or actual scandal must lead their coverage. 

Can anyone defend, for example, the prominent and repeated coverage that Stormy Daniels has received?   If CNN received a lurid videotape of Stormy and the president on the same day that North Korea declared that it wanted to denuclearize their country, which would be the lead story?  The editors would be agonizing!


Tell the truth, would your rather be reading about Stormy?*

A bombshell announcement in health care came this week when when 3 titanic corporations stated they aimed to reform health care coverage from within.  Amazon, JPMorgan Chase and Berkshire Hathaway will combine their resources, ingenuity and mammoth leverage to bend the cost and quality curves in opposite directions.  While this will undoubtedly be good news for their million or so employees, will it be good news for the rest of us?  Hard to say.

Amazon inspires a range of emotions in businesses and individuals across the nation.  Their economic triumph is iconic, but this success has had great costs for businesses and individuals across the country.  Have you seen many small hardware stores, book shops, music shops, clothing retailers or any of the small businesses that used to be dotted across the land?   If you want a closer glimpse of the culture of working at Amazon, I suggest that readers view the 2014 documentary Amazon Rising, or peruse a 2017 book called Nomadland, by Jessica Bruder, which chronicles what life is like inside Amazon’s walls.
Just today, I read about an Amazon patent that can track workers' location and even what they are doing with their hands, unwelcome technology for workers who have nasty habits.

I have no doubt that these companies can fashion a health care system that would correct many of the health care system’s deficiencies at large.  Here’s why.
  • They have unlimited cash
  • They are aiming to provide coverage to employed people, and do not need to address the uninsured or unemployed.
  • They have stratospheric expertise in finance and technology.
  • They can exert enormous leverage over insurance companies, hospitals and the pharmaceutical companies. 
  • If they can track where an employee’s hands are, imagine how they can track health care expenditures and outcomes and have incentives in place.
  • They are large and rich enough that they could self-insure their employees, which would whittle away administrative costs. 
What is less clear, is what the effects of this disruption would be to the health care system at large.   Would hospitals and insurance companies and drug companies who are excluded survive?  Would medical costs on the rest of us be raised in order to offset the Trio’s discounts?   Is their true intent, despite their denials, to become a profit center for medical care in the United States?  

I thank readers who have made it this far.  Those who didn’t likely clicked off in search of a morsel on Stormy.  I'm sure that Amazon is tracking them.

*Photo credit:  Glenn Francis
Attribution :  © Glenn Francis, www.PacificProDigital.com


Sunday, January 28, 2018

Patients Bill of Rights - Time for Version 2.0?

How often do we read or hear, “I have a right to …”   Everyone wants to have his rights respected.  Gun owners, prisoners, civil libertarians, union members, non-smokers, protesters and ordinary citizens all want our rights to be validated and respected.  What happens when the exercise of my rights encroaches on yours?  It is these questions that occupy much of our judges’ time and attention.  These are not easy calls to make.  The fact that so many of our Supreme Court decisions are decided by a 5-4 vote indicates that these issues are controversial, complex and vexing.

While we all pride ourselves here in America on our individual rights, these may be at the expense of our community’s rights.   I don’t envy societies such as China or Russia where the state’s rights are paramount.  But, there is no consensus, even here, as to where to draw the line between protecting an individual and society at large.  Consider how vigorous the debate has been on the tension between protecting individual civil liberties and national security. 

'My Rights Outweigh Your Rights'

If it were true that reading our e-mails without a warrant would prevent a full stadium from being blown up, would we support this?  What if our kids were in this stadium then?

