Consumer Rights and Insurance

I have been reading posts about insurance companies not paying for this or that. Remember, that is their only product- the ability to pay or not. They are nothing more than risk brokers. If you viewed them as a local grocery store, they would be one that sold only one product- lottery tickets. Except in this game, the insurance execs get the money and the patients get sicker.

In dealing with insurance companies do the following:

1. Call to get a name of a supervisor AND the medical director
2. Do not try to speak to that person unless you like being on hold for hours
3. Write a letter to them. Be sure to include the nature of the problem and the solution you recommend.
4. If THAT person does not respond to you in 3 weeks then write another letter
5. In this letter, reproduce the firsts letter but this time send a copy to the following bodies:
a. The State Insurance Department (they are all online- Google your own State- complaints can be online,
b. The Office of Professional Medical C0nduct (everey State has one)- complain specifically about the Medical Director. While our archaic laws prevent us from suing these "doctors" for malpractice, they do have professional licenses and their behavior in the interests of the insurance companies actually violates many of these ethics. The OPMC by law must investigate and if found in violation they will yank the license of the medical director. THIS IS MY ABSOLUTE FAVORITE ATTACK STRATEGY!

Fight back. Do it all in writing. The people you speak to on the phone are hired robots.

Related Topics: Getting the Care You Need, The Cost of Pain

Technorati Tags: claims, consumer rights, health insurance

Grand Rounds this week

Thanks to KevinMD for the nice mention in this weeks' Grand Rounds. Grand Rounds is a weekly round-up of posts from medical weblogs around the blogosphere written from the perspective of doctors, nurses, patients and other health professionals.

- Dr. K

The Health Care Asylum

When Government and Media Fill a Void

"All you need to start an asylum is an empty room and the right kind of people"
Eugene Pallette in 'My Man Godfrey'

Nature abhors a vacuum. For years I never understood that line. I always thought that it meant that if you suck everything up there will be nothing left for anyone else and you will be hated. That, of course is not nature and a vacuum but the American insurance industry- sucking up all that is left of healthcare dollars. What I have learned over the years is that if an important thing is left unattended, then it will be attended to by default- usually by the least qualified. This leads us to the obvious- The Government and the press are waging a war they call healthcare reform with no clue as to the problems or the solutions. Our healthcare reform vacuum is being filled by the vacuous. Heaven help us.

If all you did was read the press recently this is what you would learn the "reason" why healthcare is in trouble in America:

1. An unacceptable number of people are uninsured
2. American medicine generates tens of thousands of fatal errors yearly
3. We have a shorter life expectancy that the British, French, German, Canadians, and Japanese
4. 16% of our resources go into healthcare
5. There is over 700 billion dollars of waste in American medicine

Source: Bush's Turn to Health Care, Sebastian Mallaby, NY Sun, January 17, 2006

I bring these up, not to point out the NY Sun's expertise in reporting healthcare (not) but only that these are common complaints and were so noted in this article. Unfortunately, solutions are rarely offered in these reports.

One of the big problems we are having is connecting problems with solutions. Here is what the Asylum inmates are saying now:

If you pay bonuses to hospitals and doctors that score well on quality and price measures this will work. Brain dead. The Harvard researchers who preached this should be ashamed of themselves. Maybe they should move to Yale instead. Here's a reality check for Ivy League researchers- insurers don't want to pay. They not only don't pay doctors and hospitals market value, they don't want to pay at all. Ever. They will delay payments and rachet down payments to squeeze out more stockholder value. They certainly will not pay "bonuses." In New York, Oxford Health Plans has not raised any of its reimbursement for 6 years. Not even covering inflation.

Paying market level is NOT A BONUS.

Also- who defines a quality measure? The National Council of Quality Assurance (NCQA) rates health plans on things like pediatric immunization and pap smears. This means that an HMO can hire Vin Diesel to blow up San Francisco but if he immunizes the 3 surviving children and does a pap smear on their mother The Vin Diesel HMO scores high in NCQA ratings. Nice job. Pin a medal on his chest and sign me up.

A small percentage of the gross profit of American insurance companies can pay for the healthcare of the uninsured for 17 consecutive decades. Anyone ever think of that as an idea? That is a little too complex for the current "Abramoff Congress"- Democrats and Republican who have their heads so far up the insurance company lobby's rear that the sun won't shine on the backdoor of healthcare for eons to come.

