June/July 2009 - On Fear…

It really is another of those four letter words that your mom told you not to use. But it remains in our vocabularies, just under the surface, rarely spoken and never admitted.

But there… none the less.

And it shows up whenever healthcare change is discussed or planned.

The articulation is a bit unusual. In medicine, our anxiety and fear is huge as we contemplate a system designed by others… by non physicians. The first articulation of our fear is to discount and position ourselves in the entrenchment mode. This then forces the funding agency to institute process and policy to force the desired change. We throw out our chests and say that we know best and continue to practice with medical ways that were in vogue during our training…ignoring current teaching or evidence.

I will change when they pry my cold dead hands off of my stethoscope…

To accept the new way of providing care would somehow be dishonest to the physicians who trained us. Dishonest to our tradition, dishonest to our way…in reality we are fearful that it will somehow change our world view or our style.

There are some things that will never change.

People will continue to age and face the disease process of aging.

People will continue to need someone to assist them in discovering their health problems and applying the current medical knowledge that is in vogue… at this moment. But we have to remember that this body of knowledge changes, and we must change with it.

I am always in amazement about how we are motivated by fear. The people who are hired to sway opinion know this, matter of fact, there is probably a database somewhere of the effect of fears. And like Pavlov’s dog, there is a standard reaction on our part. They press the button, we respond in a standard fashion.

For all of our sophistication and education, we find it hard to not react like some trapped biological creature.

Friends, there are many of us that have had our fill of the current healthcare system. We also are not willing to be manipulated by fear of change or fear of what could be. Matter of fact our disdain for the current path is such that we would do about anything to get off of this treadmill, which does not value our time or skill set. We also do not believe the lies of the opinion manipulators…we know about the current cesspool of healthcare. We fight that battle each and every day.

For those of you that have found your comfortable niche in the current system, I am afraid that you anxiety is about to become full scale. As a nation, we cannot afford your comfort. I sense that we yearn for something better, something different; something designed to do what healthcare delivery is supposed to do.

Does this mean that every portion of the current system should be thrown out with the “healthcare bath water”…No. But, just as the correction that has recently become reality in the financial sector, there is a correction getting ready to happen in the delivery of health care in this country.

It may be painful…corrections often are.

Seems to me that we have two options, to face it with fear and send our message that we are satisfied with a non-sustainable system as it burns down around our fiddling, or rather find the valuable pieces, work to maintain them and embrace the change that will allow each of us to take better care of the patients for whom we have responsibility.

May 2009 - You have to help me…

I am going to quit going to hospital committee meetings…

If I do not, I am going to have a stroke. You know how I get. I am fervent about anything that I do in life. It goes way back to a snippet that I remember from childhood, “Mike, if it is worth doing, it is worth doing right”…that little saying has been a guiding light for me.

But there are some places that this approach just will not work and current hospital rules and regulations seem to be one of those places…I am just going to avoid the meetings and the discussions. I am going to take the path of just living in oblivion and not worry about it any longer.

So I am sitting in a Patient Quality Improvement meeting at one of local hospitals. As per our approach, each hospital section is giving updates to the committee on patient safety or patient care improvement that they are dealing with. I am a great believer that this process is extremely important as we try to improve the patient care and safety of the care in our institutions.

If we never look at it, it never gets fixed.

And there is advantage in having the multi-disciplinary perspective of the committee to look at problems and proposed improvements. Nursing always keeps me honest and sees a problem from a different perspective than I am going to see it. Over the years, I have learned a great deal as I participate in this process. I am hopeful that I have been helpful and not obstructive as I attempt to represent my portion of the medical staff in these meetings.

I am sitting there, enjoying my salad and chicken strips that taste better when dunked in the ranch dressing. In reality I am minding my own business, trying to participate in the meeting by listening and contemplating…

But then it happens. The button is pushed and just like the trapped rat that I sometimes see myself…I respond with red face vehemence and so angry that I cannot even think of the words to say. Sitting in a room of thirty folks who serve on this committee or report to this committee… I start my tirade. You can see in their faces that I am walking that thin red line as I accelerate into the territory of being a “disruptive physician”

I am just not going back to these committee meetings.

