Reports from Overseas January/February 2001

The World Congress on Lung Health had physicians from about 60 countries represented. These are opportunities for me to get an overview of medicine as it is practiced throughout the world.

A physician at the Congress from the United Kingdom stated that he is very unhappy with his medical practice in the National Health Service (NHS). He felt that everyone he knew was unhappy with their practice and the bureaucracy associated with it. He is looking forward to retiring, when other sources of income materialize, and felt that most physicians he knew are looking towards almost any opportunity to retire or even work in a non-physician capacity.

A physician from Finland stated that he is currently working in Norway, which pays the highest salaries in Scandinavia. The government there is more wealthy due to oil revenues and thus are paying doctors better. This shouldn’t surprise us since we are seeing doctors uproot their families and practice for a temporary better deal in many states in our country.

A doctor from South America stated that he no longer can afford to buy medical textbooks or belong to medical societies. He said he is expected to work longer hours with no increase in his government wage. Sound familiar? Seems like we were able to de-professionalize ourselves without the help of government medicine. No wonder socialized medicine doesn’t sound so bad to many of the new generation of American doctors. We’re almost there.

Hospital Doctor, subtitled as “21 years as the leading newspaper for all hospital doctors,” reported that the “consultants” (hospital doctors) in the National Health Service will not receive the promised intensity payments in their pay packets because the British Medical Association is unable to reach an agreement with the government on how the money should be allocated. It seems the government wants to allocate the money as a reward for consultants’ workload and job intensity, while the BMA wants it distributed equally to all consultants rather than on how hard they are working.

On reading the above report, Peter McDonald, a consultant surgeon, stated, “I felt something snap within me. With my loyalties to the NHS for more than three decades repaid by lies, I know I am not alone in feeling repulsion in the way doctors are being portrayed by our masters and the media.” He points out that some consultants have been on call every third day for 16 years. His own hospital received a fine for having the longest waits on trolleys (gurneys). The business manager was asked to stay within budget. So he destroyed (closed?) a ward. It had the desired effect. Money was saved; nurses drifted off into other activities or took retirement, and the budget was balanced. McDonald feels that with the crises in nursing and ancillary staff, the NHS is in danger. Will doctors be the next to leave? For the first time he is contemplating leaving the NHS.

Meanwhile another issue is headlined: “BLACKMAIL” – Government tells medical profession: Do it our way or else. The Government feels that some doctors in the NHS are devoting too much time to private practice. New consultants are expected to accept a ban on private practice for at least seven years to ensure proper management of their time. This is to reduce the maximum wait to four hours for emergencies, three months for an outpatient appointment and six months for an operation. Prime Minister Tony Blair said, “Though most consultants work extremely hard for the NHS, beyond their contractual commitments, there is no proper management of their time.”

NHS spending is scheduled to rise £15 billion over the next three years, according to Chancellor Gordon Brown. This includes £300 million from duty on cigarettes. It seems that more doctors are coming at cross currents with paradoxical health issues. “Dear Patient: Please smoke more so that there will be more tax money to pay me a better salary so that I can treat your cigarette-induced disease in greater comfort.” Although it may be legal, it is always unethical to ever accept tax money from the diseases we are trying to treat. Doctors should always have a higher code of ethics than politicians.

In a debate on whether self-regulation for doctors should be ditched, Dr David Starkey argues that the whole arrangement of professional self-regulation is justified in terms of an independent profession, devoted to the welfare of the patient. However, in the modern NHS, medicine is no longer a profession. Doctors are, for the most part, salaried employees and rationers of health care, which means they cannot put the concerns of the patient first. It is impossible to advocate for the patient and manage budgets. He feels there is evidence of rapidly declining standards of health care in the UK compared to the rest of the world. He also feels that the approach of New Labour, with its standard-setting and targets, is only worsening the problem, and the form-filling will eat up even more of the doctor’s time – time they could have spent caring for patients. The solution, as Starkey sees it, is for patients to fund much of their health care privately, empowering themselves to demand the best service from their doctors.

Dr Tony Copperfield, a GP practicing in Essex, comments on how rationing in health care is suddenly becoming a hot potato. But, he states, rationing is nothing new. “Waiting lists for surgery effectively ration operations – by the time that my patients reach the head of the queue for hip replacements or cataract extractions, they are, invariably, dead.” Copperfield goes on to explain that they will demonstrate a better sense of priority than the Americans. He cites, “In the infamous Oregon experiment, the US public apparently rated breast augmentation more important than plating a fractured femur. A generation of full-breasted American females will soon be walking with a limp.” He feels rationing helps restore a sense of perspective. “Patients should be limited to a seven-minute GP consultation, two problems per attendance, and a maximum of four consultations and one home visit per year.” He further feels that prescribing could also be rationed: “No more than three courses of antibiotics per patient per year.”