Certainly there are answers out there but in the end, everyone thinks it's the doctors, hospitals, and patients that are ruining health in America- it is actually the overregulation and the raping of the system by greedy insurers, pharmaceuticals and failure of the lobby-controlled government to act responsibly.

In a truly superb book, Healthy, Wealthy, and Wise, five points were noted by authors John F. Cogan, R. Glenn Hubbard, and Daniel P. Kessler:

1. The tax law needs to be changed to reduce the preference for medical-care purchases through employer-based insurance.
2. Health insurance regulation needs reforming.
3. Health information needs to flow more freely.
4. Hospitals, doctors, and insurers need to control anticompetitive behavior. (a corollary is that the government needs to free them in the free market)
5. Reform the malpractice system.

These are clear and concise suggestions. So what does the Government and the Press say about this? Nothing. They just heap blame on anyone EXCEPT insurance companies.

The uninsured will not magically awake to insurance one day. Doctors do not charge too much for services. Hospitals really do care about the health of patients. Hello.

Years ago, healthcare rooms were filled with caring doctors, nurses and hospitals. Someone thought that while this clinical room was full, the finance rooms and regulations rooms were a bit empty. We then filled them with criminally insane insurance executives, Senators, and Congressmen that control healthcare in America like Nurse Ratchet in One Flew Over the Cuckoo's Nest. Where is McMurphy when you need him?

Dr. K.

Related Topics: Doctors Malpractice Fears Hurt Healthcare, Washington's Health Agenda At Odds With Voters

Technorati Tags: healthcare, reform, medicare

The Prize Nobel

The Prize Nobel- A Lesson for Us All that George W. Bush is not a scientist

The Nobel Prize in Medicine in 2005 went to two remarkably courageous scientists from Australia. Their discovery has done more to save lives and illness than most even could have imagined. What did they do? They discovered, slightly over 20 years ago that ulcers which cause tremendous damage and even cancer are caused not by stomach acid but by a bacteria H. Pylori. What was a most remarkable feature about this is that the discovery at the time was not accepted by the scientific establishment as often is the case in great discoveries.

Many people are writing now about how mainstream science shunned their discovery and it took at least 10 more years to gain acceptance. I will hit this from a different angle. Neither doctor was shut down after their discovery. Neither doctor had their funding stopped. Nether doctor had a government trying to regulate their science. They were free to create and more importantly their critics were free to criticize. They were then free to react to the criticisms and the free flow of information that followed brought about the truth that these two great scientists made the remarkable discovery.

Science and medicine is about free discovery to the benefit of mankind. So what the hell is W. making speeches about limiting stem cell research? It is absolute lunacy that the public even accepts that a non-scientist, a politician has the nerve to even get up on a podium and try to spell the word science. Since when did World scientists need to be told by someone who probably never took a science course how to go about free discovery? President Bush, in his "decision" to limit stem cell research has killed millions unnamed and unknown people. In essence his act has aborted the lives of those born and unborn. I think the Right to Life committee should take away his membership card.

Just in case you don't know - the way the government "stops" research is to stop its funding. Most scientific research requires government funding- otherwise private corporate industry funds research. There really is nothing that bad about corporate research except that is it usually targeted to a product. Don't get me wrong- that is not particularly bad but it needs to be combined with science that supports the freedom of ideas and experimentation.

Essentially government is saying- "It's my ball and if you don't play by my rules I am taking the ball away." Well here's a reality check to W. and Congress: It is not your ball. The people own the ball. You are borrowing it from us until we vote you out of office.

This needs to be on the agenda of every election in America. Stem cell research. It is not only about the limiting of science freedom but it is a limitation of freedom of expression. In the constitution it says, "Congress shall make no law limiting the freedom of speech and expression." By taking away funding for any lab doing a particular research that is not illegal they are indeed doing this.

The limitation of stem cell research is unconstitutional. Do you think that's crazy? We have a President who graduated from an Ivy League college (not mine thank God!) who can't spell nuclear. Now that's crazy.

Dr. K.

