Overheard In The Medical Staff Lounge

Current Issue

A Simple Way to Kill Yourself Without Assistance

Dr. Rosen:      There is an increasing emphases of Doctors assisted killing their patients. Is it appropriate for the messenger of healing to assist patients in terminating their lives?

Dr. Milton:      That is a very disturbing question. And our professional organizations seem to be advocating this.

Dr. Ruth:        I would never have thought that when I went to medical school such a subject would ever be considered.

Dr. Michelle:   I would not and could not be involved in such a travesty. 

Dr. Sam:         It beats anything that I could have ever imagined.

Dr. Patricia:   It certainly makes me feel uneasy with my own professional colleagues.

Dr. Edwards:  Let’s think about this a moment. What do you think will be the ultimate outcome of this?

Dr. Sam:         I know a lawyer with Merkel Cell CA in his thigh that invaded his femur when it became very painful. He told his wife let’s move to our vacation home in Oregon so I can put an end to this suffering. 

Dr. Edwards:  But dying is not a painful proposition. We have plenty of drugs now to let everyone die in comfort. Why not let nature take its course?

Dr. Rosen:       I don’t think the general public believes that. It’s not been so long since many people didn’t want to be around a dying person. Some were so petrified they sent them off to the hospital to die. And after they died, they left the bed unable to even touch their loved ones.

Dr. Edwards:  Then we went through the long ethical dilemma. How to let our patients die? We couldn’t even let our terminal patients die in peace. When the heart stopped, we pounded on their chests, frequently breaking ribs. If they survived, they would really have severe pain from fractured ribs. The respiratory therapists were always nearby with their ventilators waiting for the doctors to intubate the dying patient so they could hook them up to breath for them.

Dr. Rosen:      Then we had a real ethical problem. Can we ever turn off the ventilator? Isn’t that called Mercy killing? Isn’t that criminal? A felony?

Dr: Yancy:      But the hospitals loved it, especially while the ventilators were running and collecting revenue by the minute, by the hour, by the day . . . by the month . . . by the . . .   until the court allowed the doctor to turn off the ventilator.

Dr. Rosen:      That could take a week or more after the patient had effectively died.

Dr. Yancy:      You can see why hospitals love it. At $500 an hours, the weeks, months, etc. was a gold mine for the hospitals.

Dr. Edwards:  Remember the Karen Quinlan fiasco? When they finally got the court order to turn off the ventilator, Karen kept on breathing.

Dr. Rosen:      Which goes to show you what actually happens when lawyers and courts practice medicine. Doctors no longer provide appropriate care. They are unable to make appropriate medical decisions—like checking for spontaneous breathing when making rounds.

Dr. Edwards:  Maybe Karen was able to breathe on her own six months earlier on her year-long expensive life-support ventilator care.

Dr. Milton:      Can we explore that possibility a little more? Let’s assume that without the court interference, and the doctors would have followed normal quality of care, they might have found that she could have been breathing on her own 200 days earlier without life support. Now just take the cost of daily life support in your hospital. We know it’s quite variable. To be in the ICU costs several thousand dollars a day. Then add on the charge for life support which will also be several thousand dollars a day. Looks like the 200 days could add up to more than half a million dollars saved in hospital charges. Before long, you’re talking real money.

Dr. Rosen:      Some physicians felt collecting an ICU treatment charge every day was gouging the system. And when they addressed it, the hospitals did not understand why. I remember once when I was managing a patient on life support who also had an infection, the infectious disease doctor suggested that we both continue to see the patient every day but only put a charge in every other day.

Dr. Milton:      When the hospital administrator heard this, I bet he thought you were stupid. Wasn’t the name of the game to charge whatever the traffic will bear?

Dr. Rosen:      That’s what the hospital thought and how the hospital practices. It is unfortunate that the lay public doesn’t believe that doctors are cost conscious.

Dr. Milton:      That’s because some doctors do gouge the patients.

Dr. Rosen:      How do the new staff members view this?

Dr. Ruth:        I think most of them go with the flow. They don’t want to make waves early in their careers .

Dr. Rosen:      Most of them have government sponsored debt. So they have become slaves to the government. So the next generation of physicians will no longer be independent. They will practice by whatever rule they think will prevail and get their student loans paid. They no longer will be a servant to their patients.

Dr. Michelle:   How sad.

Dr. Rosen:      But they may think they have the patient’s best interest at heart, even to the point of Mercy Killing.

Dr. Ruth:        Tragic!

Dr. Rosen:      And that’s why it’s hard to have an ethical discussion about doctors being an accomplice to the patient’s suicide vs murder.

Dr. Yancy:      I caution patients who are on Beta Blockers for their high blood pressure what could happen if they over dose on this medication. They already have low blood pressure on the medication and their heart rate goes down to the 40s.  I tell them if they took 5 or 6 of  these as they are about to retire, their heart rate could go down into the 30s and their BP could drop into the 60s. Then if they took twice that many when they turned off their bedside lamp, their pulse would continue downward and their blood pressure would drop even further. Then the brain and kidneys would not be perfused and they would sleep  very soundly. They may then not awaken in the morning. If that is their intent, be sure to tell your wife that you love her and that you’re not feeling well and will retire early.

Dr. Rosen:      You’ve just outlined why Doctors never have to put a needle in the patient’s vein and inject anything lethal to assist in a suicide. Let the patient do it on his own and keep your white coat on. Never wear the black coat of the executioner.

Dr. Edwards:  Yes, let’s not be an accomplice to killing.

Dr Yancy:       Beta Blockers give your patients a peaceful painless death.