The Sunday Telegraph reported that, with the NHS waiting lists growing and the cost of medical coverage insurance seriously damaging one’s wealth, more people than ever now opt for pay-as-you-need health care. The journalist, Emma Simon, lists the cost of private treatment, e.g., hysterectomy for £2,300 to £4,300 and hernia for £895 to £2,025, as cheaper than the cost of health insurance. Hospitals are now providing loan facilities, but these require customers to repay the debt in 12 months. A new concern, Go Private, charges £18 per year per household and will pay your medical bill and then finance the actual costs for you. It is suggested that patients shop around for the best treatment for their money and then finance costs as they occur if they need to. Go Private says their service empowers patients to look after their own medical care.

The Queen expressed her regrets that Madonna, who lives in England, felt the National Health Service was so Victorian that she had her baby in Los Angeles. However, the press expressed their approval that, since she could afford private care, this allowed those who needed the NHS to obtain care.

In the two weeks that I had the occasion to review the newspapers, I noted in the British papers (unfortunately, I couldn’t read the ones in the other languages) hundreds of stories of unrest in the National Health Service. Talking with doctors from the various countries basically revealed the same story. It seems that we are at the crossroads in medicine in this country. Can we learn from the British and the world experience? Wouldn’t it be better to build on the private insurance and cash system we now have, rather than go down the road of further government medicine. Other countries, which have national health plans, are making desperate attempts to re-institute health insurance or even pay cash and finance health care after the fact? If you would like to participate in a dialogue on this subject, please send me an email.


Marijuana / Medicare Audits March/April 2001

Noteworthy articles from Humboldt, Del Norte, and San Joaquin Counties.

The Bulletin of the Humboldt-Del Norte County Medical Society has been publishing a dialogue on an article: “Medical Marijuana: An Oxymoron,” by Denver Nelson, MD. Tate Minckler, MD, an editorial board member of The Bulletin, has expounded further on this proposal for legalization of marijuana which he thinks physicians should take more seriously. “Our national experience with an attempt to prohibit another recreational drug (alcohol) was not only totally unsuccessful, but also is a continuing unmitigated disaster. We not only did not stop the consumption of alcohol, but placed the determined drinkers at real risk from adulterated and incompetently produced ‘booze;’ we also lost huge tax income for our state and federal governments. However, the worst of the negative effects of Prohibition was the creation of vast criminal empires which catered to the demand. The most important of these is the Mafia, still with us today, almost eighty years after Prohibition gave them a fabulous financial jump start.” Minckler feels that attempts to prohibit marijuana are following the same exact paths. A) We have not significantly dented the use of marijuana. B) We spend tremendous sums of tax moneys on interdiction rather than actually collect taxes on what should be a legal recreational drug. C) We have created a large international population of ‘criminal’ growers, transporters, pushers and users. D) We have a very real problem with illegal activities including occasional murders related to the marijuana culture. Minckler does not claim that legalizing marijuana, any more than legalizing alcohol, solves all related problems. “It does take these recreation drugs out of the black market, it wipes out almost all of the criminal incentive, it adds to the tax base, and will provide very important relief to the prison system. It is not a perfect solution, but it is a better solution than that which we now suffer.” He concludes that “Legalization is a reachable goal: Prohibition is the impossible dream.”

Tate also reports that Americans throw away millions of tons of disposable but non-biodegradable diapers each year. A food scientist from the University of Wisconsin suggests that the 20 million tons of unwanted marine wildlife caught by the commercial fishing industry yearly can be “processed” into an odorless biodegradable protein gel from which diapers can be made. The gel absorbs up to 600 times its weight in liquid and degrades in about 30 days. It would help the wasted fish and the growing landfill problem.

John Kiraly, III, MD, reports in the San Joaquin Physician on “Anatomy of a Medicare Audit.” In April 1999, he received a request for medical records for 30 patients, including exact copies of all consults, progress notes, treatment records, laboratory reports and flow sheets. He was to reply to National Heritage Insurance Company, the Medicare fiscal intermediary, in 30 days. When his office manager called NHIC, the LVN assigned to the case stated, Dr. Kiraly made too much money last year.” He was an outlier – but for the wrong specialty in the wrong community. Medicare never got his correct forwarding address. He meticulously compiled and sent the records, confident the auditor would only come up with a trivial sum.