Related Topics: Physician-Lawmakers Debate Stem Cell Research, The Future of Stem Cells

Tags: stemcell,research,webmd

The 411 on Healthcare in America

All the Hollywood Experts

I turned on the Bill Maher show the other night. I tend to agree with him 50% of the time. The rest of the time, I guess he is wrong. He had Tucker Carlson, Michel Michaels and Spike Lee on. Essentially an all-media show. They decided to talk about healthcare at one point.

What in the world do any of these four people know about healthcare? Who died in this country and made a Hollywood director, an ABC News Correspondent, and a political writer the sheriffs of healthcare in America?

What can really make you mad is the same old cliches about the major problems we have. The cost of healthcare. 45 million people without insurance. Are these a problem? Absolutely. Maher pulled out some BS statistics that our infant mortality rate is higher than other developed countries. No, duh.

We are also one of the only "developed" countries that has a widely diverse population. Effectively we are a perpetually developing developed country. In France there are the French. In Germany, the Germans. In America we, thank God have everyone. Thomas Friedman noted in a recent Charlie Rose interview that creative advances come out of the diversity of the US. Countries like China, India, and Singapore are competing on the science front, but according to Friedman, also recognize their own lack of creativity. These developing countries are concentating on the basic sciences. We are fortunate to have both-creativity and good science. When asked about Europe (Bill Maher's developed nation) he said (and I am paraphrasing) "the world always needs a museum."

Let me give Maher the 411 on healthcare in America. It's the insurance companies, stupid. It is not the hospitals. It is not the unions. It is not the employers. It is not the doctors. It is not the lawyers. It is the insurance companies who are raping profit from healthcare at a rate unprecendented in any other industry.

The insurance industry is so tied into Congress that it is unlikely that any reasonable insurance reform will ever get done. We don't need the government to make up more programs for the uninsured we need the insurance companies to be put out of business- completely- if they fail to have a social conscience. If you read any of the horror stories of people not getting their health benefits actually paid by companies and standard treatments denied for concocted reasons you would know that.

To solve the problem we need to solve the insurance problem. Whether that is within the current system of a diversity of private and public health plans or a single payor system is not the issue. The issue is for us to identify the problem as insurance reform and put our energies towards that.

Tags: healthcare,healthreform,healthinsurance,webmd

Ineffective Congress

Once Again- Lost Opportunity

This year there is going to be yet another example of why Congress is ineffective in helping healthcare. In NY we have Senators Schumer and Clinton (Hillary). Despite their rhetoric this is what is coming down. Here is the BIG change they voted on:

Medicare is cutting payments to doctors 4.5%.

That's it. What an amazing piece of healthcare innovation. Despite the fact that I voted for Schumer and my wife voted for Hillary (I could not vote for her the first time around because what she did to healthcare when she was self-appointed Empress of healthcare change- I still have some hope for her), I see that they seemed to have forgotten that in the last ten years there has been a thing called INFLATION and increased MALPRACTICE PREMIUMS. Medicare has not kept up with this.

Why does this matter? It matters because at less than $60.00 reimbursement for a visit on an established patient with multiple medical problems we will see more and more doctors now start getting out of the Medicare system.

Here is a simple fact. Doctors fees make up less than 15% of the entire Medicare bill. Therefore, representatives in Congress saved the system 4.5% OF 15%, at the expense of changing the marketplace in medicine. That works out to a whopping savings of 0.68% (or less than a penny on each dollar spent!).

Nice going yo-yo heads. Now you wonder why Senators and Congressmen are below the common field mouse in the pecking order of respect in the world.

Just a thought for the beginning of the week.

Related Topics: US Healthcare Spending Nears $2 Trillion Picking the Best Medicare Drug Plan

Technorati Tags: medicare, malpractice, congress

Saving Your Life for $59.04

Valuing Your Health at Wal-Mart

I went on the Wal-Mart web site recently. I personally have never been in a Wal-Mart. This is not for economic reasons because in my family paying retail is a mortal sin. It is only because there is no Wal-Mart anywhere near my house. From what I have been told by people who work in my office who do live near a Wal-Mart is that the value of your purchase is amazing. You can get anything at the lowest rate. Quality items. Good American products. I decided to test this.