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The Staff Lounge Is Where Unfiltered Opinions Are Heard

Overheard In The Lounge

Previous Issue

ICD 9 is being retired. Are you staying for ICD 10?


Dr. Rosen:      The latest word is that the International Classification of Diseases, 9th revision, which was supposed to be retired in Oct 2014, had a one year reprieve to Oct 1, 2015. Has anyone heard anything differently?

Dr. Ruth:        I understand that insurance companies were unable to make the changes by Oct 2014 and thus the delay. We’re getting ready to convert in October.

Dr. Edwards:  We’re still discussing whether we want to proceed. We’ve gotten so many offers for training with ICD 10. We haven’t bought any of them yet. We thought we’d hang low.

Dr. Michelle:   We’ve not gone to any of the training courses. They seem rather expensive.

Dr. Milton:      There are always those who will make money on any program shoved down our throats.

Dr. Patricia:   Our Practice Fusion Electronic Medical Records is all geared up to substitute the new codes in October. Their training videos are free to users. They also state that they would help us walk through any problems we might have.

Dr. Edwards:  We also have Practice Fusion which is now the largest and most popular EMR for Medical Offices. It’s on par with EPIC for hospitals which Kaiser Permanente spent billions on installing. It works very well to interconnect their 20 medical office buildings and three hospitals in Sacramento.  What is the down side of using ICD 10?

Dr. Rosen:      Remember we had a physician in Sacramento go to jail for 22 months for using the wrong ICD 9 code 20 years ago. But ICD 9 has 16,000 codes. The new ICD 10 has about 68,000 codes. Then there are the Current Procedural Terminology or CPT codes which are also extremely important.  In fact one has to have the correct diagnosis that justifies the procedure. The data reflects that 59% of doctors disagree with the Centers of Medicare and Medicaid Services (CMS) as to what are the correct codes. Hence, in any dispute, CMS could put up to 59% of physicians in jail with our present code structure.

Dr. Edwards:  I think you have just convinced me that I must eliminate Medicare and Medicaid by October 1, 2015. There are already a dozen different codes for the various cardiac diseases. I see what you mean. With four times as many codes, it may be difficult to make the correct diagnosis in heart disease without a cardiac cath.

Dr. Milton:      You’re giving me major trepidations on the ICD 10. I never even considered eliminating Medicare and Medicaid. I understand there are huge risks involved in resigning from Medicare. We had our practice evaluated for a Concierge practice and the numbers didn’t add up. And if you jump through all the hoops of resigning from Medicare, you can’t let covered patients pay you. What to do? Become an employee again?

Dr. Dave:        The law doesn’t allow the corporate practice of medicine. The corporation can influence your medical decisions. Hospitals are getting around that by forming Medical Foundations which is only one step removed. One such foundation bought up a large number of medical practices and paid a salary of $180,000 according to some people that should know. The doctors were given a two year contract. They had plush surroundings. Hallways twice as wide as most medical office buildings. Rest rooms twice as large. But expenses caught up with them. When the two year renewals were given, the salaries dropped to $140,000. The local paper last week featured a journeyman plumber who made $120,000 a year. He had On-the-job journeyman training, no college. Physicians generally have 8 to 12 years beyond college of post-graduate and post-doctoral educations and training. How did this de-professionalization occur?

Dr. Rosen:      That’s a huge topic for another day. But at this time we all have to make a decision as to what we’re going to do by October 1, 2015. I have made mine. I placed a sign in my office on January 1, 2015, wishing them a Happy New Year and stating that this office would close on June 1, 2015 and we would do no insurance billing after July 1, 2015. That will give me three months to complete all my insurance billing and collections. I’ll put my charges on my Bulletin Board by next month. Those that wish to continue in my practice can do so by paying at time of service with cash, credit card or check. Each patient account will close at the completion of the visit with a super bill in their hand for tax ID purposes. I think this may be the first step in reassuming medicine as a profession. I may not be able to charge $50 for a 1-15 minute phone consultation and $75 for an email consultation like my attorney does. But I will charge $10 for a phone call and $25 for an email all through my Practice Fusion EMR which can record them in HIPAA compliance and charge the patient’s credit card, should they wish this service.

Email any comments to medicaltuesday@earthlink.net  (Earthlink.net uses only lower case letter)


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The Staff Lounge Is Where Unfiltered Opinions Are Heard

Overheard In The Lounge

Past Issue

Medicaid patients with HMOs think they are insured

Dr. Rosen: Now that Obamacare has been implemented, how is that affecting our practice?

Dr. Dave: It has increased our complement of Welfare Patients under the illusions that they are now in an HMO. 

Dr. Sam: But they aren’t like an HMO patient. The new clothes has not made a difference in how he acts.

Dr. Edwards: Just giving someone new clothes does not change the person.

Dr. Milton: New clothes do not change the man unless it changes his perception of who he is. And that doesn’t usually happen. My psychiatry colleagues say that they have difficulty in doing that even with two or three years of talk treatment.

Dr. Ruth: We receive a number of requests daily from welfare patients who try to avoid stating their previous welfare or Medicaid status. They feel they are now first class citizens with an HMO. But my front office is very skillful in picking up from their language that they are medical recipients in sheep’s clothing.

Dr. Edwards: Isn’t it tragic how these Medicaid and welfare patients think that now they have HMO coverage, that they have usual insurance. Some have even told my staff that they have called more than a dozen physician’s offices and none were willing to accept them.

Dr. Patricia: We are also receiving a number of calls daily from patients who think they have health  care coverage under the new Obamacare. These have to be dealt with very carefully.  Once they get into your practice, it’s very hard to get them to move on. They act very litigious. And litigious threats can become lawsuits which will tie you up for months and  possibly for years and bankrupt you.