Six months later, he received a “preliminary Notice of Audit Results” that he had been overpaid $34,806.93, with an “Extrapolated Overpayment: $57,975.93.” The auditor had systematically down-coded nearly every service and denied payments on others. Overpayments were extrapolated by use of “Statistically Valid Random Sampling,” for a 66.6 percent increase. After two sleepless nights, Dr. Kiraly mobilized his team for the ordeal – office manager, practice consultant, and later, statistician. He covered all expenses, including airline travel. For three solid days and much of the nights, the team compiled a detailed rebuttal. Six months later, the “Final Notice of Audit Results” arrived. The actual overpayment had been reduced to $13,194.37, with a “Statistically Valid Random Sampling” increase of 80 percent extrapolated to $23,576.61; a payment was due in 30 days, after which interest would apply.

Dr. Kiraly canceled staff bonuses and pension contributions and requested a hearing; it occurred five months later. He again made preparations with his office manager and practice consultant. Dressed professionally, he made an introductory statement. The chairman of the society’s reimbursement committee testified to his character. His team then performed a code-by-code defense; Dr. Kiraly contends physicians are too emotionally caught up to speak on their own behalf. Two weeks later, the actual overpayment was reduced to $667.60, with a 417 percent extrapolation to $3,454.33. Kiraly appealed to an administrative law judge and requested a refund. He received $20,031.28 – without interest.

To prepare for court, he hired an academic mathematician who found that the extrapolation formula was statistically biased against the physician, and that the carrier had failed to properly follow HCFA guidelines. He arrived at the Social Security office in Sacramento on the appointed day, was electronically frisked for weapons (his team was not), and led through a series of locked doors to a miniature courtroom. After being sworn in, the team challenged the extrapolation formula and a denied procedure never announced in the Medicare Carrier’s newsletter. They conceded the $667.60. Three weeks later, the judge’s “Notice of Decision” found entirely in Dr. Kiraly’s favor and even returned the $667.60, finding that recovery of overpayment would be against “equity and good conscience.”

Dr. Kiraly feels the $10,000 he spent was worth it. He recommends a consultant first be hired for a pre-audit, to determine if your records meet requirements. If audited, hire a consultant to assemble records; properly detailed and organized records are essential from the outset. A lawyer is generally unnecessary, unless fraud is alleged. Most of all , he urges not surrendering without a fight. Don’t be one of the 70 percent who writes that check immediately. Remember, 90 percent win something back if they appeal.

He reminds us that Medicare is voluntary. Many of his colleagues are deserting Medicare because of absurd intrusions. He feels practices are in a critical condition. Medical school applications are down and 30 percent of practicing physicians are expected to retire in the next five years. He urges us to join in the fight before medicine declines into a spiritless mediocrity.


MBA Medicine, Unneeded Amputations and “Fraud” May/June 2001

Sidney Goldstein, MD, emeritus head of cardiovascular medicine at Henry Ford Hospital, in an article in Internal Medicine News, remembers the pundits who predicted that MBA medicine was a phase and that America would focus on healthcare deficiencies, not ambulatory patients with “through-put” efficiencies. How wrong they were. The tidal wave of changes in the last decade has washed away standard practice in a system dedicated to efficiency, and cost containment has emerged from the rubble.

The number of Americans without health insurance now exceeds 40 million. There are deficiencies in healthcare in urban and rural America. Now people want protection from the healthcare system through a Patient Bill of Rights that, if achieved, will do little to improve patient-physician inter-reaction.

The brief pause in escalation of costs championed by HMOs is over, and a rise in cost is resuming. Academic medicine has been gutted by the pressure to increase patient volume, decrease inpatient days, and shorten encounter time in the clinic. Teaching has diminished, along with personal guidance in history taking and physical examination. Students have become more interested in discussing the easily collected laboratory data and radiology findings.

Research was a part of the interaction between learning and teaching, and patient care was the crucible within which it all came together. In its quest for economic survival, academic medicine has accepted the ground rules of MBA medicine: teaching adds no efficiency and does not enhance the financial performance of the academic hospital. Medical school faculties are looking to improve patient productivity in order to improve their salaries. The academic physician now differs little from his colleague in the community hospital – both compete for the well-insured patient with little regard to either academic standards or social responsibilities to the community at large.

Carl Elliott reports in the Atlantic Monthly that Robert Smith, a surgeon at the District Royal Infirmary in Scotland, amputated the legs of two patients at their request and was planning a third amputation when the hospital trust stopped him.