My blood pressure, my pride or my ego just cannot tolerate this any longer. I am too old to play these games and my soul cannot tolerate one more cynical disillusionment. It would be better for me to just sit quietly in my office and chew on an apple, maybe meditate or read encouraging prose.

And I bet you are wondering about the button that was pushed…well it seems that the rational rules and regulation has been stretched by hyperbole to the breaking point. The Oklahoma pharmacy rules and regulations, or at least this rendition of interpretation says that I can no longer send home unused medication with a patient that I am discharging from the hospital. Seems that most hospitals do not have an outpatient pharmacy license and that by distributing that asthma inhaler or that half-empty bottle of antibiotics, as the patient is discharged, is now somehow illegal and we need to have this codified into local hospital regulation. All because that is seen as outpatient dispensing…and Dr. Pontious we don’t have a license for that…

I do suppose the hospital is going to reimburse the patient or their insurance company for cost of the unused doses…not. We are just going to pour this medication/resource down the drain.

But who am I to challenge this most recent interpretation of the rules…I only know one way to express myself and that is becoming less and less politically correct each and every day.

If you all know of a program that will help me with the “Don Quixotesque” approach that I take to my hospital committee work, will you please, please, please let me know?

I am going to quit going to hospital committee meetings…

April 2009 - On Fraud and Abuse...

I know, the question brings anxiety to the hearts of each one of us. The last word that any of us want to hear is this "fraud" word. Yet it is going to become much more prevalent in our professional world as the Medicare Fraud and Abuse team will be knocking on your door in the very near future.

Let me see if I can clarify for you the reason that my "crystal ball" shows this prediction.

Oklahoma will soon be the site of Recovery Audit Contractor (RAC) activity, as the contracts for our region have been awarded, after some back-room manipulation of the process. You will remember that it was the RAC auditors in New York, Florida and California who sought out and found huge amounts of Medicare Fraud and Abuse, recovering massive chunks of change for the infractions of Medicare rules and regulations. Section 302 of the Tax Relief and Health Care Act of 2006 makes the RAC Program permanent and requires CMS to expand the program to all 50 states by no later than 2010.

Now most of you reading this editorial are thinking that you are not going to be affected by this piece of information. And all is well in your portion of the world. But you really need to re-think this through a little bit more fully...

Fraud is defined by the Merriam-Webster Online Dictionary as "intentional perversion of truth in order to induce another to part with something of value". That seems like a pretty clear black line to me, you step over it and you are guilty. I am not sure that Medicare's black line is quite so clear or quite so black and I am suspicious that these companies that do the RAC Audits are even more comfortable with a pale shade of grey.

I will remind you that these RAC auditors work on a contingency fee basis. They keep a percentage of the money that they recover as fraudulent billing. This turned out to be a significant amount of money from the three states that were in the demonstration project.

Let me see if I can give you a bit of the rock and hard place that you will find yourself as it comes to fraud and abuse, as defined by the RAC auditor. Chest pain is a common presentation for those of us in primary care and cardiology. Typically the patient is admitted and a series of tests and evaluations are accomplished. Based on these tests you and I are able to risk stratify the patient and determine which patient will need surgical or further cardiology intervention from those that have another process going on or who will need medical management of their disease.

This is typically covered for the Medicare patient by Part A, with an annual co-pay from the patient of around $1400.

But the story does not end there. If the patient does not require further intervention or if they did not have a myocardial infarction, Medicare is now telling you and me that we should have known that and this patient should have been placed in an "observational outpatient" status. Now of course when a patient is in "observation" this care is covered under Medicare Part B and it is covered at one tenth of the rate that an admission is covered and the patient is responsible for 20% of each and every service, lab, Xray, study etc. that they had during their stay, and the copay is for each and every observational stay that they have over the year.