Dr. Milton: Physicians at the Association of American Physicians and Surgeons have shown for more than a decade that having insurance may not provide you with health care.

Dr. Rosen: Let’s not forget the famous case in Canada where Dr Jacques Chaoulli went before the the Canadian Supreme Court and Won: Final verdict: Canadians don’t have access to healthcare, they only have access to a waiting list. Isn’t that what Americans are learning from Obamacare. They don’t really have access to health care. They now just have an HMO card.

Dr. Milton: The person that implemented RomneyCare in Massachusetts stated that people are  basically stupid about health care. He then got a promotion to help develop Obama Care. He thought most Americans are equally stupid about their healthcare. 

Dr. Rosen: But it doesn’t stop there. The Congress has a confidence rating approaching 10%. The president has a confidence rating that’s now below 40%. Why would any thinking progressive or regressive or conservative American put any stock in any health plan  developed by these medical illiterates?

Dr. Milton: And we have to be very careful not to fall for another catastrophic political conundrum. I think that many Americans are not sufficiently aware of Governor Romney and Governor Christie being RINOs, Republican In Name Only. If such a person would be nominated for president, that would spell the death knoll to the Republican Party. And then Goodbye to the American Dream of Freedom that is scarcely two centuries old. Hillary has said Americans have too much Freedom. It’s hard to socialize and restrict freedom without being a tyrant which she would be good at—probably as good as our current White House occupant.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard

Overheard In The Lounge

Past Issue

How can we reduce reversed race riots?

Dr. Rosen:      The events of Ferguson, riots, continue to have huge medical implications.

Dr. Sam:         But the riots didn’t start until Jesse Jackson arrived and stirred up his base. 

Dr. Dave:        Without Jesse Jackson, there probably would not have been any riots.

Dr. Edwards:  That’s probably correct. Racial prejudice today is primarily from the black against the white.

Dr. Milton:      Talk radio suggested that Black people are more prejudiced than the white.

Dr. Edwards:  Maybe we are placing the emphasis on the wrong end of the problem?

Dr. Rosen:       Our editor has just eliminated the rest of this column feeling it would be misinterpreted by some.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

Overheard In The Lounge

Past Issue

How can we control health care costs?

Dr. Rosen:      Last week we discussed how dangerous “Repeal and Replace” would be. No one has really outlined a simple replacement for the thousands of pages of Obamacare. What changes would you make? 

Dr. Sam:         I think our system was actually rather good. We had Medicare for the seniors over 65 and those that are disabled. We have Medicaid for the poor who can’t afford private care.  Everyone else should be working and thus are covered through standard insurance.

Dr. Yancy:      I think we have the level of what constitutes the poor set too high. It should never include  more than the bottom 12% to 15% of society. I’m sure that income follows a bell curve. One could make a case that those that are more than 2 standard deviations out from the mean are truly poor.

Dr. Edwards:  That certainly would make more economic sense than just taking items that a group think are necessities. The cost of food is easily calculated. Clothes are more difficult. Some  will “need” clothes that are twice as expensive as others. There are many factors of taste. Having a committee like approach will exceed what is absolutely necessary. There will never be agreement as to what is necessary.

Dr. Milton:      Drinking, smoking and gambling habits are really variable. I have people of welfare smoking two or three packs per day. Some that drink a fifth of Vodka a week.

Dr. Ruth:        I have one welfare family that spends one entire welfare check a month on a trip to Reno to gamble. I think we have to call that a disease. We had dinner with one couple there and they were dropping quarters in the slots as we were in line for a buffet. When we got to  the food he had won one small handful of coins and bragged about his winnings. He totally discounted the money he lost and chalked that up to pleasure and vacation spending.

Dr. Kaleb:       Remember when President Clinton said welfare should be limited to couple of years. We saw many of our Medicaid patients obtain a job rather quickly rather than wait out the two years.

Dr. Patricia:    I see many of my patients go to the ER rather than come to my office for routine  complaints because of evening conveniences.

Dr. Michelle:   That’s a significant excessive or glutinous cost since ERs are never less than $1500 when office calls are about $150.

Dr. Rosen:      What if we had a $50 ER copay and a $5 office copay? How would that change the equation?

Dr. Milton:      I don’t think any of my Medicaid patients would pay $50 to go to the ER. They would see me the following day.

Dr. Edwards:  I second that.

Dr. Rosen:      It seems like we could save about 80% in this segment of society with just a reasonable  and affordable copayment. If we just keep adding up all these savings, health care costs would plummet. At least in the Medicaid portion of society.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

Overheard In The Lounge

Past Issue

Repeal & Replaced are two dangerous words

Dr. Rosen:  The T-S-R folks are searching for new items to levy taxes on. Obama care has latched on to medical equipment as a new revenue source.

Dr. Edwards:  That should be one of the first items that the new congress repeals. That’s an unnecessary cost for health care which in turn is used for other government largess.

Dr. Milton:  What about the new taxes on the Internet for interstate commerce items? Catalog items, which is a similar trade, have been free of taxes for a long time if they were sent interstate.

Dr. Rosen:  The volume of catalog items has never been increasing at a rate that interstate items have increased in recent years. Government Taxing authorities are seeing internet sales as a gold mine for increasing their revenue and power.

Dr. Dave:  And for enlarging the size and inefficiency of government which in turn will also increase our personal income taxes as well as other taxes.