These patients did not need amputation for medical reasons and were considered competent by the psychiatrists who examined them. Elliot outlines many of these instances, including self amputations. He found one list serv of 1400 interested subscribers on the Internet. Psychiatrists and surgeons continue to be baffled by this interest.

Several physicians discussed their Medicare investigations at a recent Association of American Physicians and Surgeons conference on physician problems in the current healthcare environment. One had finished serving a prison sentence and gave his first speech since addressing a federal judge six years earlier.

Jeff Rutgard, MD, an ophthalmologist in San Diego, had built a flourishing practice with one ophthalmologist employee through hard work and vigorous self-promotion. From 1988 through May 1992, he received $15.5 million from Medicare. This accounted for 80 percent of his practice. At 6 a.m. on Monday, April 27, 1992, Dr. Rutgard and his family were awakened by armed federal agents who entered his home with a search warrant; he was told other agents were at his two offices.

Dr. Rutgard was soon stripped of his medical license. On March 24, 1994, a federal grand jury returned a 217-count indictment against him, mainly alleging unnecessary cataract surgeries or improper eyelid surgery billings for a small number of patients.

Dr. Rutgard hired a nationally known attorney who stated he would need 3-4 months of full-time preparation and a $1 million advance. The trial was originally scheduled for June, reset for August and occurred in October. At a pretrial court appearance in mid-September, Dr. Rutgard moved to relieve his lead attorney and obtain a continuance. In supporting affidavits, both the national attorney and a local co-counsel declared that they were unprepared. But the judge denied the motion and proceeded to trial with this same attorneys.

After a five-month trial, Dr. Rutgard was found guilty of a number of acts of mail fraud and false claims involving $65,000 in Medicare billings. At the prosecution’s urging, the trial judge found that Dr. Rutgard’s entire practice was permeated by fraud, and extrapolated the $65,000 — less than 0.1 percent of the practice — to all Medicare proceeds received. As a consequence, he was fined $16 million and given an 11-year prison sentence. He was denied bail pending his appeal and sent to prison without the courtesy of saying goodbye to his wife and five children.

From prison, it took Dr. Rutgard three years to appeal. The appellate court, after reviewing the trial evidence, reversed many of the counts and found only $45,000 of billings in question. Importantly, the appellate court threw out the extrapolation to $16 million, declaring the prosecution had not met its burden of proof. The case was sent back for re-sentencing.

By then, Dr. Rutgard’s appellate attorney had found evidence to challenge many of these allegations on blepharoplasties which constituted the major portion of the $45,000. Included was an affidavit from a UCLA Professor of Ophthalmology that he found nothing below the standard of care. However, the same trial judge did not allow introduction of this evidence that should have been available for the original trial had the defense been prepared. The judge changed the prison term to the five years served and only reduced the fine. He did not require that the defense attorneys return the money advanced.

After the verdict, one juror wrote to the judge that he did not think his guilty vote meant jail time – and if he needed cataract surgery, he would want Dr. Rutgard to do it. Another juror told the San Diego Union he felt Dr. Rutgard was innocent but voted him guilty because it would require too much government money to allow the doctor a new trial.

The testimony given by Dr. Rutgard’s fired office manager and one biller was the basis of the grand jury indictment. Other billers who signed statements disputing the fraud were never allowed to testify. Three years later, the same office manager and assistant biller were deposed in another trial and testified that Dr. Rutgard had not fraudulently billed Medicare.


Third Party Medicine / Medicare Fraud July/August 2001

Thomas Mueller, MD, an otolaryngologist in Everett, WA, is tired of gloom-and-doom messages and thinks it is time for physicians to take the lead. While problems in medicine are legion, the solution is simple but not easy.

“As rapidly as possible, as many physicians as possible need to end all third-party relationships,” Dr Mueller writes. Patients should submit receipts to their insurance company for reimbursement, under the terms of their contract with the insurer. “Every other proposal falls short of accomplishing the goal [of restoring free market in medicine] and does little to control the reign of bureaucrats….all other proposals are simply like rearranging the deck chairs on the Titanic”

His proposal requires no new legislation, simply a critical mass of physicians to take the lead. That might not be very many.

Paul Marguglio, MD, a Healdsburg internist and president of the Sonoma County Medical Association (SCMA), states that now is the worst of times for medicine. He embarks on a 15-year perspective, outlining what we’ve been through and where we are today.

The lead article in Sonoma Medicine is by Herb Brosbe, MD, “How I Learned To Love Medicine Again.” On the last day of August 2000, one hour before a meeting with the director of his medical group, “I received a telephone call from the CEO. ‘You’re terminated. We’re done dealing with you.’”

