SOLVING THE PROBLEM

Obviously, solving our healthcare woes is way beyond my pay grade; however, the exercise is mentally stimulating.  If the goal is providing healthcare for all, no matter how I redesign the healthcare system, all solutions seem to lead to socialism, an outcome that cannot be tolerated.

If you accept the premise that healthcare will be meted out based on the individual’s ability to pay for it, then other options exist.  If a minimal standard for access and care is established and provided by government clinics, then there is room for a private, pay for service, system to coexist.  Certainly, the inequality of the two systems will cause a public outcry and be advantageous to the haves, increasing the rift between the haves and the have nots.

No matter how you look at it, either system will require the elimination of third parties who siphon healthcare dollars off the top, generating massive corporate profits and sending healthcare costs soaring into the stratosphere.  As I have previously discussed, during the early years of my practice, healthcare costs were far less.  A school physical was $5. Today, an office spends more than $5 on EMR input, billing the insurer, the patient, and malpractice coverage.

The difference between the early years and today are many.  One of the major differences is who paid for the visit and who the contract was between.  In the early days, the patient was responsible for paying the bill at the time of service as the service was between the patient and the physician.  The patient then sent the receipt to his insurer who addressed the bill according to the contract the patient had with the insurance company.  The physician and insurance company were not contracted for the patient’s service. Each patient contracted for different deductibles directly with each other and the physician charged reasonable fees for his/her services for the area he/she practiced in.  The patient fought it out with the insurance company if the full cost of the service wasn’t reimbursed to the patient.  

Today the physician has the contract with the insurance company.  The insurance tells the physician how much it will pay for a service.  That doesn’t mean they are paying what it is worth or what it costs to deliver that service.  It just means that is what the insurance can get away with paying in this day of discounted fee for service medical care.  Generally, it is less than what it costs the physician to provide the service.  In addition, most policies now have very high deductibles that put more and more of the burden on the patient as out-of-pocket costs until that catastrophic limit is reached.  Thus, many office visits are effectively self-pay and this causes people to put off going to the doctor, sometimes with bad consequences. Unfortunately, the bottom line is that we are getting less coverage with far higher premiums.  You are paying more, insurance companies are paying physicians less, and the insurance executives come out smelling like a rose.

Can you fathom how expensive auto insurance would be if it covered every part on your car?  Imagine you need windshield wipers, brakes, a new transmission and tires.  You tell the auto shop, “just send the bill to Blue Cross.  They cover everything for the life of the car.”  That level of coverage would cost thousands of dollars a year.  On top of the owner’s cost of insurance, the mechanic would have to raise his fees to cover the expense of dealing with the insurer.  Rates would skyrocket.

So, maybe the answer is a two-tier system: one for the haves and one for the have nots. One government run one and one based on “major medical” insurance with, as in the old days, the patient contracting with the insurance company and directly paying the doc.  By eliminating the doc/insurance company contract, office overhead would dramatically fall and savings could be passed on to the patient. 

We accept the inequality that exists between the haves and the have nots in every other aspect of life.  A roof over your head and sustenance should be just as much a human right as healthcare; yet we accept the inequalities that exist in housing and living expenses.

Of interest is my experience with Concierge Medicine (contract between doc and patient).  Many of my Concierge patients were in the have not segment of the overall population.  They put medical care in the same category as food and scraped together enough money to pay for it. Not one patient ever expressed a regret. 

It appears that either we accept the inherent inequality of a two-tier system or accept socialism.  Neither sounds like a good choice.  What would you suggest?

Here’s your music and a joke.

If I had a dollar for every time socialism was successful, I’d have zero dollars.

Which is funny because if it did work, I’d also have zero dollars.

HEALTHCARE 4.0

The easy work is done.  Over the last 4 articles, I’ve listed the major players in our healthcare system and reviewed some of the obvious faults with each player.  Finding fault is the easy part.  The hard part is finding solutions that correct the faults found in the system.

I’ve clearly stated that the insurance industry, as we know it today, has to go.  They skim massive amounts of healthcare dollars right to the top.  At the same time, they demand extensive and extremely costly data input, eating up more healthcare dollars at the physician, lab and hospital levels.  In the end, the insurance industry flourishes at everyone’s expense.

I’ve also stated that the EMR (electronic medical record), which serves as a glorified billing agency, has to be resurrected and utilized for its original purpose: to improve medical care by actually keeping a pertinent record of the individual’s care and making that record available to all treating entities.  We need one standardized EMR design based on scientific research, utilizing AI (artificial intelligence) to monitor care and suggest possible avenues to improve that care.