Dr. Rosen:  We were in SF last week and it’s always enlightening what the center of the T-S-R folks are doing. Condo owners are complaining that the taxes on their parking space is equal to the taxes on their condo. The owners complained that is not their understanding of the intent of the last SF initiative. The city stated that was the way they understood the law. The condo owners asked how could they appeal? The city said, “There is no appeal. Your parking space has a separate parcel number and therefore is subject to the same taxes as your condo”

Dr. Edwards:  What a devious way to double your taxes!

Dr. Dave:  How can we stop this runaway government?

Dr. Rosen:  That’s not all. They also tax the size of your roof in addition to the size of your house.

Dr. Edwards:  I don’t think this can be stopped outside of the political realm. We have make sure to reduce the number of sympathetic T-S-R folks in Congress and the Legislatures.

Dr. Milton:  We have to be very careful not to over react. Otherwise the election two years from now could go the other way.

Dr. Rosen:  I completely agree. I think the two most dangerous words the conservative use about the new health care fiasco is “Repeal and Replace.” No one has designed the “Replacement” yet that the people will support.

Dr. Edwards:  That’s why we have to chip away in increments, like the tax on medical equipment.

Dr. Rosen: Remember President Ronald Reagan. I’m sure he would have like to repeal Social Security and Medicare and Medicaid. But having people on SSD be reexamined saved a lot of money. Most work injuries don’t last a lifetime but generally just a few years. So  he was able to remove a large number of people who no longer were disabled from the disability roles. That was a big savings to tax payers.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

Overheard In The Lounge

Past Issue

How to Survive obamacare

Dr. Rosen:      The elections are upon us and we have doctors running for office.

Dr. Dave:        But they are all running in the wrong political party.

Dr. Yancy:      It’s hard to understand why former colleagues in this room are now running on the Tax & Spend & Regulate party? We have traditionally been in the freedom party.

Dr. Sam:          Physicians have come over into the T & S & R party for a number of years. What makes us think we have so much power that we can gain more by this force than in the free market?

Dr. Rosen:      Do you think physicians still have the prestige that most of us think we have lost by this  fringe group. I'm not sure that we've retained any of it.

Dr. Edwards:  I agree. I still frequently see physicians make such embarrassing statements as don't you give doctors a discount?

Dr. Dave:        Now that's just as bad as I saw overseas when I over heard, "Don't you give us Americans a discount?"

Dr. Yancy:      Now that we've discounted all of healthcare in this country, are the T S R's happy?

Dr. Paul:         I guess you're putting me in the T S R group. Let's face it there are a lot of poor people in whom having Medicaid is appreciated. We have had a Medicaid practice and that hasn't changed. What's your problem?

Dr. Milton:      Now that Obama has solved the health care conundrum in this country, by over filling the Medicaid folks, has he really made health care available as was advertised?

Dr. Paul:         My Medicaid practice is as full as ever. I have to see 8-12 patients an hour to fit them all in.

Dr. Rosen:       Let's see. At 8 patients per hour or two every 15 minutes or a patient every 7-1/2 minutes, how can you deliver any good Quality of Care? If it takes you two minutes to record your visit, can you even get the chief complaint and good vital signs in 5 1/2 minutes?

Dr. Paul:         Remember these are poor folks, some are destitute, they are happy with any attention  they get and even one prescription is a treasure for them.

Dr. Edwards:  I guess I've heard of the physician who had no exam table, no writing desk, and only one wall writing area for the chart. The nurse brought the patient in, the doctor started talking as the patient walked towards him, he started writing the prescription which he handed to the patient as he walked past him with his stethoscope out to catch one or possibly two              breaths and then shake hands as he escorted him out the second door.

Dr. Paul:         I have an advanced EMR program. I just need three words and the program types up the entire history and physical exam in a logical format.

Dr. Rosen:       You've got to be kidding.

Dr. Paul:         I just have to mention the organ system, such as "heart" and then one symptom, such as "can't sleep flat" and then one drug for the prescription that I've already written like "diuretic" and my favorite diuretic is already programmed into the system and, voila, the  chart is completed, I sign it, and walk to the other door to greet my next patient. Five minutes max. I've gotten up to 10 or 12 patients an hour.

Dr. Rosen:      What if you have a CMS (Center for Medicare and Medicaid Services) review?

Dr. Paul:         I've already had a review. They thought for a family doctor I had one of the most complete records they had seen.

Dr. Rosen:      So if you can maintain the pace of 10-12 patients an hour at $150, you're making $1500 to $1800 an hour or $15,000 to $18,000 a day.

Dr. Paul:         Why do you think Medicaid reviews me? You just have to run a tight ship.

Dr. Rosen:      If your schedule were made public, CMS would cut the re-imbursements drastically. And the internists among us that see four patients an hour would have to get another job.

Dr. Paul:         That's your problem. As you can see, I'm making a lot of money on Obamacare.

Dr. Edwards:  I don't think any patient of mine would come back after a 5 minute appt as you describe it.

Dr. Paul:         So all doctors with sophisticated care as you have as an internist would go under. My practice with minimalist care that follows the letter of the regulation to a "T" would survive.

Dr. Edwards:  But do you think your minimalist care is good Quality of Care, the Hall Mark of what is proposed by CMS?

Dr. Paul:         That's not the issue in Obamacare. Your care has to pass Obamacare schedule of rapidity of care to meet the deluge of patients enrolling and still meet the CMS guidelines of their QOC. You're meeting the CMS guidelines of care which may yield higher QOC. But you will only be able to see about one-fifth the number of patients, and unless you get rid of most of your support staff, you won't be able to meet your mortgage and practice obligations, much less have anything left over for you and your family.

Dr. Edwards:  So in reality you're saying that I have to lower the quality of care.

Dr. Paul:         Would you like for me to spell that out for you?

Dr. Edwards:  No thanks. You come across loud and clear. No one in Washington has ever made it any clearer.