He writes, “There was nothing brave or heroic about being fired; about having the locks of our office changed to deny us access to our records and patient files; about watching helplessly as my practice of 18 years was divided among other doctors. Begging health plans and other medical groups to intervene fell on deaf ears. Phone calls, e-mails and letters to the California Department of Managed Health Care went unanswered. A letter to the SCMA Ethics Committee went unacknowledged. I was in crisis. No practice. No job. No income.”

He then rediscovered a known truth: “Crisis can be a foundation for powerful changes. A deeply rooted process of values clarification evolved. I loved my profession, but I hated my previous job. The tensions between staff and patients, the endless apologies for poor service, the many uncompensated hours of paperwork – all made for horrendous working conditions.”

“Why did we participate [and] continue to participate? Because we’ve been trained to always serve….We were also afraid. If we didn’t participate, our patients would be sent elsewhere.” He felt he became a provider for an insurance industry rather than his patients.

While Brosbe was hiking in Point Reyes, a naturalist told him, “I’ll always remember our family doctor. He always took time with you. When he put his hands on your stomach, looking for a source of your pain, you knew you would be okay. You always knew how much he cared. You are very lucky being a family doctor.” Brosbe immediately urged his patients to obtain lower premium insurance by paying for routine outpatient care themselves so he could spend time with patients. After two months in a partnership practice, he is “deliriously happy” with no stress or anger or paperwork. Dr Brosbe challenges the members of his medical society to send a memo to their patients saying: AS OF DECEMBER 2001, WE WILL NO LONGER BE ACCEPTING MANAGED CARE.

I interviewed Dr. Don ReVille about his Medicare problem of some five years ago. He had converted to a skilled nursing facility (SNF) practice and joined the California Association of Medical Directors for Skilled Nursing Facilities, became its president and, later, president of the national organization.

His SNF practice grew to 400 patients. His sign-out partner, who needed six weeks to accommodate pulmonary surgery, asked him to cover his 600-patient practice. This combined 1000-patient number triggered a red flag on a Medicare screen. An extensive investigation of ReVille focused on Sutter Oaks Alzheimer’s Center, where he served as Medical Director and had made rounds for several years, accumulating approximately 60 patients.

Because medical interviews and examinations of demented patients do not produce significant medical information, the Director of Nursing suggested he order his time by first making Charge Nurse rounds, chart rounds and then walking rounds to perform examinations dictated by the medical condition.

This approach worked productively for over 10 years, until Medicare arrived and said the American Medical Association/Health Care Financing Administration guidelines required he spend at least 15 minutes per month with each patient plus several functions. The Medicare investigator agreed that Dr. ReVille was practicing good medicine; however, because his practice did not conform to the AMA/HCFA E & M codes, he would be prosecuted for fraud.

Dr ReVille spent $25,000 in retainer fees before an attorney would discuss the case. After another $40,000 and tons of what appeared to be boiler plate (computer-derived) documents, Dr ReVille was assured that his attorney knew lawyers at HCFA who could have the case dismissed for another $35,000 fee. This attorney bailed when Dr ReVille refused to ask colleagues for loans. A second attorney was hired for $20,000 for the trial.

The U.S. prosecutor compared Dr ReVille to Attila the Hun. His attorney asked for a recess, took Dr. ReVille aside and advised him that his guilt was obvious and, to avoid prison time, he should so plead. ReVille asked for a second legal opinion, which concurred. Dr ReVille signed a document stating he had violated the AMA/HCFA E & M guidelines, hoping to get on with his practice and his life. But he was sentenced to 21 months in federal prison. After 13 months he was released, to face the loss of his house, automobile, practice and reputation.

Later, in reviewing the Medicare regulations, he noted that he was required to do two of three E & M guidelines regarding nursing home patients: (1) Review the medical chart; (2) Make face-to-face contact and/or perform an examination; (3) Formulate a medical decision. His legal counsel and the federal prosecutor stated that his sentencing was based on the requirement that he perform all three items. Since he did perform the required two, he feels the case against him should have been dismissed — in which case he would still be a licensed physician rather than a felon.