The conflict between an individual’s and the community’s rights is active in the medical arena.  Consider a few examples where one patient’s benefit is at other patients’ expense.
  • Physicians give out free samples of medication to patients, who cherish this giveaway.  The cost of this largesse must be borne by the rest of us who must pay higher drug costs.  Nothing is really free, is it?.
  • A man has a right to ride a motorcycle experiencing the thrill of the open road with the wind blowing through his helmetless hair.   If a tragedy occurs, who picks up the bill?
  • A physician prescribes a biologic treatment for Crohn’s disease.  It costs $2,500 each month and is to be administered forever.  If the drug delivers as promised, which is usually not the case, one individual will benefit.   Should the physician consider how many folks could have been helped if these funds were devoted to influenza vaccines, mammograms or smoking cessation?
  • Salvage chemotherapy is given to a patient who is unlikely to benefit.  The aggregate costs of these kinds of treatments could pay for family health centers in underserved neighborhoods. 
The ethos in the medical profession has been that a physician is solely concerned with the patient in the office, and not the population.  This is how I practice.  But, the argument that physicians should be concerned with the greater good and a fair allocation of finite medical resources is potent and reasonable.  For the time being, my patients understand that my advice is directed to protect only their interests.

When you’re in your doctor’s office, do you want him to be thinking about you or everyone else?



Sunday, January 21, 2018

Amazon's New Headquarters Sweepstakes - A Plan to Win

Northeast Ohio, where I reside, won the lottery and was selected for two Amazon fulfillment centers which will employ thousands.  Let’s leave aside whether those jobs will be sustained, or replaced by robots, drones or some yet to be discovered job-killing advancement.  Of course, our win here was not quite like cashing in on a lottery ticket.  Lottery winners purchase a very cheap ticket and then cash in with a huge return on investment.  That’s why folks buy them; they pursue the dream of winning a huge windfall.  Would lotteries be as popular as they are if ticket prices were ten times as expensive?  I’ll answer that.  No.  

It's Time for this Foreigner to Step Down

The grand prize of the Amazon Sweepstakes is the site for their 2nd HQ.

Applying to become an Amazon HQ center is no cheap lottery ticket.  Cities across the country have been tripping over each other as they raced to genuflect in front of Emperor Amazon promising him zillions of dollars of tax abatements and infrastructure development over many years.   The contest started with 238 cities participating in a corporate version of the Hunger Games.  This week we learned that only 20 contestants remain.  Cleveland, my city, was jilted.  Our local government has refused to share their spurned offer with us – their bosses – presumably from embarrassment of what they were willing to give away.  City residents who are starving for social services, pot hole repair, crime prevention, educational reform and neighborhood renewal may have balked at giving away zillions of dollars to a wealthy, corporate behemoth. 

Cities across the nation and beyond shamefully fawned for attention.  Tucson sent a huge Saguaro cactus to Amazon’s Seattle HQ.  The mayor of Kansas City wrote 1000 5-star Amazon reviews.  Stonecrest, a Georgian town, offered to rename itself Amazon.

New York City, one of my favorite locales on earth, is still in the running.  Here’s what I would suggest to Mayor de Blasio to separate his city from his competitors.   Tear down the Statue of Liberty, which the Trump Administration may be planning anyway.  This foreign female colossus doesn’t comport with his America First vision.  And, it fits in well with today’s mission of monument and statue revision.  Then, rename Liberty Island to the Isle of Bezos and lease it to Amazon for a buck a year.  If de Blasio reads this post, his initial reaction will be ‘why didn’t I think of that?’

In the perfect world that we don’t live in, all cities, states and nations would agree to offer no inducements for corporations to choose them for new plants and factories.  Amazon pulled in about $44 billion in the 3rd quarter of 2017.  Are they such a fledgling company that can’t afford to set up shop on their own?


Sunday, January 14, 2018

Is Trump Mentally Unfit for Office? The Goldwater Rule Violated

Many of my readers do not know who Barry Goldwater was, let alone of the Goldwater rule established by the American Psychiatric Association in 1973.  The rule advises against psychiatrists commenting on the mental health of public figures they have not examined.   Obviously, a psychiatrist or any physician who has treated a public figure is prohibited to offer any public comment unless he has been authorized by the patient to do so.  On Tuesday, Dr. Ronny Jackson, the president’s personal physician, will discuss the results of the president’s recent medical examination with the press.  The boundaries of what Dr. Jackson can report will have been set in advance by the president.  


