Saturday, June 30, 2012

What's Unspoken about Obamacare

     In the aftermath of the Supreme Court's ruling this week on the Affordable Care Act, known as "Obamacare," two areas of important subject matter seem to have dodged debate.
     Yes, I am proud that the three branches of our government acted together with great discernment to pass the law in Congress, confirm it in the Legislature, and approve it in the Supreme Court.  Justice Roberts provided the deciding vote, Justice Scalia's libertarian dissent was a masterpiece of eloquence, and the enforcement of health insurance for every American using a tax penalty will finally place us in the ranks of civilized nations when it comes to taking care of our own.
     Yes, it has been deplorable that many working Americans could not afford or obtain health insurance and therefore risked financial ruin if they were to become very sick.  Like other doctors I have not known how to handle patients who showed up at my door with what could have been cancer or advanced heart disease, but had no money and no insurance.  Doctors all over the country routinely sent these patients to university hospitals down the road, where expensive work-ups and treatments were bankrolled, ultimately, by the government.
     This has been hashed over in news analyses since the ruling was announced on Thursday, June 28, 2012.  The big question is "Who is going to pay for all this health insurance?" You would think we were a nation in dire poverty.  But enough people are talking about all that.
     My question isn't, "Who is going to pay for it?" but "Who is going to benefit from this ruling?"
     What do you know, but if it isn't the insurance companies!  And the pharmaceutical companies!  The more we force people to get health insurance and urge them to go to the doctor, the more the insurance and pharmaceutical companies stand to post skyrocketing profits.  As if they weren't posting those profits already.
     Is anyone bringing this up?  What a victory for insurance companies!  And for prescription drug companies!  They must be throwing parties in their plush office suites!  Would it be discourteous for the rest of us to shine a spotlight on this fact, as though we were pointing to important personages in bed with other people's wives?  Are the insurance and pharmaceutical companies in bed with Congress?
     Is there some reason Obamacare doesn't address and restrict the obscene profits being made by both insurance and pharmaceutical mega-corporations?   Could it be that the number of lobbyists these subgroups have in Congress far exceeds that of any other special interest groups?  Could it be that the money those lobbyists promise for re-election campaigns is not to be turned down?
     The cost of health insurance and pharmaceutical medications cannot be overlooked when we talk about reducing healthcare spending in America.
     There will never be true healthcare reform in this country until someone puts the brakes on runaway insurance and pharmaceutical company profiteers.
     Health insurance companies generate their profits by:  1) denying insurance coverage to people who really need it, and favoring those who don't have health risks;  2) refusing to pay doctors for necessary services;  3) playing games with billing, coding and documentation requirements, as well as with "covered" and "non-covered" services, so that the difficulty of submitting payable claims results in non-payments to doctors, and savings for insurance companies;  4) arranging for insurance companies, not doctors, to make decisions about what is and isn't necessary healthcare for patients;  5) refusing to pay for what task forces and research studies have decided are important preventive tests;  6) confounding the world of medicine with   insurance coverage consisting of hundreds of different "plans," which no one, not even insurance representatives, can interpret--thereby garnering huge "savings."
     Pharmaceutical companies generate their profits by:  1) overcharging for products; 2) hijacking the FDA in order to extend patents on expensive products ad infinitum, thereby keeping generic equivalents from entering the market;  3) making special agreements with health insurance companies and payers like the VA Hospital system to carry their expensive products preferentially;  4) locking the borders for physicians and other Americans who might otherwise purchase the same medicines at lower cost from other countries;  5) impugning and restricting the sale of nutraceuticals that might have an effect equivalent to high-cost, brand-name medicines;  6) supporting a three-to-one ratio of pharmaceutical lobbyists per congressperson at any given time in Washington;  7) wooing and guilt-tripping physicians into prescribing absurdly expensive products by hiring chic, overly-cheerful, well-paid "drug reps," who bring free lunches to clinic, and act surprised that the doctors are so busy, and insinuate themselves anyway into the doctors' and nurses' days with the knowledge that their products will thereby find their way into the doctors' permanent pharmacopaeia, despite their relative uselessness.
     I will not support nor have faith in Obamacare unless it acknowledges that a large part of the "high cost of healthcare" falls to the insurance and pharmaceutical industries.  We must limit the influence these megalithic businesses have on Congress, and stop scapegoating the wrong players--doctors and patients, as well as small businesses that "fail" to provide health insurance to employees.  As long as insurance and pharmaceutical companies are the invisible benefactors of healthcare reform in this country, America's politicians don't care about their constituents.  They care about their political careers and their financial backers in the next election.