From Bureaucrats & Other Professions September/October 2001

A LESSON FROM TEACHERS: In a remarkable twist, our Governor is handing out $350 million in bonuses to teachers at 4,800 public schools for raising their students’ Stanford 9 test scores. The teachers say this $591 bonus is nothing short of a bribe, suggesting that they have been holding out against their students. Hundreds of teachers have been forwarding these “bribes” to scholarships and charities. . . . Meanwhile, a health insurance company has stated that they would reward doctors for improving the patient’s health care, rather than reward them on yesterday’s emphasis of saving costs. Shall we give these “bribes” for medical student scholarships? . . . A patient of mine who teaches for the San Juan Unified School District requires a morning dose of Xanax before facing her classroom of students. Because the many rules essentially prevent her from maintaining order to teach effectively, she is no longer interested in having her children learn anything. Her sole objective is getting through the school day without an injury or having violence erupt. . . . A doctor from one of the IPAs told me his challenge is getting through the work day navigating the rules of the IPA, insurance carrier, Medicare, and hospital as smoothly as possible. He can no longer be too concerned about the patient. . . . Is this the leveling of the professions?

MARKETING OR SALES: Southern California Physician describes a course titled Practice Promotion 101. Howard Bronson, a marketing director for Practice Builders, states that confusion over sales versus marketing will defeat a physician’s outreach efforts. He reminds us that sales activities and materials are practice oriented; marketing activities and materials are patient oriented. Selling is preoccupied with our need to sell our professional services. Marketing is aimed at pointing out to our patients how our services will meet his or her needs. . . . A good reminder for us to maintain patient oriented thinking.

BRINGING ANATOMY INTO THE DIGITAL AGE: Joseph Paul Jernigan, a convicted killer, donated his body to medical science after his execution. His body was lightly embalmed and air freighted to Denver. There, scientists contracted by the National Library of Medicine performed MRIs and CTs and froze the body solid. The NLM had been looking for an average man who died on schedule before disease overtook him. After sawing his body into four pieces, the scientists encased the chunks in blue gelatin and began to slice, milling from the feet to the head. After 1,877 cuts, the cross sections were digitally photographed. The photos were collated with the CT scans and three-dimensional-imaging technology brought the data to life. After months of work, the scientists emerged with 15 gigabytes of data that constituted the Visible Human Male, the most accurate human anatomical model ever seen. Jernigan now lives, according to the New Yorker, on thousands of Web sites.

DOES A CHAPERONE PREVENT SEXUAL ACCUSATIONS? In 1995, Dan Alexander, MD, an internist in New York, saw a patient for a variety of acute complaints. Although she was asked, the patient did not divulge her current psychiatric treatment. Her therapists testified that the diagnosis was histrionic personality disorder and that she had not cooperated with treatment. In 1998, the patient filed a malpractice suit, claiming multimillion dollar damages, and caused an inflammatory front page article to appear on the Jamestown Post-Journal headlined “Lawsuit Alleges Malpractice, Molestation.” Two years later, the patient voluntarily discontinued the suit, with prejudice. However, after the article appeared, four other patients filed complaints against Dr. Alexander, some related to examinations which were performed five years previously. As a matter of office policy, Dr. Alexander always had a female chaperone, who was a health care professional, present during breast and pelvic examinations. At the hearing, the chaperone testified that she observed nothing unusual or improper in the examinations. However, the Hearing Committee rejected her testimony because of her “obvious interest in the well-being of the respondent after working closely with him for several years,” and upheld Dr. Alexander’s de-licensure in New York. Dr. Jane Orient, Executive Director of the AAPS, feels that it will be extremely difficult, if not impossible, for any physician to have a fair opportunity to defend charges of such inappropriate conduct.” The complete brief is posted at

PRESCRIBE PAIN RELIEF, GO TO PRISON: In 1996, investigators arrived, guns on hip, at the Salt Lake Headache Clinic of Dr. Robert Weitzel, demanding patient’s charts, and a witnessed urine specimen. When the urine sample proved to be clean, the investigators interrogated staff, acquaintances, patients, and reviewed Medicare billing records and practices. When these all passed muster, they descended on the hospital and found a nurse who felt there were five questionable deaths in the winter of 1995 and 96. A physician was found who rendered an opinion that the care was not standard comfort, end-of-life care but constituted “active euthanasia.” In September of 1999, Dr. Weitzel was arrested on five counts of murder, had to post a $100,000 surety bond, a $25,000 cash bond, despite the fact that two of the bodies exhumed had no detectable levels of morphine and the third had levels commensurate with the amount prescribed. He was then de-registered by the DEA and has been unemployed since. Dr. Weitzel sold his home, liquidated all his assets and went into debt to pay legal bills. He was unable to recruit witnesses in Utah because of the defamatory publicity. Out of state witnesses were threatened and harassed. The prosecutor’s witnesses were paid as much as $40,000 for their testimony with one asserting that administering morphine every three hours rather than every four hours would cause blood levels to rise inexorably. Everyone was stunned – including the prosecution – when the jury returned a verdict of guilty on two counts of manslaughter and three counts of negligent homicide. When given a sentence of 1 to 15 years in prison, one juror stated, “I didn’t know he’d go to prison.” The charts in question and a summary of the legal events are posted at Dr. Weitzel can be contacted