I hate to admit it but, ultimately, I THINK THE SOLUTION TO OUR HEALTHCARE PROBLEMS IS UNIVERSAL HEALTHCARE (UH).  While UH is the mostly likely solution, it is full of risk.  First of all, who runs it and how is it funded?

The politicians on the left, want to build and run UH.  Unfortunately, allowing our government to run and fund UH would let the biggest serpent of all loose in the garden.  Congress is completely inept when it comes to handling money!  Just look at what’s going on today!  We are looking at a possible governmental shutdown again.  Congressmen and senators spend our money as they see fit and take no responsibility when they screw up.  Their answer to “I lost your money” is to raise taxes and do it again.  

Every year I was in practice, Medicare created new, costly regulations and reduced the amount paid for services.  Every year, in December, budget talks stalled and payments for Medicare patients were threatened or halted.  Every year, physicians nationwide are threatened with Medicare audits looking for theft and abuse.  If UH is going to have a chance, the government can’t possibly run it.

So, if the government can’t run it, who can? And how do you fund it?  While it may sound ridiculous, maybe the Bezos, the founder and CEO of Amazon should run it.  Running UH as a not-for-profit business may be the answer, and Amazon certainly appears to excel at the business of providing the public with what it wants.

Imagine a system where healthcare providers were paid a reasonable yearly salary commensurate with their training and with merit increases based on the quality of care they delivered.  Imagine a world where every medical procedure/medication/test had a known fixed price.  UH would run its own pharmacies and hospitals.  Imagine a world where care facilities were all built on the same, efficient platform designed to maximize care and minimize expense.  Yes, the business world is good at optimizing efficiencies to generate income.  In our world, it would optimize efficiencies to generate wellness and cover its overhead.

So, who pays for it?  I would propose that the government funds the system through a fixed tax similar to the social security tax paid today and that the government be banned from using the proceeds for any purpose other than funding UH.  In addition, a reasonable copay would be charged at every instance when a patient accesses care. Further, a “sin tax” would be levied against those individuals who persisted in doing unhealthy acts despite adequate counseling and warnings.  

Who pays for the unemployed and impoverished individuals needing healthcare?  Initially, the government would cover their needs.  Ultimately, they would be hired and trained by the UH, serving in a multitude of roles.  Their new job would not only provide them with an income, but medical care as well.

UH would not be a panacea.  It would have its own set of problems.  We’ll discuss them at a later date.

Here’s your music.  The joke of the day is the proposal above.  It will never happen; and, if it does, Congress will turn it into one more graft riddled, poorly managed governmental institution.

ELECTRONIC MEDICAL RECORD

I’ve discussed the first three players in the current medical system in the last three days: patient, physician and Pharma. The fourth player is, by far, the most virulent of all the players.  Despite the fact that player number four is not even human, the almighty electronic medical record, EMR, has taken over the control of almost every aspect of the healthcare industry. 

The EMR has grown and propagated to the extent that all players in the medical game have to bow to its lust for data and control.  Much like the insurance companies slithered into our offices and hospitals, so did the serpent called EMR.

The EMR promised to improve care by making medical records more accessible, offices more efficient, billing more standardized, along with dozens of other never realized benefits.  To the best of my knowledge, there has never been a study that showed that the EMR improved any outcome or care. 

What the EMR has done is enslave your doctor, his/her staff and you.  As you know, I’ve been seeing a lot of physicians.  Before I can see any physician, I have to go online and fill in the blanks on countless forms.  I’ve filled out the same forms three times over as, despite earlier promises, EMRs don’t talk to each other. 

Physicians and their staffs spend a large part of every patient visit filling in computer templates.  Template medicine tends to train those using it to think the way the template would like you to think.  Your doctor should have an open mind, ready to explore all aspects of your health.  Instead, he/she may well be closed minded, concentrating on asking the questions needed to answer the specific questions the computer requires him/her to answer.

So, how did the EMR become so powerful?  It became powerful by wrapping itself around the financial heart of the medical complex: billing.  WHEN THE EMR BECAME RESPONSIBLE FOR BILLING AND RECEIVING MONEY DUE FOR SERVICES RENDERED, IT SPELLED THE END OF THE PRACTICE OF MEDICINE AS I KNEW IT WHEN I FIRST OPENED MY OFFICE.