Is the DOJ in Trouble?

     "Very few people on the Hill would accuse this particular DOJ [Department of Justice] of being competent.  There's been a long cumulative history of incompetence," poliical pundit Michael Gerson said on PBS News yesterday.
     He and another expert on politics, Mark Shields, were commenting on the current state of affairs at the highest levels of our government.
     Naturally these statements interest me.  If the DOJ's competence is suspect at the highest levels, what about members of the DOJ who are responsible for "low-level" activities, such as the raid on my medical clinic and the forfeitures of my bank accounts?  Could there be a pattern of "incompetence," in Michael Gerson's words, that permeates the entire Department of Justice?  Might there not be enough oversight of DOJ activities?  Is it possible for the DOJ to investigate, accuse, and arrest citizens without sufficient cause, and to deny them due process?  Might there be a permissive attitude regarding attacks on us all, especially if the yield in terms of recuperation of money for the federal government, or publicity that shows how "tough on crime we are," or the inculcation of fear in the general public serve a higher good, namely to increase the power of the DOJ?
     Michael Gerson is not alone in his assessment.  There is widespread criticism of our DOJ these days.  For the first time in American history Congress voted to hold a cabinet member, Attorney General Holder, in contempt of court.  The Attorney General is the head prosecuting attorney for the entire country.  Holder declined to divulge the facts behind the "Fast and Furious" mission, which involved transfer of thousands of guns across the Mexican border and resulted in a multitude of deaths.  "There was dissembling on the part of the Justice Department," the commentators said.  "They gave misinformation to Congress.  The DOJ didn't want to be subject to hearings, so they used Executive Privilege to protect the jobs of mid-level Justice Department employees."
     The DOJ also messed up in the John Edwards case.  It's true that Edwards may have used campaign contributions from friends as hush money to protect himself from scandal.  This was a question of morality, not legality.  But this case in North Carolina wasn't the domain of the DOJ, there was no precedent for using campaign finance law to condemn Edwards, and it served as another example of the DOJ overreaching, acting incompetently, and exposing weakness.
     The DOJ also lost in the high-profile case against Roger Clemons, the Hall of Fame pitcher accused of taking steroids.  Because of an anti-trust provision for baseball in Congress this case was heard in a top-level court and was a stain on Clemons' reputation.  The outcome?  The DOJ didn't have enough evidence to convict him.  It was another black mark on the DOJ's record.  Are they wasting taxpayers' money going after people without sufficient cause?
     I am one small person, a lowly doctor in a rural area trying to do my job.  Perhaps I cannot compare myself to these high-profile cases.  But I can't help wondering if the DOJ as a whole is infected with the bug of intrusion and attack, so much so that its henchmen don't discriminate very well when they decide whom to investigate.  As long as the FBI and DOJ can keep their evidence secret, their operations aren't subject to criticism.  The motivation for their agents to raid, steal, and attack under the pretext of protecting America is very strong.   They end up harming innocent people.
     When the FBi invades your life there is scatter everywhere.  Shards of self-doubt enter your relationships.  Questions about your integrity surface, questions that would never have been raised in any other way.  Your reputation in the community is marred.  My reputation has been harmed by the FBI's virulent attack on my office and by their need to publicize it.  
     My staff tells me that from the outset on the day of the raid TV-20 cameramen were at my clinic shooting the story, and so were newspaper reporters, writing away.  No one in my office called these people, no one in the neighborhood could have known the raid was going to be "news."
     The FBI must have given the media a heads-up about the imminent raid on my clinic.  It seems they love publicity.  I wonder how they feel now about the negative publicity for the DOJ, which must answer to all United States citizens for its blatant political motives, for its misappropriation of power, and for the apparent incompetence of our judicial system.
     My life will not be the same since the FBI raid and forfeitures.  I understand that "many countries are much worse." But this fact doesn't exonerate the American justice system.  Corruption is first an individual problem, and then becomes a social problem.  A corrupt society improves one person at a time, as each one of us attends to his own behavior and understands the motives behind it.  Maybe the FBI agents acted out of envy or greed, or the lust for power in an environment with too few restrictions on what can and can't be taken from others.  The envy and greed aren't the problem so much as the agents' not knowing whether envy or greed serve as the impetus for their disintegrating acts.  As long as they don't know themselves very well, our Justice Department employees are not serving society, but endangering it.
     The government should be careful where it sends its henchmen.  Our society feels endangered from my vantage point.  A disintegrated life is no small thing.  