Alright then, I understand that somehow I am supposed to know this. I suppose there is scientific data to show that this is a reasonable way to manage the patient who presents with chest pain and that I am not going to force my patient out of the hospital prematurely and into an early infarction because this early discharge.

But what I don't get is the fact that I was supposed to know this three years ago...

It turns out the RAC auditor can come in and review my Chest Pain "admissions" and dis-allow them, force the hospital and the physician to re-pay the monies that they charged for these admissions and then can go back three years from the time of the audit and demand that money back as well.

It is beginning to dawn on me how such a large sum of money was found in the demonstration project...

For a physician to challenge each and every charge of "Fraud and Abuse" will take a huge amount of time and effort. Even if you win, there is no compensation for the time and effort that were required, much less your legal fees.

I am getting chest pain just thinking about this...

And talk about "intentional perversion of truth in order to induce another to part with something of value"...just who is committing the fraud here...

March 2009 - On the Clinical Narrative…

The very nature of any physician’s work is focused on obtaining the clinical story and then documenting this story. In the vernacular of the day, this is a clinical narrative. We perform the task day in and day out; we were taught the skill during our medical school days and hopefully have perfected it through the constant use of these skills.

And yet there is the tendency to not see it for what it really is.

I obtained my bachelor’s degree from a liberal arts university. At the time, I was not aware that the path I was taking was a bit different than the path of many of my medical school colleagues. I was taught the skill of writing as an underpinning for anything that I would do in the future.

At the time I settled in and learned the skill and found that their premise was correct, being able to write and critically look at literature really was something that improved my ability to problem solve and communicate.

This has not changed over the ensuing years.

I remember being quite frustrated by the focus in medical school to memorize. At first I resisted, as my undergraduate experience had tainted me with the idea that memorization was the lowest level of education…the stuff that they teach first graders…yet that was the mantra and so I memorized and rememorized, often not ever fully understanding the material.

This edition of the Journal includes the initial installment on Narrative Medicine. Drs. Vannetta, Schleifer and Crow have put together a series of articles that will explore the issue of the clinical narrative, as they attempt to help all of us understand Narrative Medicine.

Maybe it is time to refocus a bit and see if you can revisit some of the ideas and approaches that you have not even considered since the days in which literature and ideas were forced upon you.

Take a moment before you read this series to remember the last book that you read or the last discussion you had that was based on how an author dealt with a clinical issue. For most of us, it will be difficult to remember the book or the collection of short stories. We as clinicians have fallen into the same trap that our world has fallen into…we want the story line fed to us as an executive summary or an outline.

Hopefully this series on Narrative Medicine will cause you to pause, maybe even assist you in taking an improved history, learning the full clinical story and communicating it in your writing. Surely this will result in a better product and better communication in healthcare. For a moment, try not to think or write in “medspeak”, try to avoid the medical code that has crept into our vocabularies and our communication style.

Savor the moments for a while…

I can already sense that you think this approach is not relevant in your world, you are too busy, or it can’t make you more efficient nor earn you more money…I am convinced that we lose the richness of our profession when we discount or try to take shortcuts with our narratives, our reading and our communication.

I seem to remember a time when books were discussed and ideas were argued based on a short story or a clinical case that was reviewed. I found it a much more fulfilling approach than obtaining all of my opinions about the problems facing medicine on the op-ed page of the newspaper.

I wonder if Drs. Vannatta, Schleifer and Crow are not on to something with this series on Narrative Medicine. Watch for their pieces in the next few editions of the Journal. Maybe they can entice all of us back to a discussion group or maybe encourage us to write of our frustrations or our joys, or our failures and our triumphs.

You know it could happen…and I am pretty sure we would be better for it…

February 2009 - Nothing Happens in Isolation…

I think that I have complained about this before, but recurrent messages are something that I have never really apologized for in the past. So if this message offends you are causes you to lose sleep, well just get over it.