It was ingenious.  It was as if my free will was kidnapped and held for ransom.  Check 25 items on your practice’s EMR and you’ll get paid $37.50.  Check 30 items and get paid $60.  All of a sudden, your primary role as a physician has shifted from caring for your patient to checking boxes. The same goes for each of your staff members.  It’s even worse in the hospital.  The last newborn I attended to took 40 minutes of care in the room with the parents and their child and 60 minutes on the computer clicking all the boxes the hospital required, as well as those the insurer required.

Let me quickly mention the fifth party involved in your medical care.  The number 5 bucket holds everyone else.  The primary players in group five are the administrators.  Their job is to turn a profit, even when they work for a not-for-profit organization. I’ll never understand how not-for-profit hospital chains get away with generating huge profits.

Back to our task at hand, redesigning our healthcare system.  Just as I’ve told you that the insurers must go, the EMR must stay.  However, the EMR needs to be tamed and used to improve patient care, not to bill for it.

So, we need to eliminate insurance companies and redirect the EMR.  How do we do that?  I’m open to all suggestions. I don’t really believe that our system is fixable.  I don’t believe a better system can be designed.  Tomorrow, I’ll explore universal healthcare, a single payer system.

Here’s your music for the day and a joke.

What’s the difference between a piano and a fish? You can tune a piano, but you can’t tuna fish.

HEALTHCARE THREE

There are four major players and many minor ones in the healthcare game.  I’ve touched on two.  Today, I’d like to focus on Pharma and I will group the major manufacturers of modern day pharmaceuticals with the Walgreens/CVS of the world.

In the beginning, there was Tom, the local pharmacist.  He was part of your family and my teammate.  I wrote the prescription and he filled it or made it.  He then sold it to you at a reasonable cost.  Tom was in charge and set the price.  If you couldn’t afford it, he helped you out. 

Tom really was part of the team.  If you weren’t filling your meds as you should, Tom called me.  If you were in trouble, Tom called me.  “Doc, I’m worried about Bessie.  She’s looking poorly and not keeping up with her meds.”  His input was very valuable. 

Then came Vickie, a cross between a corporate pharmacist and your family pharmacist.  Vickie got to know her patients/customers and took an interest in their health, much like Tom.  Remember yesterday’s serpent?  Well, he slithered into the pharmacy the way he found his way into my office.  He offered to pay for your medications.  Since you were no longer personally responsible for the full cost of your meds, you spent unwisely.  “Doc, the brand name only costs $5 more than the generic; I want the branded product.”  Even though the generic, which cost 1/5 as much, was just as good, you got the branded.  The insurance company paid the extra and increased your rates to improve their profits.  Cost of medications skyrocketed. Cost of insurance skyrocketed. 

Once the insurers were firmly in control of the filling of prescribed medications, they crushed the small, private, family pharmacy paving the way for a Walgreens/CVS on every street corner.

In the new world, I still wrote the prescription; but the corporate pharmacy could no longer tell you how much it cost nor fill it until the serpent/insurer was consulted.  Transparent pricing went out the window and prices rose sharply.  Complicating matters, big pharma (the manufacturer) also increased the wholesale cost of its products which increased the retail cost and led to today’s overwhelming cost of care.

When I was in Italy, my friend had a problem with her eye.  I told her the eyedrop she need was expensive (around $80 in the States) and we went to the pharmacy.  Lucky for us, the pharmacist understood English and could sell us the eyedrops without a prescription.  The cost of the identical product you could buy in the US, seven dollars!  How do you account for the $73 dollar difference?  Well, you have to feed the serpent, your pharmacy benefits manager.  Then you have to feed the serpent’s cousin, the malpractice attorney who sues everyone he can every time he can.  Then you have to feed the serpent’s other cousin, the attorney hired to defend against the malpractice attorney.

If the above sounds twisted, it is.  If all of the legal intrigue was not bad enough, you have to understand that compounding the problem is a governmental obstacle course that has to be traversed by all players.  Each obstacle costs money and the costs are then shouldered by the patient/consumer.

Again, we find that, to build a successful, cost efficient healthcare system, one thing we have to get rid of are the serpents and their cousins.  Tomorrow, I’ll comment on the effects of the tort system in the US.

Do you have any suggestions on how to remake the healthcare system in the US?  Please feel free to share your thoughts.   

Here is your music and joke.

My teacher asked me, “What is the meaning of Apocalypse“..

I didn’t know what it meant, and she got really angry. I mean come one, it’s not like it’s the end of the world.