What Happened after My Court Hearing for Temporary Relief

     The microphone was turned off.  The court stenographer had closed her typing apparatus.  The judge had indicated with a hand motion that we could go home.
     It was five o'clock on September 14, 2011, the date of an Emergency Hearing which I had requested via a Pro Se Motion to the Court.  I wanted the judge to concur with my position that the FBI needed to return all my clinic's medical records and at least some of the money it had confiscated in the last hundred days, so that I could keep the clinic open for patient care.
     Although there was minimal argument from the federal prosecutors, everything seemed to go their way.  The judge declined my requests and didn't give a reason.  I understand now that he had been the one to sign the Search and Seizure Warrants allowing the FBI to stampede my clinic on June 6, 2011, taking medical charts and supplies, and to forfeit all my bank accounts, leaving me without a way to pay my staff or bills.  Maybe the judge couldn't rule in my favor because he had been the one to allow them to take everything. 
     Everything, that is, except my brain.
     I was disappointed, but I had my pride.  
     I walked over to the prosecutors who were chatting with their cohorts, the FBI agents.  During the Hearing the two prosecutors had been positioned up front, near the microphone.  They were the ones who responded to questions posed by my lawyer and by the judge.  They were highly skilled at using language that carried virtually no message. Their goal was, of course, not to permit me a clue as to why they had raided my office and hobbled my ability to practice medicine.  The FBI agents, lined up against the wall, formed a buttress behind the prosecutors.  Together they seemed an impenetrable barrier to the truth.
     But now, the Hearing over, I thought they were conversing about important matters.  I got this impression from their faces, which were now and had been for the entire day a study in expressionlessness.  When I came near, however, I could overhear their powwow, and in fact they were talking about sports, a subject that  has no interest for me.  It seemed acceptable therefore to interrupt them on my way out, and it would have been rude to pass right by without saying a word after we had spent all day together.
     "Hello, everyone," I said, reaching out to shake their hands.  
     One FBI agent shook my hand, but I believe it was a blunder.  He quickly pulled it back.  The others kept their hands at their sides.  In my memory they all seemed to be wearing the same dark uniform, but of course this couldn't have been the case.
     It was impossible to make eye contact.  I wondered how this was taught in their training.  It seemed a very difficult faculty to master.  Since I have a son with autism I know that people with autism have great difficulty making and holding eye contact.  But the federal agents couldn't all have autism--no, that would be highly unlikely.
     "Congratulations on your success today," I said, smiling.  "You won in all four areas.  I'm impressed.  I don't know how you did it."
     Some of the agents seemed to be nodding their heads and smiling back, but it must have been a reflex that came from good breeding.   It's possible I  imagined it.
     "I want to thank you for helping me to get out of medicine," I went on.  "Most doctors would rather not practice any more, but we don't know how to stop.  The world of medicine has gotten so difficult and, frankly, it's dangerous.  But you have made it easy for me.  Without money, medical charts, and supplies I can simply shut the doors and hang up a 'Closed' sign."
     The prosecutors and FBI agents maintained their frozen expressions and stared at me.
     "Now I can go fishing," I said.  "My doctor friends will be envious."
     My lawyers had caught up to me, so I turned to go.  "Thanks again!" I said over my shoulder as I left the courtroom.