Dr. Paul:         Why should they?

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

Overheard In The Lounge

Past Issue

Insurance companies practicing medicine

Dr. Rosen:      The other day my doctor asked me what I did with all the information I received from our patient’s insurance carrier telling us how to care for our patients. How do most of you handle that scenario?

Dr. Edwards:  I frequently scan the letter if I have an extra 30 seconds and then I toss it.

Dr. Milton:      I usually give it a five second glance and then toss it. . .

Dr. Ruth:         I read the first 20 or 30 before I realized that they were all government induced and thus of little importance except for their bracing for their own legal defense from a hostile government.

Dr. Joseph:     As a retired surgeon you’d be surprised by the number of letters I still receive from insurance companies and pharmaceutical companies. That cost is a total waste of health care dollars. And I’m not sure what the reasoning it.

Dr. Michelle:   I have my staff attach these letters to the patient’s chart so I can quickly cross check the topic with the patient’s medication list if from a pharmaceutical company or against the patient’s diagnosis list if it’s from the CMS (Center for Medicare and Medicaid Services).

Dr. Rosen:      Much of this imposition of our time is no longer letters, brochures, or even samples. The new twist is a CD or even a CDROM from an insurance carriers, HMOs, IPAs, as well as pharmaceuticals in providing. I actually inserted one of these monstrosities into my computer, and within just a few minutes I had a giant textbook of information on display.  It seemed like an 1800 page textbook of pharmacology. Since I had patients waiting, I had no time to peruse this any further. In fact, I never had an opportunity to return to this disk.

Dr. Sam:         I had similar experiences. After tossing the first few, I started using those CDs as mats for tea or coffee cups.

Dr. Patricia:   Thanks Sam, that’s a great idea to make use of those CDs. I always hate to throw useful things away.

Dr. Paul:         I seem to keep everything that’s sent to me. I have books, journals, by-laws, drug company paraphernalia, and patient derived trinkets all over my office.

Dr. Patricia:   Don’t the patients feel you might be a little disturbed mentally?

Dr. Paul:         I don’t know. But so many of them seem to be impressed by what they see.

Dr. Rosen:      I have a small sculpture of a silly old dog standing upright with a white coat and stethoscope that catches the fancy of just about every patient that comes in. I’ve kept it there for years. It’s even gotten a smile out of some of the most sourpuss patients in my practice. That’s worth its weight in gold.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

Overheard In The Lounge

Past Issue

What is a doctors biggest challenge? Obstacle?

Dr. Rosen:      What are the biggest challenges we face?

Dr. Edwards:  Drowning in the minutiae of life. The things we have to do that don’t help us, our patients, society, or the cost of healthcare.

Dr. Ruth:        That’s an interesting way to put it. I think of all the ways insurance companies prevent patients getting the best care. We have to complete enormous amounts of forms and justification for everything we do. Doesn’t anyone trust us anymore to do the correct thing?

Dr. Milton:      Does any of that improve patient care? I don’t think so.

Dr. Sam:         I agree. In fact it decreases quality of care. Many times I think the care that I plan exceeds the care recommended by insurance companies.

Dr. Yancy:      Isn’t that the truth? The insurance companies, HMOs, Medicare, Medicaid all want us to work faster and be more efficient and they keep putting in road blocks so we can’t to do  that efficiently.

Dr. Rosen:      They think by eliminating tests and procedures they lower the cost of care. They can’t connect to the next level where morbidity increases and life takes a sharp turn to the left.    

Dr. Sam:         Of course a dead patient consumes considerable less health care costs.

Dr. Rosen:      But you best not mention that fact our loud.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

Overheard In The Lounge

Past Issue

What is the status of our medical coding situation?

Dr. Rosen:      What is the status of our coding situation?

Dr. Edwards:  The ICD 9 is now computer derived for diagnosis. If one’s diagnosis is accurate, the ICD 9–code should also be accurate. The highest risk now is the CPT codes - current procedure terminology.

Dr. Rosen:      The CPT code now is the libel factor. What is your input factor? Is it accurate and sustainable?

Dr. Edwards: I’m not sure facts matter anymore.

Dr. Rosen:      My estimation of my work and input is the best that I can do. Isn’t that enough?

Dr. Edwards:  That depends on the reviewer and his feelings towards you. Do you know him? Do you trust him?

Dr. Rosen:      Do you want your future dependent on his feelings at any given time? Do you want your future dependent on his decision?

Dr. Edward:   How unfortunate. Never in my life have I had to plan my future around an unknown decider?

Dr. Rosen:      Welcome, Edward, to the world of government health care. If you don’t survive, you can always return to Kansas and farm.

Dr.  Dave:       But you know, even the farms are controlled by the government. How many acres can they plant? How much will the wheat or corn be worth when you harvest?

Dr. Rosen:       The bureaucrats don’t really care. They make their income no matter if the farmers go broke or even if they went bankrupt.

Dr. Dave:        Unbelievable.

Dr. Rosen:      In Orwell’s 1984, the 30 year 2014 version would be the same. Nothing ever changes. The government will always put the proletariat back into chains. They don’t understand freedom, the very reason that America was founded.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

Overheard In The Lounge

Past Issue

Patients are the big losers in Obamacare

Dr. Edwards:  Anybody feel sorry for our patients in Obamacare?

Dr. Dave:        They voted for it. Why should we feel sorry?

Dr. Edwards:  But they didn’t know what they were voting for.

Dr. Dave:        But they should have known. It was the same garbage that the Tax, Spend, and Regulate (TSR) party has been spewing forth for several elections.