MEDICARE REGULATIONS: Philip Alper, MD, FACP, an internist in Burlingame and Medical Director of the First Data Bank Corporation, refers to Medicare’s assault on oncologist John F Kiraly III, MD, (reviewed in this column recently) in his column in Internal Medicine World Report. Ironically, he had just read congressional testimony by Michael Mangano, Acting Inspector General of HCFA claiming that such things do not happen. “Provider concerns relating to inappropriate investigations and audits are unfounded and both HCFA and the OIG are reaching out to provider groups to reassure them, claiming physicians and other health care providers are not subject to criminal or civil penalties for honest mistakes, errors, or even negligence.” Dr Alper then refers to his experience with former HCFA administrator Gail Wilensky at a meeting when he described the corrosive effects of Medicare regulatory activity on physician morale. He was told “our pain is not real because what upsets us is not happening.” We have selected an example of professional homicide for each issue of this column this year. It’s difficult to comprehend that congress and bureaucrats don’t understand or even believe the results of their legislative and regulatory actions.

DRAGON NATURALLY SPEAKING: I have decided it is time to get serious about the medical version of dragon NaturallySpeaking voice software on my computers. My consultations, office calls and e-mails are voice dictated right into my desktop or laptop computers and files are synced in an electronic briefcase on diskette from one to the other. This is my first VOICES column voice dictated. I’m projecting that my voice will last many years longer than my fingers running on a keyboard. I think I just figured out how to delay my retirement by 25 years. The benefits and efficiencies of the telecom age are phenomenal.


World Congress on Health & Medical Information November/December 2001

I find the Medical Information Technology revolution fascinating. It is moving too fast for some, and not fast enough for others. This year, during our annual trip to London to visit our daughter, I attended the timely “Tenth World Congress on Health and Medical Informatics.” Information Technology (or IT) is becoming so important that many firms have elevated their head of Information Technology to board status as Chief Information Officer (CIO) on a par with CEOs, COOs and CFOs.

I had no grasp of the resources both government and private organizations have devoted to converting all information into digital form for electronic processing. Nor did I fully understand that in many spheres there is resistance to making great amounts of information available to people who could use it to make our healthcare system more efficient.

This past year, Parkstone installed a personal digital assistance (PDA) system that interfaced with my MediSoft billing software. It enabled me to write prescriptions digitally on a hand-held device. The PDA provided insurance data on each patient so that I knew, for instance, which bronchodilator or steroid inhaler or leukotriene inhibitor was covered by my patient’s insurance. It seemed every insurance company had an arrangement that did not match the average wholesale price (AWP) listed in the Drug Topics Red Book. (The same applied to all drugs in any of the insurance carriers formularies.)

It saved my staff at least an hour a day of phone processing the prescriptions written for equivalent drugs not on a particular formulary. (I’m sure there was a similar savings of pharmacist’s time.) Saving 10 percent of a physician’s overhead does reduce healthcare costs.

Unfortunately, Parkstone laid off its work force in the economic downturn. When a PDA window malfunctioned, there was no one to service it. The cost savings disappeared.

Large costs are also saved as hospital records are converted from handwritten to digital. If doctors write orders digitally on a computerized patient chart, and if the therapeutic indications and economic costs are instantly available, treatment improves and costs decrease. In one study, up to 13 percent of associated healthcare costs were saved.

But as our hospitals digitized pharmacies, laboratories and x-ray departments, the information was not instantly available to physicians. Hence, we work in a time warp. If, as we write an order, we instantly see a comparable drug that is equally or more effective — or a test that gives equivalent information — we automatically save money, sometimes up to half or more of the cost. As annual healthcare costs in this country pass $1 trillion and march towards $2 trillion, reducing healthcare costs by 10, 13, 20 and sometimes 50 percent, would provide substantial savings.

During the week of this Congress, The Economist reported there are now one million Brits in the waiting queue for obtaining healthcare, 47,000 waiting into their second year. The UK is feeling the impact of the European Union. Its courts are giving Brits the authority to obtain healthcare on the continent, which would then be paid for by the NHS of the UK. The article supported this as a market approach to medicine, but it isn’t the true market — it simply pits the inefficiencies of one socialized system against the other.