HEALTHCARE PART 2

Yesterday’s article appeared to lay the blame for our malfunctioning healthcare system squarely on the shoulders of the patient. While a portion of the blame belongs to the patient, the bulk of the problem lies elsewhere.  Today, we’ll look at the physician’s role.

In 1984, I opened my office. I was a self-employed physician, as were most physicians.  I employed 2 nurses, an x-ray tech/receptionist, and my wife was my billing department/manager.  I didn’t know it at the time, but I was living in the golden age of medicine, 

The patient/physician relationship was fairly simple.  You registered on paper, no computer.  I took a history and examined you, then scribbled my findings on paper.  I ordered whichever test you needed, performing almost everything in the office.  I explained what I had found and wanted to do, then I gave you a paper bill and sent you to the front desk to be discharged. Most of you actually paid the bill and then received a receipt that YOU could send to YOUR insurance company if you had insurance.

Because our relationship was limited to you and me, I could tell you exactly what everything was going to cost in advance.  Believe it or not, a school physical was $5.00. An office visit cost between $15-20.  A lab culture was around $8.00.  X-rays were expensive at $25.00.  Life was great.  In retrospect, we lived in the Garden of Eden. I had the tools needed to care for you and your family without outside interference.  Then it went to shit!

You, the patient, and I, the physician, share the blame for what came next. There was a serpent in the garden and we listened to it!  Even though the cost of your medical was the cheapest you would ever see, you had other expenses and did not want to pay the bill at the time of service. The great serpent, the insurance company, promised that they would take on your burden and negotiate a better deal for you.  All you had to do is pay them quarterly and turn over all of your healthcare rights to them.  You bought in!

Your physician felt cornered and defenseless.  One day, two suits came in to my office with a business proposition.  They sat at my desk and explained to me that they were going to take all of my patients away if I did not sign on the dotted line.  They explained that their company was the largest healthcare insurance company in the US and that they were actively signing up my patients as we spoke. They would pay a discounted fee schedule which they would create and I would bill them, not the patient. I threw them out.  They kept their promise, and I came crawling back.

Eden vanished and here we are today, living under the rule of the serpent. In the end, I still had 2 nurses but I had 5 people in my billing staff.  Not only did we have to bill the insurance company, but we had to “code” every charge and diagnosis and then be prepared to fight for our rightful money.  No longer was I paid for my services.  I was reimbursed by the serpent at a time and rate dictated by that very serpent.

You screwed up by inviting him into our garden. I screwed up by allowing him to stay. Whereas, in the beginning, I knew what everything I did for you cost and could price accordingly; in the end, I couldn’t tell you what anything cost.  A strep test might be reimbursed at $7 on one fee schedule or might be reimbursed at $20 depending on which version of your insurance you bought. 

Oh yes, while the serpent initially promised to take on your financial obligations, as it grew bigger and fatter, it turned on you, demanding more money upfront and later in co-pays. Prices skyrocketed. To get paid a dollar, I had to charge five.  In the end, the cash price was unaffordable, making it a necessity that you have insurance, further strengthening the serpent.

And in the end, the serpent took away my title of DOCTOR, a once trusted member of your family, and branded me PROVIDER, along with a host of newly minted provider extenders (nurse practitioners and physician assistants).

At this point, I can promise you that, in order to revamp our healthcare system, the serpent must go.  As long as the insurance industry remains in control of each healthcare dollar, they will suck us dry.  (The CEO of Anthem is paid $14,000,000 plus benefits a year.  Where does that money come from? Physicians and patients!)

Tomorrow, we’ll go further into the worm hole.

Here’s your music and a joke.

Life insurance agent to would-be client: “Don’t let me frighten you into a hasty decision. Sleep on it tonight. If you wake in the morning, give me a call then and let me know.”

This drunk wanders into a hotel lounge where an insurance convention just happens to be taking place. The drunk is hell-bent on causing trouble and he yells, “I think all insurance agents are crooks, and if anyone doesn’t like it, come up and do something about it.”

Straight away, this guy runs up to him and says angrily, “Hey! You take that back right now!”

The drunk sneers and asks, “Why, are you an agent?”

The man replies, “No, I’m a crook.”

HEALTHCARE

First, let me admit that I don’t believe there is anyway humanly possible to change and improve our healthcare system.  Every component, and there are many, is broken.  Fix one and you are bound to break another.  That being said, if I was tasked with improving our healthcare complex, the very first thing I would do is formulate a list of the key players and the role each plays within the system.