Dr. Rosen:      It’s like so many of our colleagues that have been in the TS&R party who are convinced it’s the progressive way of moving forward. They don’t understand that they are really the Regressive Party and moving backwards.

Dr. Edwards:  That’s like many of our Academic Colleagues.  They want to be the “Liberal” thinkers and don’t realize that the name change to Liberals was exactly the reverse of its intended meaning. They no longer have an open mind.

Dr. Rosen:      Their minds were closed to all progressive ideas. So they were truly regressive—returning to socialistic ideology—the ideas from which our forebears escaped.

Dr. Milton:      They are closed minded to all innovative thinking. And they want to be innovative?

Dr. Edwards: What about our colleagues at the AMA? Why did they support ObamaCare? Why don’t they understand the damage it does to their membership and our patients?

Dr. Rosen:      They are getting to be like the British Medical Association. The BMA is the official bargaining unit for the NHS. They are union workers.

Dr. Milton:      Physicians hopefully will never stoop to union status, collective bargaining, and striking.

Dr. Rosen:      That would be the death knell to us as professionals.

Dr. Dave:        But don’t you think that is the intent of Obama, the TS&R party, CMS, HMOs and others?

Dr. Ruth:        What a horrible thought!

Dr. Dave:        They want us all to be employees. Employees of the government, insurance companies, hospitals, industry, and anybody they can better control.

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Overheard In The Lounge

Past Issue


Dr. Rosen: A Retired Air Force Col told me in my private office the real story of Benghazi.

Dr. Edwards: The Benghazi story has really been hitting the news recently.

Dr. Milton: I wonder why this sudden interest is surfacing again. Read more . . .

Dr. Ruth: Aren’t they going after our Secretary of State?

Dr. Edwards: Going after? Or just trying to get at the truth as to whether she was derelict in her duties. This would give us some indication whether she was fit for higher office.

Dr. Rosen: Did you know that the White House has a Diarist?

Dr. Yancy: Is this a replay of the Nixon tapes? He wanted every word recorded to make the most complete and authentic record of a presidency ever?

Dr. Michelle: Those tapes did leave the Nixon White House and Nixon left the Office of the Presidency. But these records of the Obama White House would never leave the White House. How could they?

Dr. Edwards: There was a reporter who stated that someone had acquired a copy of the Diary. The President allegedly was in the Situation room on September 11, 2012, when there was a call about 10 PM. It was reported as being to or from the Secretary of State while our Diplomat in Libya was being sodomized by the attacking Muslims.

Dr. Rosen: Although we had jet aircraft on alert within one hour of Benghazi, the President and Secretary of State felt this assault on our Ambassador was retaliation for the anti-Muslim film that was shown that the Muslims felt was offensive.

Dr. Edwards: The Secretary of State felt this was an expected reaction to the film and it was probably best to low key this as she signed off and the president left for a political engagement.

Dr. Dave: Didn’t they realize that this was on the Anniversary of 9-11-01? Shouldn’t that have set off an alert like other anniversaries of 9-11-01 did?

Dr. Kaleb: Isn’t it criminal on the President’s part not to protect an official representative of his government?

Dr. Dave: Well, isn’t it criminal on the part of our Secretary of State to brush this off as our being offensive to Muslims and their response was appropriate?

Dr. Michelle: How can gang sodomizing ever be appropriate?

Dr. Edwards: After being in the situation room monitoring our international Ambassador being sequentially and repeatedly sodomized by the 50 or so Muslim intruders, could the President be so cold and non-caring that he could leave the situation room for an election debate?

Dr. Rosen: My ranking retired military officer stated that an estimated 50 Muslims sodomized Mr. Christopher repeatedly until he was near dead and then shot him so he wouldn’t suffer any more.

Dr. Ruth: I can’t even think they were that sensitive to his condition or show any compassion to his suffering.

Dr. Michelle: I can’t even think that our Secretary of State would be so insensitive to such cruelty. How could anyone ever think of voting for this incompetent inhumane woman for President?

Dr. Rosen: Don’t you think she feels so aloof from the average citizen that she feels she can masquerade herself as sensitive, caring person fit for public office?

Dr. Michelle: She’s not running for New York Senator, but for the Presidency of the United States of America. Doesn’t that require a higher ethical standard?

Dr. Rosen: I would certainly hope so.

Dr. Dave: And if she won, wouldn’t that tell the world we’re no better than the Muslim attackers and anal rapists?

Dr. Rosen: What is this country sinking to?

Dr. Edwards: When did criminal behavior in the civilized world become acceptable behavior?

Dr. Rosen: Maybe the world is getting less civilized.

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Overheard In The Lounge

Past Issue

Should Nancy Pelosi be prosecuted for malfeasance?

Dr Rosen: Is Obama Care in full swing now?

Dr. Milton: What is most amazing to me is how it even got to here. Didn’t Congress do due diligence on it?

Dr. Yancy: They haven’t even found one congressman or senator that’s admitted to having read the entire 2000 pages before voting.

Dr. Dave: Congress never does due diligence or we wouldn’t have so many unintended consequences after a bill is passed into law.

Dr. Ruth: I couldn’t believe that Nancy Pelosi admitted that she needed to have the bill passed so she could read it?

Dr. Yancy: Well I guess she didn’t want to waste her time if it didn’t pass? She must be one busy lady.

Dr. Rosen: But don’t we elect our representatives with the obligation to thoroughly research any measure before they make it the law of the land and force the citizenry to obey that law? Is it not Malfeasance in office not to even know the details of any bill that is passed? Isn’t that a prosecutable offense and grounds for impeachment?

Dr. Patricia: Rosen, you really make your point very clear about malfeasance. I just thought she was another incompetent member of congress. Yes, I think she should be prosecuted.