I do not agree with people or orgainizations that don’t follow the same rules that I follow. Failing to live up to this premise has recently caused some government appointee’s to not be able to assume the positions to which they had been asked to serve. If I don’t pay my taxes or follow this Medicare law or that, then I will suffer the consequence…and you know that it is what motivates me to live up to that standard. I will not expect to benefit from fraud or deceit or taking liberties with the regulations.

It is a rule, so I live by it. This is a simple concept that was taught me by my folks, long before medicine became a reality in my life. When you send me a bill, you get a returned mail payment for the service that I consumed.

Seems that not everyone plays by that rule. Seems that there are many in the health care industry who see themselves above that rule, or maybe they just see it as taking a bit of liberty with the rule.

Nothing happens in our world in isolation…absolutely nothing.

I have used these editorial pages to complain of Trailblazer, the Medicare intermediary for our region. Many of you have experienced their difficulty with paying clean claims in a timely fashion. When they were taking over the Medicare payments, I seemed to hear stories of claims not being paid for three to four months and then further stories about how they interpreted the regulations and rules a bit differently than the last intermediary.

Now all of this is perfectly legal they tell me…because they needed transition time to make the change over and you and I need to have patience with them…because your check will be in the mail…all the time they are keeping the money, money earned for services that you and I provided to their patients. We did not ask for our fee up front, we played by the rule…but alas they somehow do not have to do that…

I now find out by letter that the health insurance plan for Oklahoma State Employee’s has recently hired on a new administrative organization (do you smell “lowest bidder”…), and they are asking for my patience as they make the transition, as it has been a little bit of a problem getting everything figured out in a timely fashion. All the time they keep the money that they owe me, in their bank account, drawing interest, while clinical practices are having to go borrow money to pay their clinical staff.

Nothing happens in our world in isolation…absolutely nothing.

We are living in very fragile times in healthcare. I write from the perspective of a family physician. Among my colleagues, the profit margin is small and getting critically smaller each and every month. For any insurance company to stand behind the mistruth of “administrative problems” as a reason for not paying an appropriately submitted claim is wrong. You and I should not have to put up with this level of incompetence.

At some level they are committing fraud each and every time they play this game.

I have a couple of solutions for dealing with this kind of incompetence. First, inform all patients with the “administrative problem” insurance that because their insurance company is not paying claims, you will be forced to have the patient pay for the service before it is provided and they then can collect from their insurance company…wait I think this has been done before…and the problem was…

The other idea I have is to require the insurance company to pay my claim immediately on receipt of the claim. If there is a problem with the claim or a mistake on my part, they can submit a refund request from me and I will negotiate the return of the money paid for my services. And of course I will do this in a timely manner, I pay all of my bills in a timely manner…

Nothing happens in our world in isolation…absolutely nothing.

January 2009 - The Problem with Brinksmanship…

It seems to me that the most common way that you and I become motivated about an agenda is with the practice of psychological brinksmanship. Let me see if I can clarify this idea for you and help you see what I am seeing.

Let’s take Medicine Day for instance. A group of doctors from throughout the state of Oklahoma shows up at the state capital to have a focused conversation with the legislators, on the issues that matter to us. Now never mind that that the concepts are poorly coordinated and articulated. If it is too well “scripted” it comes off as insincere or orchestrated. Never mind that the articulated logic fails the test of common sense. Never mind that the real issues really cannot be articulated, for a number of politically sensitive reasons, so we plod on…doing the best we can.

And it has nothing to do with the content or the message…it has everything to do with the sheer numbers of white coats that show up.

I ask you, “is this anyway to support the issue de jour?” No one seems to care about the greater issues involved. I get the sense that we are giving the wrong message, in the wrong format, to the wrong folks.

But then I am no expert in this process.

But this is how the game is played Dr. Pontious…get used to it….

It happens ever day at the state capital. You and I are not going to change this time honored process. You and I are not going to get anywhere in the huge scheme of things by grumbling about what an inefficient and ineffective use of time this will be.