I drove up north and went into Wal-Mart in Newburgh, NY. By Google Map directions this is a 1 hour and 19 minute ride. When I walked in I went to the information counter and a very nice woman named Sherry was there to assist me:

Sherry: "Hello, Welcome to Wal-Mart, can I help you."
Dr. K.: "Yes, Sherry, I am looking for some basic items for my life."
Sherry: "Oh, that is no problem, we stock a huge inventory here at Wal-Mart."
Dr. K.: "That's great Sherry, but I am on a budget."
Sherry: "Well, Sir, you certainly came to the right place. At Wal-Mart your dollar really goes a long way."
Dr. K.: "Excellent. Here is what I need. I need "an office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history - an expanded problem focused examination - medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity.
Sherry: "Oh. Well according to our catalog, that is a 99213."
Dr. K.: "Bingo, Sherry."
Sherry: "Are there any other items you need besides that?"
Dr. K: "Well, not right now. After the 99213 I may need to get some more things like a 74182."
Sherry: "Why, you are a very knowledgeable consumer. A 74182 is an abdominal MRI. Currently we have these in stock. We were running this as a Web special but some people had resolution problems with their monitors."
Dr. K.: "I know- I was in the neighborhood anyway so I figured I'd pick it up some things from your Recommended Gift List."
Sherry: "That's fine. What is your budget?"
Dr. K.: "Well, I am on Medicare and I have been allotted $59.04 for a 99213. I assume that you accept assignment on Medicare?"
Sherry: "Let me get the manager."

Manager: "Sherry tells me you are interested in our 99213, is that correct?"
Dr. K.: "Yes it is. I am looking for a 99213 for my chronic diabetes complicated by kidney failure. I have my Medicare card so you can be reimbursed $59.04 for this complete management."
Manager: "Well, Sir, we do have an ample supply of tremendous quality of domestic and imported 99213s but since we would be out of business if we gave such a product at $59.04. We opted out of all government programs."
Dr. K.: "That's outrageous. Healthcare is a right! You must give me my 99213 for $59.04. It is in the Constitution and the Declaration of Independence (maybe not in that order)."
Security: Come with us sir...

So what is continued management of your diabetes and kidney failure actually worth by Wal-Mart standards? Let's go to their Web site:

• Plasma Screen TV: $1698.00
• MP3 Player: $208.82
• Kodak Digital Camera: $209.88
• 10' Portable DVD player: $199.94
  

I chose these because these were listed by Wal-Mart in the section:

Gifts Making the Must-Have List

Based on this, the things that I must have total: $2316.64

Based on the fact that if my doctor could not control my runaway train diabetes and my kidney failure for $59.04 I would not be able to even consider getting these MUST-HAVE items. This makes the treatment of these terrible life-threatening diseases by a medical professional who was in school for about 3.65 million years worth the following:

59.04/2316.64 or 2% of the value of these items. So using the #1 retailer in America as my source, the MUST-HAVE gift items are 50 times more valuable than my health.

Maybe I can ask Sherry at Wal-Mart if I don't have to pay the co-pay since I took up so much of my valuable time waiting to shop there by being in the car for the drive.

Dr. K.

Glossary of Terms:

99213- This is the code for a follow exam used by Medicare and all insurance companies. The code is part of a book the size of Mt. McKinley called CPT: Current Procedural Terminology, copyright AMA. All events in a medical office are "coded." There is a fee associated with these codes. Doctors in the Medicare system (pretty much all doctors) are required by law to accept the fee determined by Medicare. The example I used 99213 is actually a proper code for a follow-up visit for a patient with chronic diabetes and kidney problems. The $59.04 is the actual fee the physician gets paid for any and all time and effort involved in this encounter. Even if you treat the billionairre Warren Buffet, if he has Medicare you will have the grand opportunity to collect $59.04. In 2006, Congress determined this was excessive and lowered it 4.5%. That should either balance the budget completely or purchase more time at Scores (a gentleman's club) for Congressmen and their lobbyists.

Sherry- a sweet liquor. I really did not meet a person named Sherry. I need to put this in on the off chance that there actually is a clerk at Wal-Mart named Sherry. If that was the case (and according to Murphy's law it is) then she would promptly get a lawyer and sue me. Another great American tradition. I would then have to pay her considerably more than $59.04. She would probably be able to buy the Must Have list for the entire eastern seaboard. Her lawyer, of course, would get 33% of that. That is a lot of plasma TVs for one person.