I’d start with the patient’s role.  As long as we are free to do as we wish, whichever overall solution you choose for the provision of healthcare is destined to fail.  Think about it.  I have a melanoma on my chest.  It’s been biopsied and I’ve seen a surgeon.  Monday, I’m seeing an oncologist/surgeon.  I’ll have surgery and that will probably be it.  If I’m unlucky, I’ll need chemo.  The treatment of my melanoma is expensive.

Thirty years ago, my dermatology professor said, “Stewart, it’s not if you are going to have skin cancer, it’s when are you going to have skin cancer.  You need to avoid the sun and wear sunscreens!”  I love the sun.  It’s my God given right to get tanned.  I’ve been soaking up the sun since I was born.  I created the cancer and now I expect someone else will pay to fix it.

The same goes for smokers, drinkers, drug users, anti-vaxers, etc.  People have a right to abuse their bodies and then expect that someone else will cover the expense of fixing it.  Not only do they expect someone else will fix them; but, since they aren’t paying for it, they expect that “everything humanly possible” will be done to keep them alive.

“Everything humanly possible” is what the family of the chronic lunger with cancer who is in the ICU on a ventilator demands of me and the ICU staff.  It matters not that the patient smoked himself to death.  It doesn’t matter that he will live the rest of his life on a ventilator.  The family wants Dad kept alive at any expense!  

Now, let’s look at the same patient where somebody else is not paying for his care.  “Doc, we want everything humanly possible done to keep Dad alive.”  The doc responds, “We’ll do as you ask but it will cost a minimum of $25,000 a day.  How would you like to pay for that?”  Been there, done that.  The family’s response will be, “You know, Dad’s lived a good life, and he wouldn’t want to be in a nursing home.  Bring in Hospice.”

So, how do you build a system that provides and pays for the care of people who hurt themselves knowingly?  Do you take away their right to sunbathe, smoke, do drugs?  Do you strap them to the table and immunize them?  Of course, not!

What about a system that rewards healthy living and penalizes those who do harmful activities?  Unfortunately, that won’t work either.  Mr. C smokes and drinks heavily.  He’s constantly ill and can’t pay his bills.  We’ve done “everything humanly possible” to help him and he owes us $2,500 dollars for care delivered over many visits for several years.  My office is ready to send him to collection.  I bump into him in a local restaurant.  He’s sitting at the bar drinking. “Doc, I can’t believe you’re sending me to collection.  You know I can’t afford to pay you.  You’re an SOB.”  I actually answered him.  “Mr. C, I wouldn’t be able to afford to pay my bills if I smoked 3 packs of cigarettes a day and drank 5 cocktails a day, every day, either.  By cutting you a break, I’ve been subsidizing your smoking and drinking!  That stops now.” How do you penalize Mr. C?  Do you deny him access to healthcare?  Obviously, you can’t!  So, you have to provide care to Mr. C and he will not pay any penalty you impose.

No matter what healthcare system you build, patients who are free to do as they choose will destroy it.  How would you handle the patients who, as a consequence of their lifestyle, consume large amounts of healthcare dollars?

Tomorrow, we’ll look at the physician’s role in this mess.

APOLOGY

As a writer, it’s often difficult to put down in words exactly what your brain wants to say in such a way that you cannot be misunderstood.  Sometimes, what you say is not what you meant.  Sometimes, what you say is what you meant but your reader interprets what you say in a way you did not anticipate.  Sometimes, you mean to provoke thought and action, and you fail.  Sometimes, you provoke thoughts and action you did not mean to provoke.

Writing is tricky.  Yesterday’s article upset one of my readers.  In retrospect, she was right.  The article appears to disrespect and demean some members of the service industry.  I assure you; I meant no disrespect.  I’ve taken down the article and want to apologize to anyone who felt slighted.

In 1976 I worked for Carol’s Hamburger, a forerunner of McDonalds.  I made $1.40 an hour and came home at the end of an 8-hour shift covered in sweat and oil from the fryers.  During college I bussed, waited tables and short order cooked at Barnaby’s.  I understand, firsthand, the plight of those individuals who work in the service industry.

As a waiter, I was at the mercy of the kitchen staff.  If they messed up, I caught flax.  At the time, it seemed as if I caught flax for anything that went wrong, whether it was a long waits getting seated when we were mobbed, or an order misplace.  A good tip saved the day (and helped pay for college.)  A bad tip or no tip at all ruined the day.  You would be surprised at how many customers left without a thank you and a tip.

In looking back at the years I practiced medicine, I smile when I think of those occasions when someone “tipped” my staff or I.  The rum cake that misses “P” brought or the lunch that Mr. “C” sponsored at Christmas every year will not be forgotten.  These “tips” were a nice way of saying, “You’re truly appreciated.”