My words here will be representative of “more of that negative rhetoric so closely linked to physicians”. We just do not get it…and as a consequence we lose repeatedly and become more resolved that this system of activism is archaic and contrived.

So what is this about Brinksmanship that I speak of…let me re-focus for a moment. The only way to motivate you to pry your hands off of the comfortable world and work to which you have grown accustomed is to create a crisis. To lead you to the brink and to manufacture an outcome that will strike fear in any rational red blooded Oklahoma physician. It really is only then that scheduling that time out of the office to make an appearance in your legislators office becomes a reality…rhetoric will not cause it, guilt about the importance, or even the loss of political voice will not manipulate you into moving out of your comfort zone.

I am not one to play the brinkmanship game. It is much like my mothers warning to me that if I did not behave, she would tell my dad when he got home…by the time he got home she had forgotten…I figured this out at an early age.

Because you are much too sophisticated for me to manipulate, let me put it this way. Professional organizations represent their constituency. The staff of the Oklahoma State Medical Association does this for you and me on a daily basis. There comes one day a year where they ask for you to show up and move out of the comfort zone and by the fact that you discuss with your legislator face to face, our issues get the hearing that they are due. When you decide not to participate the issues are swept by the wayside.

Friends, the orbits of the political constellations in Oklahoma favor Oklahoma Medicine right now…it is time to put the complaints and the cynicism behind us and work for the common good.

See you at the Capital…

December 2008 - On Oklahoma’s Mental Health…

A huge thank you needs to be extended to the OSMA Council on Public and Mental Health who have overseen and cultivated the articles that are contained in this edition of the Journal. My thanks to Jenny Boyer MD for working so successfully with the authors in the production of a great set of articles that are clearly focused on the Mental Health issues facing our state.

It is a job well done…

And you just knew that I would not leave it at that comment...

These papers are meaningless without your time and thought. To fill these precious pages with irrelevant material is not the goal of the Journal. There is something in here for each and every one of you. Whether it is an update on depression or the latest on approaches to substance abuse, the material is custom fitted for the Oklahoma physician.

But it does absolutely no good sitting here buried… it must be read and digested and become the cause for thought…

Each and every practicing physician in this state has experienced a crumbling mental healthcare system. Whether this is manifested by the inability to obtain adequate psychiatric consultation or inpatient psychiatric care, or whether it manifest itself in the chaotic psychiatric medication management that many of us have to provide, because we were under-trained or possess some prejudice regarding patients with psychiatric illness…it all comes down to the fact that being mentally ill in Oklahoma is a dangerous place to be.

I have written in these editorial pages before regarding the degeneration that the public mental health system. With chronic under-funding, it is a miracle that we have any system at all. For some reason we are unable to make the case with our legislators who control the public purse strings. Is it stigma? Is it prejudice? Or is it just our inability to get to the point that we understand that the mentally ill in this state will always be with us?

Surely our public servants are not naïve enough to believe that if we choke the funding to this area of the population, they will just go away…somehow finding their way to another state or another portion of the country.

I am not sure about you, but this is another of those areas in Oklahoma that causes me to be embarrassed. And yet it continues to fall off the radar screen in terms of advocacy, there continues to be a deafening silence of voices advocating for change and focus from our state legislators in this area.

God help us if we would ever be dependant on advocacy from our federal representatives…

And then there is the rural/urban disparity in terms of mental health care in this state. The scarcity of psychiatric providers in non-urban Oklahoma is way beyond the crisis stage…and yet there is little being done to alleviate this problem. I have not heard of additional training, I have not seen expanded funding to offset the costs involved in providing mental healthcare outside of the critical mass of our urban centers.

Maybe it is time to revisit this topic as an agenda for organized medicine. Maybe it is time to come out of the closet and advocate for those who are unable to advocate for themselves.

I am proud of the members of the OSMA Council on Public and Mental Health and their advocacy in this area, maybe it is time for the rest of us to support them in this effort.