It’s not unlike a social scientist who refers to our HMO system as market-based, rather than as corporate socialized medicine. In a true market, the purchaser of healthcare (the patient, not his employer) chooses the highest quality (doctor) at the lowest cost (office calls competing with each other). An office call in the UK now averages seven minutes. It is inconceivable that information technology can allow the clinical decision-making process to occur faster and still remain a human or humane interaction.

The Economist article cites the number of doctors the UK needs to bring its standards in line with modern countries. There is a seven-year plan to correct these inefficiencies. The last plan apparently did not accomplish this goal. Remember, the Communist Russian 15-year plans failed in their goals also.

Doctors throughout the world are using IT with increasing frequently (from 10 percent to more than 90 percent in just over five years). Patients are also using it more. In the UK up to 90 percent of patients come armed with computer printouts to discuss numerous options, diagnoses and treatment plans during their seven minutes. One speaker contended this may not improve care and may even have an adverse effect. Patients may be afraid to ask questions and, consequently, use information inappropriately. It certainly changes the equation.

One presentation at the Congress touted professions and citizens (notice the change to a political characterization of patients by government purveyors) who are networking for integrative care. The brochure introducing the “Miguel” story was illustrative. It showed how 18 government programs — listed as clinical messages, email, clinical bookings, shared records, care protocols, mobile services, home-care monitoring, telemedicine, surveillance information, [medical] yellow pages, professional guidelines, quality management, public health information, continuing professional development, reimbursement, electronic commerce, patient IDs, and resource management — all helped Miguel start his insulin administration, anticoagulant controls, antihypertensive management and a new diet. At the same time, his GP put him in touch with social security because his problems seemed incompatible with his work.

Then it showed Miguel at home inhaling a cigarette in his ideal, new, healthy environment, essentially negating the entire bureaucratic effort.

This World Congress was the 10th triennial conference of the International Medical Informatics Association, with 1200 participants from about 50 countries representing all continents. From the list of participants, it appears that about half were physicians and the rest were technical and administrative people who are trying to help us take care of patients.

Since nearly all countries have socialized medicine, healthcare — including IT — depends on current funding by political operatives. Many lectures were directed at how to influence the governments to fund medical information technology (MIT) systems as a way to reduce healthcare costs. All lectures were Power Point presentations, and a CD was included in the handouts.

After one esoteric presentation on the global implications of MIT, a physician from Africa responded that all this information was probably quite useful to developed countries. However, in his homeland, where computers were rare and cell phones nonexistent, money for medications to treat people who are diagnosed clinically rather than electronically would be more useful.

In the final half day of presentations, a technocrat stated that the group needed to work more closely with the best diagnosticians to come up with the best possible protocols. A physician stated that unless MIT brought the information to the final point of the medical evaluation, asking a doctor to spend more time entering data deemed useless to the clinical process would never, in and of itself, be useful.

I recalled entering the conference hall an hour before the first session, three days earlier. The Docking Railway car on which I arrived delivered about 200 people. We were herded into a queue by an officer with a badge. It took 30 minutes to work my way to the desk; I registered and was given a name tag and a receipt so that I could go to a queue for booth 28 and obtain my conference materials.

Another wait. When I asked why the satchels containing the conference materials weren’t handed out at the first desk, the gentleman retorted, “You want me to lose my job?”

The next day when the certificates of attendance were ready, we went into an even longer queue. I recalled that the registration of 15,000 doctors at the American Thoracic Society never had a 30 minute wait; badges and all conference materials were given in one pass across a desk. I asked the conference secretary, “Wouldn’t it be more efficient to give all these items out at one time at registration, rather than making the participants wait in queue three times for them?” She said she did not see any inefficiencies in their system.

When I asked about the toilets (British for restrooms), I was told to take the escalator to the third floor. There were no down escalators, and after three days, my left knee was in great pain. My orthopedist, however, was happy.

Can workers in a government hierarchy ever be efficient? How can they make information more efficient for our profession? It will only come when the real medical marketplace is re-established — each patient seeking care at the best possible price. The market is ruthless at decreasing costs. Medicine should be allowed that privilege. Physicians would be up to the challenge.

Once located, the toilets were quite unusual. I had never seen waterless urinals before. It was interesting to see the men all aim for the glistening porcelain hemisphere and watch the “golden glitter” turn crystal clear. Was it being recycled? Was the ladies room also waterless? I asked one woman attendee and thought for a moment I was going to get slapped.

Fortunately, my AT&T cell phone died three weeks before I left on the trip. My Nextel replacement with GSM technology, good in 75 countries, let me stay in touch with my office for 99 cents. It worked equally well in France, Monte Carlo and Italy. AT&T’s telecommunication pre-eminence has become nearly irrelevant.