You’d be surprised at how many people never said thanks for the care.  You’d also be surprised to know that pharma and the insurers were not my friend. That quite the contrary, they created long waits (or denials of care) for procedures or medications.  They controlled prices and much more.  In return, my staff and I caught flax.

My intent in writing yesterday’s article was to remind you, the reader and patients of America, to say thanks to your physician and his staff.  They are service providers also and a “tip” for excellent services rendered, is an American tradition.

Over the years, many patients have asked how I would change the healthcare industry in the US if I was in charge.  My first thought is I’d shoot myself.  Lately, I’ve been thinking about how a sane person would tackle such a Herculean task.  In the next few weeks, I’ll try to answer that question.

Here’s your music for the day and a joke.

Morris, an 82 year-old man, went to the doctor to get a physical.

A few days later, the doctor saw Morris walking down the street with a gorgeous young woman on his arm.

A couple of days later, the doctor spoke to Morris and said: “You’re really doing great, aren’t you?”

Morris replied: “Just doing what you said, Doc. Get a hot mamma and be cheerful.”

The doctor said: “I didn’t say that. I said, “You’ve got a heart murmur – be careful.”

CODING

I’m not going to talk about me today.  Instead, I’m going to review what is going on in your doctors’ offices and why it pisses me off.  You’ve heard of March Madness. Well, welcome to December Madness.  Whereas March Madness ends by rewarding one college team with the national title, December Madness ends up with increased overhead, increased workload and the threat of a government audit and charge of “fraud and abuse.”

In 2021, the practice of medicine boils down to cataloguing you, the patient, using ICD10 (diagnosis code) and CPT (procedure code).  Everything revolves around codes.  The coding system changes yearly and there are hundreds of new and modified codes to be aware of and use to describe your patient’s visit.  Every year my staff and I had to learn all the new codes that pertain to family practice.

If you ask me, codes are worthless.  Actually, they detract from patient care and create a further barrier between patient and doctor. So, why do we have such a coding system?  The number one reason is that the AMA sells very expensive coding books every year.  The sale of their books is a major part of their revenue.  Number two is that the insurers of America use the codes as a way of controlling physicians’ behavior and cutting the insurance company’s expenses. 

The insurer, including Medicare, arbitrarily sets the payout on a given code and decides whether they will pay the code outright, deny the code,  or require prior authorization to validate its use.  When I started in medicine, I authorized a procedure prior to it being done and that was it.  Now the doctor’s staff has to call an 800 number, wait on hold forever and start over again.  Getting a procedure authorized for you may cost hours of staff time and that’s not cheap.  You also may be denied the right to do what your patient needs.

By the way, the insurer and Medicare never really deny care, they simply refuse to pay for it.  It’s your choice if you want to pay $5,000 for a non-approved procedure that, if it had been authorized, would have cost the insurer $50.  Doesn’t seem fair, does it?  Denials end up being a major cost savings for insurers and a major expense for physicians.

The number three reason is the coding system sets the physician up for “fraud and abuse’’ charges.  “Fraud and abuse” threats hang over every physician’s head.  What would you think if your doc was charged with fraud and abuse? In the US, we believe people are innocent until proven guilty, right?  Wrong!  Once its on social media, your goose is cooked. Patients who feel their physician charges too much will jump on the band wagon. 

Let’s look at how a code works.  Assume that to code an office visit at 99214 you need A,B,D,M,N,Q,R and Z.  The provider/coder is supposed to know exactly what is necessary to justify the code and document it in detail.  If the physician documents A,B,D,M,Q,R and Z, he/she has not met the criteria for a 99214.  If he does N but does not adequately document it, he is open to a charge of “fraud and abuse” for over charging.  However, there is a catch 22.  If the provider charges a 99213 (a lesser charge) and the auditor feels N was adequately documented and the charge should have been a 99214, the physician can be charged with “fraud and abuse” for undercharging.  It’s a no-win situation and I venture to say that, if a physician’s office is audited, it will be found guilty!  There is no way you can see your patient, treat your patient and accurately detail every bit of information regarding the visit. 

While I wish I was still practicing medicine, the new changes in coding make my not working more palatable.  In many ways, coding has destroyed the profession I loved.  Physicians are not paid for caring.  They are not paid for listening.  They are paid for coding.  What a pity!