Horses and Zebras and Fears, Oh My!

It is actually remarkable how much we test patients. We test their blood, their brains, their bones, and their hearts. If a bodily fluid exists, we test the crap out of it. What do we do with all that information? We file it. Why? Because you never know.

When I was a medical student in the Renaissance, under my Chief Resident Leonardo, I began to learn the fine art of making a diagnosis. Here it is - the great secret of medicine. If you learn this then you too can become a doctor (by the way, you do have to send me $75,000 to cover your first malpractice insurance payment - a slight detail I may have overlooked):

"When you are on the prairie and you hear hoofs, don't look for zebras, look for horses."

Actually I thought you had to look for Weapons of Mass Destruction. That is only in Texas, I guess.

In reality, what does this old medical adage mean? It basically means that common things happen commonly. If someone comes to you with a cough, don't think they have end stage lung cancer- look for a chest cold. In fact, it is pretty good advice. The problem is that in the Renaissance they also actually listened to the advice of intelligent people and as Shakespeare told them- "The first thing we do, let's kill all the lawyers". (King Henry the Sixth, Part II). (Unfortunately, they did not kill them fast enough.)

If you diagnose every horse that comes around and a zebra walks into your office with a martini and a grin and you miss him- you are going down. Fast and hard. The lawyers will descend on you faster than a pack of 3 year olds around a plate of Mrs. Fields cookies. Therefore, most doctors spend their time and the money in medicine looking for zebras. We look for them in the knee with MRIs. We look for them in the chest with CAT scans, and we even look for them up the butt with colonoscopy (every two years for that matter).

It is not entirely the lawyers' fault. Mostly everything else in society is the fault of lawyers but this one gets shared by the doctors. In general we are a fearful, low risk lot. Medical schools, which I refer to as Internal Medicine School, teach us to be. In medical school you are taught a deadly expression. In all the English language I know no other field but medicine that uses this term. The term is "rule-out."

How is it used? It goes like this- if someone has belly pain (oops- I should say abdominal discomfort since I am a doctor- sorry) and you suspect the cause is mainly due to a particular reason, our medical school professors have taught us to list all the possible diagnoses it could be and sequentially "rule-them out." In other words, prove they are not the cause so we can cross them off our list. Rule out this, rule-out that. Young medical doctors have a lot of lists. Actually the young surgeons didn't. We had a single list. More of a multiple choice:

Question: Should you operate on this patient?
Possible answers
a. Yes
b. Who wants to know?
c. What's it to ya?
d. Who do you think you are talking to?
e. Get out of my face

I trained in a trauma center in the Bronx (that's New York for those of you who live South of New Jersey and have yet to return back to Earth after the last election).

Lists can be a problem, though. We had lists of causes of pimples written on clipboards and our friends who graduated college with us and went to work in business had lists of dates written in black books. Guess who the real smart ones were...

Back to ruling out.

Let's take a real life example. In the Emergency Room a man is rolled in by three paramedics who resemble championship Sumo wrestlers. They actually each weigh no more than Calista Flockhart when wet but with 1,861 various black and matte gray devices of high technology like 21 inch flashlights (you don't need to be Freud to figure this one out) and key rings that can open every room and cabinet in the NY Public Library hanging from their belt, it adds to their mystique and shear physical mass. Also, Einstein noted that e=mc2. The e stands for action. You would think that "a" would stand for action but as a surgeon I choose the first letter I came across and figured I could make it work. Also I don't have the time to rule out the other 25 letters to make the real diagnosis (actually it is 22 possible letters if you believe as I do that LMNO is one letter).

