Medical Gluttony

Current Issue

Frequently not recognized by patient, family, hospital, or physician

The perspective of a pulmonary consultant occasional provides an overview of medicine. Recently a patient was referred for consultation of an emergency room evaluation. The family was very concerned over the report of a very abnormal chest x-ray.  The report indicated right middle lobe collapse, interstitial infiltrates, calcified pleural plaques, and possible pneumonia. 

I remembered him from previous consultations. He looked like a robust 70 year old Eastern European. He didn’t appear ill and looked about as I had remembered him. The son, who also served as the interpreter, re-expressed the concern of a serious and grave illness. Since his chart had been retired after five years of inactivity, a search of our computerized files found our previous consultations of 2001 and 2008.

As I perused my previous consultation, I read aloud my concern about his abnormal chest x-ray in 2001, how the patient had recalled that he had a similar abnormality of his middle lobe in Hungary in 1981, he had had a bronchoscopy which revealed a narrowed bronchus to the middle lobe, that biopsies were obtained and no cancer was found obstructing the middle lobe which is a common presentation of a middle lobe lung cancer. “But is the x-ray the same?” I stated that it is impossible to ascertain if they are identical without seeing the x-ray side-by-side on my viewing box, but that considering one radiologist reading the films in 2001 and a different radiologist reading the film in 2013, it would certain appear that they were describing essentially similar films.

“But dad is so much more short of breath,” he said. “Well then, why don’t we measure his pulmonary function and determine why he’s so short of breath.” I found his old PFT on my laptop and printed it out showing a mid-expiratory flow rate of 14% of normal, and then did a current PFT which showed the same flow parameter at 12% of normal. The son immediately mentioned that his dad had obviously gotten 2% worse. I pointed out that this was probably within the standard deviation of testing and was really the same value. The son breathed a sigh of relief and the patient just smiled broadly as if he never had any concern.

Looking over the 41 pages of emergency room testing, it was apparent this was well beyond the usual average of $9,000 for an emergency room visit and was more like a $20,000 relatively “non-transparent” charge. How can these costs be controlled? This has occurred over a long period of government meddling into physician work hours, giving ER evaluations greater latitude in charging Medicare, and lack of patient copayments and deductibility, all previously discussed in this column.  

Since the initial complaint was chest pain, and the initial electrocardiogram was normal, a 20% copayment on a $200 ECG may have satisfied the family that he wasn’t having a heart attack. If they had stopped the testing at this point when their 20% copayment was $40, it would have save Medicare more than $20,000 in costs. If the patient had gone to the same hospital emergency room where his first 2001 tests had occurred, the initial $250 chest x-ray could have been compared to the previous one and the 50 copayment may have satisfied the family and the $20,000 in hospital costs could have been contained. If the patient would have come to the same consultant in the office that saw him in 2001, a clinical diagnosis could have been made of no change. If the family anxieties could have been relieved at that point, then the whole $20,000 cost could have been contained. Continuity of care may be the biggest restrainer of health care costs increases.

But as long as the medical illiterate control the White House, the Congress, and the AMA, reason will never prevail.

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Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

Medical Gluttony

Current Issue

Electronic Prescribing, Automated Refills, and Obamacare.

Mr. Tullman, who left Allscripts late, last year . . . characterized his activities in Washington as an attempt to educate lawmakers and the administration. “We really haven’t done any lobbying,” Mr. Tullman said in an interview. (See reverence in section 4 above)

Between 2008 and 2012, a time of intense lobbying in the area around the passage of the legislation and how the rules for government incentives would be shaped, Mr. Tullman personally made $225,000 in political contributions Mr. Tullman said his recent personal contributions to various politicians had largely been driven by his interest in supporting President Obama and in seeing his re-election. . .

Industry executives say that big digital records companies like Cerner, Allscripts and Epic Systems of Verona, Wis., have reaped enormous rewards because of the legislation they pushed for. “Nothing that these companies did in my eyes was spectacular,” said John Gomez, the former head of technology at Allscripts. “They grew as a result of government incentives.” . . .

“We called it the Sunny von Bülow bill. These companies that should have been dead were being put on machines and kept alive for another few years,” said Jonathan Bush, co-founder of the cloud-based firm Athena health and a first cousin to former President George W. Bush. “The biggest players drew this incredible huddle around the rule-makers and the rules are ridiculously favorable to these companies and ridiculously unfavorable to society.”  