Thank God I was never audited by the government.  I did the best I could to code appropriately but, on a busy day, my responsibility was to listen and care for my patient and I’m sure my documentation suffered.  By giving you some insight into what goes on during and after your office visit, I hope to give you a better understanding of your physician and his/her staff.

Here’s your music and a joke. 

Boris Johnson dies…

His soul arrives in heaven and he is met by St.Peter at the Pearly Gates. Welcome to Heaven,” says St. Peter. “Before you settle in, it seems there’s a problem: We seldom see a Conservative here and we’re not sure what to do with you.”

“No problem, just let me in; I’m a believer,” says Johnson.
“I’d like to just let you in, but I have orders from the Man Himself: He says you have to spend one day in Hell and one day in Heaven. Then you must choose where you’ll live for eternity.”
“But, I’ve already made up my mind; I want to be in Heaven.”
“I’m sorry, but we have our rules.”
And with that, St. Peter escorts him to an elevator and he goes down, down, down, all the way to Hell.

The doors open and he finds himself in the middle of a lush country house garden. Standing in front of it his dad…and thousands of other Conservatives who had helped him out over the years…….
The whole of the “Right” was there. .
Everyone laughing…happy…casually but expensively dressed.
They run to greet him, hug him, and reminisce about the good times they had getting rich at the expense of the “suckers and plebs”. They play a friendly game of croquet and then dine on lobster and caviar.

The Devil himself comes up to Johnson with a frosty drink, “Have a Marguerita and relax, Boris!”
“Uh, I can’t drink any more, I’m watching my weight,” says Johnson, dejectedly.
“This is Hell, Boris: you can drink and eat all you want and not worry, and it just gets better from there!”
Johnson takes the drink and finds himself liking the Devil, who he thinks is a really very friendly guy who tells funny jokes and pulls hilarious nasty pranks. kind of like an Oxford undergrad.
They are having such a great time that, before he realizes it, it’s time to go. Everyone gives him a big hug and waves as Johnson steps on the elevator and heads upward.

When the elevator door reopens, he is in Heaven again and St. Peter is waiting for him. “Now it’s time to visit Heaven,” the old man says, opening the gate.

So for 24 hours, Johnson is made to chill with a bunch of honest,
good-natured people who enjoy each other’s company, talk about things other than money and treat each other decently.
Not a nasty prank or mean joke among them; no fancy country seats and, while the food tastes great, it’s not caviar or lobster. And these people are all poor, he doesn’t see anybody he knows, and he isn’t even treated like someone special!
Worst of all, to Johnson, Jesus turns out to be some kind of hippie with his endless ‘peace’ and ‘do unto others’ stuff.
“Whoa,” he says uncomfortably to himself, “Margaret never prepared me for this!”
The day is done, St. Peter returns and says, “Well, then, you’ve spent a day in Hell and a day in Heaven. Now choose where you want to live for eternity.”

With the ‘Jeopardy’ theme playing softly in the background, Johnson reflects for a minute, then answers:
“Well, I would never have thought I’d say this – I mean, Heaven has been delightful and all – but I really think I belong in Hell with my friends.”
So Saint Peter escorts him to the elevator and he goes down, down, down, all the way to Hell.

The doors of the elevator open and he is in the middle of barren scorched earth called Brexit Britain covered with garbage and toxic industrial waste…

He is horrified to see all of his friends, dressed in rags and chained together, picking up the trash and putting it in black bags. They are groaning and moaning in pain, faces and hands black with grime.
The Devil comes over to Johnson and puts an arm around his shoulder.

“I don’t understand,” stammers a shocked Johnson, “Yesterday I was here and there was a country house and we ate lobster and
caviar….drank cocktails.
We lounged around and had a great time. Now there’s just a wasteland full of garbage and everybody looks miserable!”

The Devil looks at him smiles slyly, and purrs, “Yesterday we were campaigning; today you voted for us”

https://upjoke.com/nasty-jokes

WANTED

It’s really not fair!  The producers of the TV show, “Wanted,” got me hooked last season and promised to do the same this season. Only, they threw in a twist that ruined the show and created this article.

The heroines in “Wanted” are two loveable females who get caught up in a web of murder, robbery and theft causing them to go on the run from the bad guys and the police.  The two women start off as strangers and become mother/daughter/sisters as they live through crisis after crisis.

As the show progresses, it becomes obvious that the women not only are running from the bad guys and police; they are running from themselves.  So, here’s where the writer sneaks up and stabs me in the back.  The young, beautiful, naïve, heroine is a character you can fall in love with.  She is running from her rich, overprotective father for a multitude of reasons.