This man is properly braced on the stretcher with a neck brace, 1,215 puncture holes from failed IV attempts and a single 27 gauge butterfly IV in his left eyeball (the only vein left). There is a machete through the center of his chest wall starting in the back and exiting out the front. Sort of an extra-cardiac stonehenge (see image to the left). The surgical team made their initial and final diagnosis - to quote the Chief Resident who was going on to the Mayo Clinic the next year after his training - "This guy is really messed up. Let's go to breakfast." The chap who was the Emergency Room resident had a few "other ideas." What was the real cause of death? He furiously wrote down the list of possibilities of diagnoses and/or the cause of the situation at hand:

1. Lead toxicity
2. Infection- he was able to note, by analyzing that the only 3 mm section of his body not covered by tattoos showed that he did not shower that morning with antibacterial soap
3. The patient was actually an active and alive member of Congress needing no medical attention at all and only a visit from a lobbyist
4. The cause of the situation was Karl Rove (eliminating any potential Supreme Court nominees so as not to repeat the Harriet Miers debacle)
5. The patient was dead due to complete shredding of the heart, aorta and 5 other major organ systems like an attack from Sigourney Weaver's Alien movie.

He eventually got it right but of course he got sued because he missed a long-standing gallbladder cancer that was eventually picked up on autopsy when the city medical examiner finally got to him 2 years and 7 months later (one month before the statute of limitation on malpractice suits). It was interesting that the surgeons were named in the suit as well even though the resident wrote a single note that was about as legible as a smudged paw print from an old Lassie episode.

Which brings us back to horses, zebras, and fears. The training of physicians stimulates the push to look for every diagnosis possible. This noble approach unfortunately is then exponentially exaggerated by the fear of lawsuits. Physicians are caught between the proverbial "rock and a hard place." If the doctor orders too many tests he is wasting the few valuable resources in medicine. If he orders one too few, that will be the test that the medical malpractice lawyer (read that as SHPOS) will seize on and sue him for missing.

Concerning wasting resources in medicine- forget that criticism- the resources in medicine are going into the pockets of insurance and pharmaceutical executives and shareholders. The private jet fuel bills from the CEO of Pfizer can pay for all of Medicare for the number of years equal to the half life of plutonium (~5700 years give or take a week or so). The second part about the lawyers is sad but true.

To quote the warden (played by Strother Martin) in Cool Hand Luke: "What we have here is a failure to communicate." That failure is because everyone and their mother think they are doctors or nurses and knows better. Sometimes they do but most of the time they do not. Left to our own devices, doctors and nurses will do their best to help you. Diagnosing disease and treating patients with terrible, complex problems is hard enough than to have a politician devil (with his hand in the pocket of an insurance company) on one shoulder and a lawyer devil on the other. At least Paul Muni in "An Angel on my Shoulder" did get the benefit of the angel.

Barring any miracle of insurance reform or tort reform our journey into the apocalypse of medical hell will be led by the four horsemen:

• War (the war between the haves and have nots in healthcare insurance),
  
• Famine (the removal of so many resources by the insurance companies and pharmaceuticals that we will be starving with what is left),
  
• Pestilence (Congress), and
  
• Death (disease- the real enemy here).

Maybe a knight in shining armor will appear on the horizon to take on this onslaught. For now, it is time for this cowboy to ride into the sunset...



Dr. K.

Glossary of numbers and terms:

1. 75,000. The real cost of medical malpractice insurance in NY for an Orthopaedic Surgeon. For the record that equals 15,000 $5.00 co-pays from patient office visits. A typical Monday in my office.
2. 1,861. The year the serfs were freed in Russia. Doctors' freedom from insurance companies lags behind obviously.
3. 21. The legal drinking age in NY. Note that the legal voting age is 18. This leaves on 3 years of sober voters. Now we can understand why Congress is in the state it is in.
4. 1,215. The year the Magna Carta was signed. The major significance of this is that I remember when I got this question right on an exam in 7th grade leading me to the conclusion that there was hope that I would get into medical school.
5. SHPOS- due to editorial constraints I can't print this.
6. The compensation, not including stock options, for a single year of salary for the current CEO of Pfizer is $17,188,437. That pays for a ton of flu shots for people who can't afford them.

Tags: healthcare,diagnosis,medicalmalpractice,webmd

A Brief Song From Broadway

Act III- I Need Morphine

While I live and work in New York I don't get much of a chance to get to Broadway. Living in the suburbs and being a surgeon doesn't allow me the hours to take advantage of one of the greatest streets in the world. I recently realized, though, that I never need to go. the reason is that I send my patients to the Recovery Room politically correct- the Post Anesthesia Care Unit. On a brief tangent, if the recovery room is the Post-Anesthesia Care Unit and the Holding area is the Pre-Anesthesia Holding area- what does that make the Operating Room- the Anesthesia Unit" Just a thought.