Dr. Joseph: Even though I’m retired, it pains me to see what’s happening to my profession. I think Nancy Pelosi demonstrates medical Illiteracy and incompetence.

Dr. Milton: You got that right, Joe. And so does our HMO which treats us as if we haven’t even graduated from Medical School with the mundane things they force us to do. One month they want us to give them the cholesterol levels of all our patients, and in a referral practice, the patients that also see a Cardiologist will have their lipids check by them. Since, we may not have that test in our file, they eliminated our quality incentive. One month they wanted us to bring in all our females of a certain age to bring their pap smears up-to-date. Well, most women resent such a focus, especially since they usually have a gynecologist that does their pelvic exam. Since our nurse practitioner died, we don’t do pelvic exams in our office. So we lose out on a significant financial incentive for a decrease in Quality of Care when there has been no decrease in QC. We tried to so some of that secretarial mapping for them one month, and after two afternoons of useless work, very few of our patients responded by getting the lab work or exam our HMO demanded.

Dr. Ruth: Since we are not involved in the HMO manipulation of care, are we talking about significant dollars?

Dr. Milton: At the last HMO meeting, I saw some of my colleagues that were reaping up to $15,000 in incentives per quarter for doing all that secretarial research for them.

Dr. Rosen: I think many doctors are not good business people and will have an employee available to do just that not realizing that the employee costs may exceed the incentive which in turn is not related to any discernable quality of care issues.

Dr. Dave: When will doctors cease being Pawns of the Medical Illiterate?

Dr. Milton: Not in our lifetime! They are too afraid of retribution. Abusive Peer Review by competing colleagues or Medicare Prosecution for using the wrong codes.

Dr. Rosen: That reminds me to warn all physicians to get out of Medicare and all government programs by October 2015 when the new ICD 10 codes will be implemented. Looking at the number of doctors prosecuted with the last change in codes, going from 16,000 to 64,000 in October 2015, almost any interpretation, whether ICD or CPT, could easily be interpreted as an error and subject to retribution, whether the Graveyard known as the National Data Bank or even a prison term. What a way to end one’s professional career.

Dr. Milton: The doctors that feel they are protected by being a hospital foundation employee will be very surprise. The hospital will be protected, even when using the highest paying codes. But they still will use Abusive Peer Review. Several were reference in this Newsletter.

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Overheard In The Lounge

Past Issue

Medicare Restrictions because of Obama Care

Dr. Rosen:       The first year of the new health care reform has been concluded. Has it affected any of our practices?

Dr. Edwards:  It has affected my practice in surprising ways. Not only with the Medicaid patients who have been incorporated into our HMOs, but also our Medicare patients who have experience untold denials of care.

Dr. Milton:      We’ve experienced similar restrictions in our Medicare population. We thought it must be from the Medicare funding that Obama transferred (or stole) from the Medicare program to his own program.

Dr. Kaleb:       We felt it must be the result of the same transfer of funds. The unfortunate result is that now both programs are so short of funds, that the strong arm of socialized medicine is affecting the quality of care in both programs.

Dr. Ruth:         Since we don’t take Medicaid in our office, we weren’t sure why our Medicare patients are being so restricted. They complain that drugs they have gotten for years, are now severely restricted or unavailable to them. They are being asked to take different and unfamiliar prescriptions. That may be simple for young people, but Medicare patients are generally old and it is difficult for them to changes habits when they were doing so well before.

Dr. Rosen:       It appears that Obama Care is causing a number of unintended consequences. The trajectory of each is still unclear and may remain unclear for years to come. The Medicare consequences are still evolving 50 years after inception. What a waste of physician talent.

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Overheard In The Lounge

Past Issue

Don’t Bill Medicaid Patients. You lose in two ways.

Dr. Rosen:       What’s new in Obamacare this week with the welfare patients being placed in HMOs?

Dr. Dave:         The oppression is beginning early. We had eliminated referrals from what appeared like HMOs except for the little Medical mark after the HMO name.

Dr. Rosen:       We had an outside business consultant review our finances. My attorney had advised me to close my practice since it was no longer profitable. I would like to practice another ten years or so.

Dr. Ruth:          Did you find any useful information? 

Dr. Rosen:       We found out our HMO was paying us about 70 percent of our fee. We found that Medicare was paying us about 60%. Most private insurers were paying us between 50% and 70% of our usual and customary fee.

Dr. Dave:         What’s surprising to me is that Medicare is still paying you more than 50%. The last time we looked at our surgery reimbursements, Medicare was at less than 50%.

Dr. Patricia:      We’re getting about the same from Medicare. It’s always over 50% and it fluctuates to over 60% at times.

Dr. Sam:          That’s why I don’t participate in any government plan whether it’s Medicare or Medicaid. The arrogance of their paying bills at whatever level they wish. Aren’t we the only profession that tolerates such discrimination?

Dr. Rosen:       Sam, putting the discussion in that frame of reference, reminds me that the biggest surprise was the Medicaid program. We didn’t average even 10% of our fee.

Dr. Sam:          Looks like you’re finally waking up to government medicine.

Dr. Rosen:       It even gets worse. Of the seven Medicaid patients we saw the last quarter, our total income was $25.

Dr. Ruth:          That’s not even the cost of billing!

Dr. Rosen:       That’s precisely the point I was leading up to. We then decided not to bill the state for their welfare patients. We will see them totally as charity.

Dr. Patricia:      That’s the only way that the patients will see it as charity. As long as you bill, they’ll think that you’re making money. They can’t conceive that you’re losing money. In fact they think that your $25 for seven patients is income. That doesn’t covering one hour of staff time to provide their services.