Running with her is a beautiful, strong, worldly woman who has led a rough life but survived doing whatever she needed to survive.  She’s running from her past, as well. She’s loveable in her own way.  So, the two loveable women grow, episode by episode, setting the hook in the viewer’s mouth and reeling him/her in.

Then, the SOBs who wrote this series ruin it.  The beautiful young accountant ends up having Huntington’s Chorea, a progressive degenerative disease of the nervous system which is going to destroy her body and maybe her mind as it kills her.  Yep, her hand starts to tremor and she goes to the doc.  The test is positive, forcing her to face the fact that she has the same disease that killed her mother.  SOBs!  I could accept if she was caught, tortured or murdered by the bad guys, but not watching her demise at the hands of her own genes.

While Huntington’s and Parkinson’s are not the same disease, they certainly share too many of the same traits, ending up the same. So, there will not be a happy ending to this show. As my readers know, I have Parkinson’s.  Just as the heroine watched her mother die from Huntington’s, I watched my father die from Parkinson’s.  I’m watching my hand tremor right now.  I’m afraid I won’t have a happy ending either. 

Nonetheless, I’ll live my life to its fullest.  I’ll cherish the time with family and friends.  I’ll also keep watching this show, hoping the writers will pull off a Hollywood happy ending.  And I’ll remind myself that I shouldn’t identify with the young, beautiful heroine. On second thought, it might be fun to be a young beautiful female.

Here’s your music and a joke.

A blonde asked her coworker, “Do you have any kids?”

“Yes,” she replied. “I have one child that’s just under two.”

The blonde said, “I might be blonde, but I know how many one is.”

OK, SHRINK ME

Another day, another new experience.  As my readers know, I’ve been somewhat depressed.  My gerontologist suggested that I see a counselor; and, as much as I didn’t want to engage with a counselor, I said I would give it a try.  Today was my first telesession. 

One career path I contemplated was becoming a psychiatrist.  I was accepted in a psychiatry residency at Stonybook in New Jersey.  Ultimately, I chose a family medicine residency; and, while I’m glad I did, I maintained a lifelong interest in counseling.  I was blessed to be mentored by an exceptional doctor.  I sat with Harry at my friend’s wedding.   I remarked that there were times when I couldn’t discern whether Harry was a patient or the doc.  Harry responded by telling me that he had the same problem.  He said, “When I’m not sure whether I’m the patient or the doc, I look for a diploma.  If the diploma is in front of me, I’m the patient.  If it’s behind me, I’m the doc.”  As always, Harry had a lesson to teach and, on that day, the lesson was that we all have emotional issues and what is truly important is that we recognize ours and put them in their proper space.

Of all of Harry’s lessons, the most valuable occurred at 3 a.m.  I was on medicine call and bumped into Harry at the nursing station.  Harry insisted that I do a thorough history and physical on the gentleman in room 315.  I told him I was exhausted and going to bed!  Harry pulled rank and insisted that I see him now as he was going home in the morning.  I gave in and met a 50 something, overweight, balding truck driver.  I did a half ass history and exam, thanked the patient for putting up with me and started for the door.  The patient stopped me in my tracks, reminded me that his doc wanted me to do a thorough H&P.  Turns out, the patient was a female who had been on male hormones for years.  The lesson was that you can’t cut corners and you can’t believe everything you see or hear.  I never forgot Harry’s lessons and my patients benefited immensely from his teaching.

So, I’ll put aside my doubts aside and give counseling my all.  Conversing with my new counselor was interesting.  She started by discussing the rules she lives by, all of which I lived by for my entire career.  She administered a screening test called a PHQ9.  I must have administered that test a thousand times.  I had scored myself before she finished the test and knew that, according to the results, I was moderately depressed.  I also recognize the tests limitations.  Overall, being on the patient side of the room was a new experience.

My new counselor was pleasant and seemed competent.  She certainly has her hands full.  Having treated depression for over 35 years, I know too much.  Nonetheless, I am willing to give counseling a chance. It sure would be nice if she has a little magic.

In the meantime, one of my patient/friends recommended that I volunteer at the Humane Society.  He volunteers to sit and pet/love dogs that desperately need attention and he thought it would be good for me.  I know how much I love when Renee pets my belly so I figure petting dogs’ bellies will make them feel good too.

Renee, it’s time!

Here’s your music and joke for today.

 Q. How many psychologists does it take to change a light bulb?
     A. One, but the light bulb has to want to change.