Senator Barry Goldwater

In the past month, the Goldwater Rule has appeared in our newspapers and all over cable news and commentary programs.  Goldwater has probably been a 'trending topic'.  This is in response to suggestions that the president may be mentally unfit for office.  I have heard physicians who have never examined the president making this claim.  And, seemingly beyond the reach of the Goldwater Rule, I have heard pundits and politicians – presumably with no medical training – suggesting or asserting that the president is non compos mentis. 

It is beyond obvious that many of these ‘mental health experts’ are simply using a new tool to attack a president whom they oppose politically or despise personally.  I oppose this practice both as a physician and as a citizen.  We cannot normalize average citizens or medical professionals on the sidelines offering psychiatric assessments of folks they don’t really know.  If this objectionable process were to become accepted, then it would be ultimately applied throughout society.  There would be an inexorable mission creep that would make all of us potential targets of these inquisitions.   If a boss at work, a teacher, an athlete or a customer started arguing, might this individual be labeled by onlookers as having a condition?

This practice disrespects those among us who truly have mental illnesses.  It furthers the societal stigma associated with these diseases that we have all worked hard to reverse.
 
There may be instances when it seems inescapable that a person is psychiatrically afflicted.  For example, folks who claim they are Napoleon, came from another planet or wrap their heads in tin foil likely have some psychiatric dysfunction.  But we don’t make policy based on rare anecdotes.

Mental illness is serious business.  Mental health professionals train for years and throughout their careers to gain and maintain necessary skills for diagnosing and treating these illnesses.  Leave it to the professionals. 

Political adversaries, columnists, cable news jockeys and average citizens have enough fodder to criticize the president without shooting arrows from psychiatric quivers.  

The wisdom of keeping silent is aged and timeless.

Those who guard their mouths and their tongues keep themselves from calamaity.
Proverbs 21:23.

   

Sunday, January 7, 2018

Al Franken Fed to the Wolves

Al Franken is out.  He volunteered to be thrown off a cliff.  Now, this gives me one less liberal, or ‘progressive’, that will give this gastroenterologist heartburn.  However, as a man who does his best to use honest weights and measures, I find his ouster to be deeply troubling.  This was not the senate’s finest hour.

What caused the stampede of his fellow Democrats last month to demand his ouster?  Yes, there were new allegations, but they didn’t seem to be qualitatively different from the prior ones. What pushed a largely silent Democratic caucus into a chorus of indignation?  Was this fair?


'Mmmm, that was tasty!'


If the charges against him – which he largely denies – are true, then he was clearly a sophomoric boor, who behaved improperly during his prior career as an irreverent comedian.  While his prior actions were offensive and wrong, I don’t think he merits being swept into the expanding cesspool of sexual harassers – men who preyed upon women using their positions of power to commit repugnant actions.  Such men deserve appropriate punishment and public opprobrium.

While I fully support the current movement to achieve a true reckoning, I am concerned about the lack of uniform standards and fairness.   With Franken, for example, there was a rush to judgment as a mob of Democrats tripped over each other as they raced for the microphones to denounce him. 

I am sure that when I hung out with the guys in college that I was present and participated in conversations that if publicized now would not show me to be the enlightened individual that I claim to be today. Am I unfit to serve as physician today?  Dredging up gutter talk and boorish behavior in a past life shouldn’t disqualify a person from his job or his place in society. 

I worry that Franken’s political demise has lowered the standard for tolerable behavior to an extent that legislators’ positions and everyone’s jobs are vulnerable for minor offenses that are alleged to have occurred either on the job or previously.  Could a senator now be brought down by a few lurid accusations that may be unproven or might even originate with the political opposition?   

For those who somehow don’t know where the boundaries of decency lie, we need uniform standards in place.  All offenses are not equal and should not be treated as such.  While we properly target sexual harassment for extinction, we should remain true to our cherished principles of a presumption of innocence and due process.  If you were charged with committing disgraceful acts, and you were innocent, wouldn’t you want a fair opportunity to defend yourself? 


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