The major push for electronic prescriptions was to capture the refill market, usurp the doctor’s responsibility for prescribing by making all prescription essentially freewheeling over riding the doctor’s refill limit which is geared to the needs for re-evaluation of the patient. In other words when a physician evaluates and exams a patient, reviews the lab work, x-rays and other procedures, the physician proceeds to the treatment plans and determines a safe interval after which the patient needs further face-to-face reevaluation. Hence, there should never be a need for the pharmacist to request a refill. For physician to respond to a fax refill request, without reviewing the chart when at the previous office visit the physician has decided on the appropriate interval, would lower the quality of care. To superficially review a chart to see if a premature renewal would jeopardize care would a clerical nightmare, time consuming of about one-half of a follow up unscheduled office visit. If the patient or insurance company paid for that like other professions get paid for the time spent, whether in conference, on phone, or email, this harassment wouldn’t be near as painful or costly.

I was at a health care meeting when the electronic prescribers held forth and bragged about being able to gender refill requests by sending a fax request for refills when the doctors considered opinion was to limit the refill requests to remind the patient that further re-evaluation was needed before the prescription was renewed.

The Allscripts reps couldn’t understand why any doctor would want to eliminated the fax reminders that the prescription had run its course. Doesn’t this just make things run smoother?

The prescription drug executives do not understand the basic nature of health care.  To interfere without understanding can be very hazardous in medicine.

 I tried to explain that they were sending fax refill requests when the last prescription was picked up and sometimes several times a week adnauseam. What they should be doing is reminding the patient that this was their last refill and they needed to see their doctor for reassessment as to the continuing need of this prescription, a possible change in medications, or a renewal for a safe period of time before the further assessment would be required. If it was a 30 day refill, the patient might be reminded that they have 30 days to see their doctor. If it was a 90 day refill, they would have 90 days to see their doctor.

Recently I was only seeing male patients for three days while my wife and office manager/assistant was visiting her sick father in Florida, I read the faxes that were dropped into my computer each day at 7 PM when I finished my patients. I counted more than a hundred refill requests each day when there should have been none. In the past I would have shredded 100 sheets of paper per day and destroyed at least one tree per day. Now they come into our computer and I could read them and deleted them electronically without such a waste of paper.

In California, controlled substances such as a hypnotic or tranquillizer required a doctor’s re-assessment after four refills. For narcotic controlled substances, a patient reassessment is required after five refills. For a pharmacist to try entice further refills by fax, without the face-to-face reassessment, can precipitate Quality of Care as well as legal issues.  There are a few frequently abuse controlled drugs that can’t be refilled at all. These patients require monthly exams to obtain these drugs. To give these patients two prescriptions with different dates so they could come in every other month, instead of monthly, could be interpreted as a major violation and make the physician liable for a felony conviction. These may not be medical limits in some patients, but they are legal limits and thus equally hazardous for the physician if not followed.

In California the medical practice act prohibits treatment without a current medical examination. A current medical examination has generally been interpreted as being examined within a year. If the patient has stable disease, whether arthritis or heart disease, we would generally give refills for the entire year. A faxed refill request may run afoul of the medical practice act which is policed by the California Medical Board (CMB) which monitors our license to practice medicine. To jeopardize our license to practice medicine is a serious threat to our future as well as our family’s future.

A physician who is diligent in writing hypnotic prescription with 4 refills, narcotics with 5 refills, and routine medications with 11 refills, should never hear from the pharmacist to vary this. The pharmacist’s job after the prescription has run its course is to remind the patient to make an appointment to acquire a new prescription from his/her physician.

So with a 100 fax refill request in a single day it would require an extra 300 minutes after hours to review the charts to make sure no medical jeopardy in Quality of Care (QOC) issues were present or legal jeopardy was incurred. If my office manager was present, she would have the same 300 minutes of work with no reimbursement.

Notis Brevis: Before you feel the above is an exaggeration, we have just completed a six-month request to see Medicaid patients that Obamacare had placed into HMOs. We had 600 patients added to our rolls. The very first day they were placed on our list, we have had up to 150 messages on our phone each day of which 100 were refill requests. These came in during each of the 24 hours of day or night. We at once realized that none of these new enrollees had jobs or worked, they all had cell phones which explain the day and night requests since these were men and women essentially at leisure without any time frame.