No matter how much we pride ourselves on sensitivity to patient issues like pain, we all seem to have our breaking points. I think, periodically, an angel is sent down to test our resolve. Invariably there will be a test we fail. Probably daily. But, with resolve, we forge ahead. Wings are heavily overestimated anyway.

So I walked into the PACU about a month ago to a whirling dervish of activity. Every cubicle was filled, doctors and nurses where chatting away, one of the general surgeons was checking Internet information for upcoming rotisserie baseball leagues- all the usual emergency medical stuff you'd expect from a top institution.

After checking my 62,000 junk mail messages on my Blackberry I could not help but hear, through the chaos of the moment, suble 152dB bloodcurdling screams coming from a cubicle that I thought my patient was in. My patient? No way. I love denial.

I walked over to the Medical Demilitarized Zone only to find 3 PACU nurses- hey I just figured out why they are called PACU nurses instead of Recovery Room nurses- they travel in packs. Nothing seems to change from Junior High School.

There on the stretcher was my patient whom I had just drained a blood collection from her hip. She was thrashing back and forth, gesturing with her hand over her forehead, proclaiming massive, intolerable pain. You gotta love the nurses. They actually listened to her and tried to calm her down. Nurses got it all over doctors- they actually have not had the last bits of sensitivity and feeling snuffed out of them as effectively as a surgical internship does. She was already up to 18 mg of IV morphine- enough medicine to stop a Mack truck, an elephant, and a Democratic Judicial Filibuster in Congress all at once. She was screaming, she was panting, she ran through emotions that I didn't even think were in the dictionary. The nurses were concerned.They looked at me- the wise, older (48 years old BTW- don't rub it in- I am getting a bit touchy about this lately) clinician. What words of wisdom would I come up with to help control the situation and maintain the dignity of the nurses, the patient, and ther relationship.

I slowly turned toward this patient, a patient of mine, a former IV drug user and more and put it all together:

"What the hell do you think you are doing? What, do you think we are on- Broadway and you are going for a Tony award? Just stop that thrashing and gesturing and dramatic yelling."

I was actually taken aback by my statement- for about a nano second. She immediately stopped, looked me straight in the eye and quietly said "I am just expecting it would hurt more later so I wanted to get pain medications now." This was really odd. She quietly sat there for the next hour with little to no pain. So why all the drama?

I think there is a huge lack of trust going on in medicine today. Patients don't trust hospitals, hospitals don't trust doctors to be loyal, patients don't trust some of their doctors and so on and so forth. I seems that when anyone wants to make a point they feel it must be extreme. Everyone who waits more than 15 minutes in my office complains they were wating more than 2 years. Doctors complain that insurance companies pay them 3 cents. It is all a poorly produced Broadway show.

The problem is that no one is directing medicine and certainly no one is producing the show anymore. All the worlds IS a stage but unfortunately we are not merely players- we are stooges to the special interest groups who care more about day to day profit than long-term health.

So when the Recovery nurses come up to me and remind me that that was a great line that night about Broadway I remind them that it is unfortunate it even had to be said- no matter how funny it appeared to be. Either way, the show must go on...

Dr. K.

Related Topics: WebMD Survey: The Lies We Tell Our Doctors, Getting the Care You Need

Big Doctors

White Towers on the Galapagos Islands of Medicine

This is such a beautiful country.

You can travel to the Grand Canyon, to San Francisco, to the prairies in the Midwest and there is nothing but beauty. One of the most beautiful urban sites is the view you get of the New York skyline on certain approach flights to LaGuardia Airport. From certain destinations you fly up the East River. To the right is Queens and the outlying middle class suburbs, to the left is the island of Manhattan in all its glory.

Recently, though, while traveling back to New York and getting a glimpse of the City I could have sworn I saw the island of Manhattan sinking in the center. It was as if a weight was present from approximately 59th Street to 110th Street causing the island to have a somewhat concave appearance. I immediately called the Army Corps of Engineers (who, by the way are on Speed Dial on my Blackberry) and since they have not been called in to do anything of worth in New Orleans by the new head of FEMA (who I think used to be in charge of french fry procurement at Wendy's) they had time to field my question. It appears that Manhattan is being weighed down by Big Doctors. Wow. All that mass in one area in the country. I never knew they were that big. Who'd of guessed?

