by Del Meyer

Doctor Phil Alper in his OpEd column in the WSJ has pointed out the shackles into which Medicare places doctors. Doctors have to be able to document the need for any test that is ordered. Gone are the days of a routine screening panel. Many patients have gotten use to coming in for a yearly physical examination. After I’ve taken a complete medical history and given them a complete physical examination, the laying of the hands on every part and orifice of the body, they look at me and say, “But I came in for my physical.” But I just did a complete and total Mayo-type physical. “But I haven’t been to the lab yet,” is the response. “Oh, you mean a blood, and urine and chemical analysis.” “Is that what you call it now?” After finding out what they think they want and what is justifiable on the basis of the medical history and physical examination, I proceed to write out a requisition for the tests medically warranted, usually less than that requested. Someone who has always had a normal cholesterol level does not justify a yearly cholesterol test. In fact, an abnormal cholesterol that has been treated and corrected, with the patient on a stable dose of a medication such as a statin or niacin, only requires being checked every three years, according to some published criteria, until the medication dose is changed.

Sometimes patients get unhappy if they can’t get what they want when it is paid for by Medicare, an HMO or their insurance carrier. Some patients simply change doctors to find one that will “authorize” the test or service they deem appropriate. Alper points out that many times neither the “lenient” doctor nor the patient realizes that fraud has been committed.

At a recent Medicare training seminar, the leader stated that Medicare hired 400 ex-FBI men and gave them guns, a $400 million budget and a directive to go out and get all those doctors that are committing fraud. However, it’s frequently the more honest physician who disgruntles the patient that gets placed in a higher profile and thus more likely to get arrested, than the quiet doctor who keeps his patients happy.

One congressman allegedly made a statement in confidence that he felt most doctors were probably doing fraudulent billing of Medicare. At one meeting I attended, an attorney stated that one of the investigative FBI men working for Medicare stated that he felt all doctors are crooks. As one attendee remarked (with tongue in cheek I hope) maybe we should have a higher goal to see how many doctors we can put into jail. Perhaps if we put badges and guns on 650,000 law men and station one in each doctor’s office in this country, we should be able to arrest all 650,000 of them by the end of the first week. One FBI officer actually went into a doctor’s office as a patient. After the examination was completed, he asked the doctor to sign a requisition so that his mother, who would be a patient the following week, could get an assistive device. After the doctor signed the request, the officer pulled out his gun and arrested the doctor for prescribing without performing a medical examination. Do we have enough prison cells to contain an extra two-thirds million physician felons? Weren’t prisons with stone walls and steel gates designed for the violent? Why are we placing a nonviolent profession behind bars?

Sound far fetched? Not really. Every day the doctor has to police numerous requests for government services. A Medicare patient requests a cane. Instead of purchasing one for $5, he sees his doctor at Medicare’s expense (about $50), requests a prescription verifying medical necessity, and goes to the medical supply house that has a medically approved cane for $100. (These figures may be a little dated.) For each doctor that authorizes a piece of medical equipment, I am sure that Medicare could find several doctors that would verify that it was “not medically indicated.” Therefore, after an outside review of such a physician, the cop can quickly pounce on the doctor that did not police this patient well enough. Tear the license off the wall, handcuff the doctor, and paddy wagon him to jail.

A more common request today is for home care from a hospital that has a home care division, developed to replace the revenue the inpatient division has lost. I have counted up to 29 items requested for a patient. These include instructing the patient about his disease (which I have already done), to taking his temperature (the family shouldn’t be bothered), to instructing the patient about his medications (which I have also done but find the patient more confused after the home care nurse goes through it in different fashion). Many doctors freely state that they have never been sure that the dozens of requests are really all that necessary. But to try to reduce it could take all morning, eliminating seeing patients. Others have stated they are concerned if they eliminate too many of the items, they invoke the wrath of the hospital by interfering with their revenue stream.

What is the answer? More Medicare regulations? We already have far more pages of rules and regulations that even attorneys can read, much less physicians who must take care of patients. Each law puts a further straight jacket on the doctor-patient relationship. Ultimately it is the patient that suffers. When doctors give up and are satisfied with being the pawns of Medicare, or the insurance company or an HMO, the patient will never partake of the modern advances in medicine we have come to enjoy in this country. Some feel that a high deductible health insurance policy is the answer. The patient pays cash for his annual exam, lab tests and x-rays. If he is hospitalized or has surgery, then the insurance is there for the catastrophe. In the long run, that will be a lot less expensive and more patient oriented than our current system.

Ghosts vs Live Inmates

Speaking of inmates, do we really need live inmates? The WSJ reported that the two senators from Mississippi were dined by a lobbyist, Wayne Calabarese, to solve the prison empty bed crises. Mississippi built 15 prisons in seven years and then ran out of inmates. Mississippi lawmakers wrote legislation that, according to corrections commissioner Robert Johnson, set aside millions of dollars for empty prison beds-or ghost inmates. Although the number of live inmates behind bars has quadrupled in the past 20 years, it was not enough to fill the beds. The prisons won this favor even as budgets were cut for classroom supplies, community colleges, mental-health services and other programs.

Almost sounds like the government spending huge sums of money in the 1970s after Medicare got into full swing to build hospital beds, which are now being closed at a great loss of capital cost and revenue stream. When will taxpayers say, “Enough is enough?”