My wife normally would come to the office and respond to the three or four phone messages, and then get on with the day’s work. During these six-months, she spent three hours every morning to record the messages and another two hours to process the requests. Our HMO felt no obligation to reimburse us for this additional work. Thus my front desk had five additional hours of work each day for no pay. We were promised these patients would be paid on the Medicare fee schedule for the first visit and all subsequent visits would be 10 percent above MediCal rates. It took us a while to figure out why our income had dropped so precipitously. Instead of $18 for a MediCal office call, we were now paid $19.80. We were forced to terminate what we had hoped was our obligation to the poor. But we were getting poor in the process and unable to pay our taxes.

Every single function with this new category of care took immeasurable longer. Doctors that saw referrals for us would not accept this new hybrid of welfare/ HMO patient. After working for hours on one referral, my wife found a consultant in a town 50 miles away. The next time she tried to use the same consultant; his practice was closed to this hybrid. We had one specialty referral that no one of the 4000 physicians in Sacramento, would accept, and the HMO called and said they found someone in San Francisco (100 miles from Sacramento) that would see her. We actually had one patient willing to make this trip before that practice was closed to this hybrid of welfare/HMO.

Thus this monstrosity of Obamacare which was to make health care more accessible has, in our experience, made healthcare less accessible and in several cases, totally inaccessible.

Medicine during the days of the county, city and state hospitals was a two-tiered system. Unfortunately it still is. With the entitlement mindset, it will always be.

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Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

Medical Gluttony

Previous Issue

The Cure

There is a striking difference in those that have pure Medicare with a personal liability of 20 percent of outpatient charges and a fixed copay of hospital admission charges and those that have Coinsurance that pays the copayment liability, the annual deduction liability and the hospital admission charges. The latter, sometimes called MediGap insurance managed by HMOs, also pays for a host of other benefits which formerly included pharmacy benefits. 

The copayment places health care in the private economy where every health care cost is evaluated by the patient on a cost/health benefit basis. This is where health care evaluation should occur—by the patient, not the government or insurance carrier.  If the physician cannot justify the benefit to the patient or his family, the patient declines the test, procedure,  consultation, operation, MRI, CT, PET scan on the basis that his/her benefit is less than the 20 percent copayment cost. He/she will then save the 20 percent copayment, but Medicare, Medicaid, Blue Cross, Blue Shield, etc. will save the other 80 percent. The financial savings is quite variable.  The individual variation in a complicated field such as health care is great. As is obvious that in this example, the patient variation will be somewhere between 20 percent for those that accept the physician’s recommendation of the cost of the recommendation to zero, for all patients who judge that the cost/health benefit ratio is unacceptable and thus decline the physician’s recommendation. Thus on a $1500 MRI not chosen because it failed the cost/health benefits ratio but is “free” in the HMO environment and thus chosen by the patient, is very costly to Medicare or other insurance carriers.  This type of health information does not lend well to double blind studies. Thus it is not generally accepted by the Tax & Spend political establishment because they do not understand the cost of unnecessary health care. They do not understand how any health care is unnecessary.

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Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

Medical Gluttony

Past Issue

Health Insurance without Copayment Causes Medical Gluttony

For the practicing physician, the difference in appetite for tests, procedures, consultations, operations, MRIs, CTs, PET scans for those fully insured and those with a significant deductible and coinsurance is phenomenal. It is most striking in those with high deductible insurance. With high deductible insurance, which is keyed to the average yearly cost of health care, every single item is evaluated with a cost/health benefit comparison. It is essentially private personal health care with the insurance kicking in only after the average healthcare costs for the average person for the year has been spent.

Patients with this type of plan always tell the doctor or his receptionist the nature of his insurance. He or she understands the yearly annual medical history and physical examination. When it comes to the rest of health care, the differences become obvious. Patient with usual insurance will expect such things as annual blood tests, x-rays, electrocardiograms even if not indicated. They will want colonoscopies starting at age 50 and every five years when the experts state that those without risk can wait to age 55. Without a family history of colon cancer and no polyps found, the GI experts state that the second one should be in the mid to late 60s. In this instance the HMOs have essentially doubled health care costs.

The line of demarcation is so clear that if a patient has been mailed the former recommendation, he or she will demand it and if the physician doesn’t comply report him to his HMO. Straightening this out will take hours of physician time in explaining why. The patient with deductible and copayment responsibility will accept the physician’s recommendations rather than the HMO recommendation. Thus halving his health care costs and staying in the highest regions of quality of care curve.

This pattern replays essentially in all areas of health care costs.

The surprise is with the current government interference in health care as pushed by the HMOs is really HealthCare Gluttony, that HMOs formerly prided themselves on avoiding. This is a rather striking change over the last two decades of non-medical personnel influencing the physician in what they think is appropriate, if for no other reason than a government mandate.

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Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

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