It reminds of a classic Jackie Mason joke.

Three people are at a party.
Person One: "My doctor is so big it takes 3 weeks to see him."
Person Two: "Oh yeah? My doctor is so big it takes 3 months to see him."
Person Three: "You think that's bad? My doctor is so big no one has ever seen him!"

It really is an urban phenomenon. Big doctors, that is. So what can make a doctor big? Here are some thoughts:

1. Medical or surgical skill at an exceptionally high level who is nationally recognized by peers and patients with ethics beyond reproach. Okay- that's 3 guys...
2. Doctors and institutions with large advertising budgets.
3. "Boutique Doctors" who decide not to take any insurance and treat only people from Greenwich, CT (or similar suburbs).
4. Fat doctors (my personal choice).
5. Doctors with public relations consultants.

I am sure the list goes on but the problem is that within all this mess you really can't tell who is the best doctor suited for your care at all times. Why is this? I don't really know the answers to this and other questions plaguing mankind for generations (although I think I figured out where the ducks go in the winter in Central Park, Holden).

The next time you make an appointment to see a big doctor make sure the office is big enough for both of you to fit in.

Dr. K.

Related Topics: Choosing a Doctor, Health Care Services

Tags: healthcare,medicalpractice,doctor,webmd

In the Healthplans that are Blind the One-Eyed Patient is King

There are only one of three explanations of the behavior of health insurance companies in America:

1. They are controlled by a small number of incredibly smart people who hire an massive number of incredibly stupid people so that an unknown but ever growing number of stockholders can make gobs of money.
2. They are controlled by a small number of mildly intelligent characters who, due to the fact that the current regulatory environment favors health plans over sanity, are luckily getting wealthy
3. They are controlled by five blind men, an elephant, and Soylent Green.

Based on recent evidence in the national journals (sort of the kind that have Elvis marrying aliens) it appears that choice 3 is the front runner. I refuse to believe that there are any intelligent life forms in insurance companies. Oh, sure there are financially savvy life forms there. Intelligent life forms - no way.

My son Jacob is 10 years old. He was playing baseball (the way the Mets have been playing he may be the starting third baseman next year). He developed pain and numbness down his arm on every throw. Diagnosis: shoulder instability and rotator cuff impingement. Treatment: Physical Therapy and anterior capsular strengthening. This was prescribed. Here is what happened:

We have Oxford insurance. Oxford just got bought out by United Healthcare. Sort of like the Corleone Family buying out the Salazzos. A third company, OrthoNet does an unknown function for Oxford. Unknown only to patients. They "review" claims and "manage" Orthopaedic care. Essentially they make David Spade in the "NO" commercials look like a yes man. Their only job is to deny claims. They do this so that they personally make more money. United/Oxford gives them more money if OrthoNet pays less claims. Based on the blind Orthopaedic consultants who bumble in the dark for OrthoNet, my son received approval for 4 physical therapy sessions. The first was an evaluation. Now there are three. The only thing I know that can happen in three days is securing Baghdad (oh, if it were so easy...)

Clearly, OrthoNet is blind to medical facts. They are blind to patient disease. They probably are illegal in what they are doing in that they receive incentives (kickback) on the money they save for Oxford/United. They are doing this using fraudulent means. They claim they reviewed my son's case but as I am his doctor, I never received a request for records. In America this is kickback and fraud.

When it comes to caring about the health of you and your family, the insurance companies will be blind. If there is a penny on the floor they will land on it and suck it up faster than a Dirt Devil.

It is remarkable that when I actually opened the letter and saw the number "4" next to approved visits it was then that I realized that you actually have to LOOK at what the insurance companies are doing. Amazing concept. If you watch your insurance company rip you off, even in the corner of your eye, one eye, you may actually see what is going on and may be able to do something about it.

We may even make you king. You can't be The King, though. That is for Elvis only.

Dr. K.

Related Topics: Checking Up on Managed Care, Top Healthcare Priorities Targeted

Tags: healthcare,unitedhealth,orthonet,healthinsurance,webmd