Dr. Rosen:       When Dr. Sanford, who was the president of the Union of American Physicians and Dentist, spoke to our group in the 1970s, Medicaid patients receive two small stickers about a quarter inch by a half inch per month, he said he would never stoop to such an insulting menial task as the paste these to an insurance form and told all his Medicaid patients that he would see them free as often as they needed him.

Dr. Milton:       I also remember him saying that they were more appreciative of his services when it was real charity.

Dr. Ruth:          It’s basically charity either way. But as long as you’re losing the cost of billing, and each patient costs you the price of billing with essentially no income from them, the patient is a liability.

Dr. Milton:       The patients don’t see it that way.

Dr. Ruth:          The State doesn’t see it that way either. They see a $100 fee and pay the doctor $10. This obviously means that doctors are charging their patients ten times what they’re worth and that’s why doctors are rich.

Dr. Rosen:       So I think we’ve come to the consensus that it’s probably not financially advisable to even bill the State for Medicaid patients. And it’s even a bad public relations endeavor. Maybe that’s also why we see such hostility from state employees.

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Overheard In The Lounge

Past Issue

Has Obamacare Arrived early?

Dr. Rosen:       Last week everyone seemed depressed over the happenings in medicine.

Dr. Milton:      We have had an influx of new welfare patients into our HMO. We’re adjusting.

Dr. Ruth:        We have not participated in accepting the MediCal patients who have been newly added to our HMO.

Dr. Edwards:  I’ve always had a base of 10-20% of my practice being welfare. We have accepted these with careful scrutiny.

Dr. Michelle:   How do you scrutinize MediCal or Welfare patients?

Dr. Edwards:  It isn’t easy. But we feel an obligation to the poorer members of our society. We can usually determine after the second visit whether they are the Dregs of Society and are “takers” and happy being “takers” or are they temporarily down and out and appreciate the American Freedom of opportunity and looking for a brighter day tomorrow. Look at the billionaires in our culture who came to America with very little cash in their pockets.

 Dr. Yancy:     I have a MediCal free practice and I intend to keep it that way. If I see a MediCal patient who really needs my surgical care, I may see one on an individual basis. But I don’t charge for my services. It’s charitable and free. I’m not going to deal with the state bureaucracy, hassles, condescending attitudes, such as let’s see a copy of your medical records or surgery reports within one week for one-third of my standard fee. My estimate is that the hassles and their costs frequently exceed the one-third fee they pay me. This means that I’m doing charity but not recognized as such. I’ll just do real charity in these cases.

Dr. Rosen.       Yancy brings up an excellent point. When we do MediCal which just barely covers our office cost but none of the doctors net fee, we get criticized for doing what amounts to charity. Why not do real charity and not charge anything for those in the MediCal ranks we see. Then control those ranks to say ten percent of our practice. Physicians would then be praised instead of constantly criticized.

Dr. Michelle:   Milton, how are you adjusting to your influx of MediCal patients into your HMO?

Dr. Milton:      It was a bigger eye opener than I would have ever thought. The very first day that those 500 welfare MediCal patients were place into our panel, we were deluged with unbelievable demands on our office.

Dr. Michelle:   What do you mean? Didn’t you just have a different type of office patient?

Dr. Milton:      If that were all there was to it, we would have been happy to service this population. But my wife, who runs my single employee office, normally came to work and had two or three phone messages and then she proceeded to the day’s work. The very first day, this increased to 60 messages. We hadn’t fully realized that these 500 patients don’t work, they all have cell phones, they called the office at all hours of day or night, and some even showed up expecting to be seen immediately. One even threatened to sue if we didn’t see him immediately. It took my wife three house to get through all these phone messages and then another two hours to process these requests. And mind you, these patients had not yet been seen or evaluated but that didn’t stop them from requesting prescriptions, lab work, x-rays, referrals before their first appointment.

Dr. Rosen:      And if you tried to explain to these folks that it would be a violation of the Medical Practice Act to do any one of those things without an exam, they would probably not understand this jeopardy of your license to practice Medicine or Surgery. And then add that would also eliminate your sole source of income would fall on deaf ears. They know that all doctors are rich and don’t need an income.

Dr. Edwards:  This reminds me of one patient that complained a lot about doctors making too much money. The rich just don’t want to pay taxes to help the poor folks. I asked him that perhaps the rich should pay 100%? He replied, “Certainly, they can well afford it.” I then suggested that perhaps the rich should pay 200% in taxes. He again replied, “Certainly, they can well afford it.”

Dr. Rosen:      That’s an excellent illustration of entitlements vs charity. Many of my TSR friends think that welfare is charity. But force charity or entitlement is not charity at all. With entitlement, people always want more. There never is enough. It brings out the worst in human beings. With charity from the heart, there is always thankfulness; it brings out the best in us.

Dr. Milton:      That probably characterizes the difference in these patients very well. The paying patient is always appreciative. All at once we have a whole slew of patients who are not only extremely demanding, but also very litigious. They report every little variance they are not use to, to their HMO and this brings a large amount of paper work to clear our name. Last week a patient asked me for some suggestions on reducing her weight. I pointed out to her that to maintain her weight, pointing with my hand, she had to be eating 2,000 calories per day. By reducing that by one-fourth or 500 calories would equal 3500 calories or one pound per week. She reported me to her HMO as saying that I insulted her by saying she was fat. I not only got letters from the HMO, but also the state agency overseeing HMO to explain my non-professional behavior and a copy of the medical chart. The HIPAA regulations essentially allow all government and insurance agencies access to a patient’s chart without the patient’s knowledge.

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