Are Solo Docs Weird?

     This is like asking if the Bait-n-Tackle shop owner down the road is weird.  Or the couple who run the fish camp.  Or the homemade pasta people.  Or the shoe repair guy.  Or all the people who sell their own products at the farmers' market.  Or those people who run hole-in-the-wall restaurants with out-of-this-world food in big and small cities across the country, the ones we tell our friends about when we come home from vacation.
     Of course they're weird.
     That's why we like them.
     I went out with a couple of successful friends tonight.  They know exactly how to behave.  They say all the right things, and when we bumped into people they knew, those people said all the right things too.  I used to envy this skill:  knowing what to say and holding back when the wrong things are about to pop out.  I certainly don't have it.  Tonight I blurted out questions that rose to the surface of my mind like ping-pong balls released from the bottom of a pond.  People fumbled and twitched, and looked at me as though I had changed the dimensions of the universe in which we were operating.  I was grateful for my friends, who knew how to set the world right again with a few well-chosen remarks and some felicitous smiles.
     We need such people because they smooth out the ground we walk on, setting a standard against which all our deviations can be measured--there's no weirdness without a standard.  And there's a lot to be said for the advantages of living in a clan:  safety, moral support, affirmation, groupthink.
     But doctors who join big groups become homogenized and, to my mind, dull.  They're always passing one another in the halls, or sharing call, or meeting in those ways people in groups seem to need to meet, with chair-people and business reports.  They see one another so much they start looking alike, talking alike, liking the same things.  The inclination to imitate is irresistible, and now we know it's because our brains have lots of mirror neurons.  We're constantly reflecting the people we're around.
      I think big groups are okay;  I just don't want to be in one myself.  I've come to accept my quirkiness, and I've found uses for it.  For one thing, other quirky people gravitate to me.  For another, people who are in the midst of suffering are able to find "hooks" in my un-smooth personality.  It's easier to confide difficult or shameful things to a person who seems sort of marginal.
     Solo docs, working by themselves so much, develop strange characteristics, like a species that has evolved in isolation.  They have longer antennae, a funny walk, strange gesticulations, and an offbeat sense of humor.  I remember asking myself in medical school when I was doing rotations with oddball docs way out in the boonies:  "Do I want to be like that?"  The answer must have been yes, because now I am.
     Can't I just keep being a weird solo doctor?  Does the world of medicine have to change so much that solo doctoring is no longer an option?  Is there anything I can do about this?  
     No one reads blogs any more, I am told, so my little blog is like a teardrop in a rainstorm.  I'm writing for myself, an exercise in solipsism.  It's very sad.  If people like me can't be doctors any more, why don't we just turn the management of the medical profession over to Wal-Mart?  They're doing pretty well.  They've got a good business model, if that's what it's all about.
     Please, World, let there be a place for solo doctors like me.

Friday, June 29, 2012

Patient #6: "Prayer"

      I draw up a cortisone injection and return to the exam room where Mrs. M. is sitting on the table with her legs dangling.  Although I am trying to conceal the capped needle in my cupped hand I can see her peering down at it.
     Mrs. M's knee is hot, swollen, and tender.  There is deformity of the bony structures, typical of advanced arthritis.  She's been in so much pain she couldn't stand up to sing in the church choir Sunday, which is finally what brought her in to see me.
     None of the usual treatments have worked:  ice, rest, eucalyptus rubs, anti-inflammatory pills.  I have always wondered why doctors prescribe one of the thirty-odd arthritis pills--so costly and carrying the risk of stomach and kidney toxicity--for arthritis, when cortisone is a cheap, quick fix.
     "Tomorrow you'll be dancing!" I tell her, and she squeezes out a small laugh.  Her mouth is dry, and she's busy smoothing her bright, flowered dress.  I know she'd like to bolt.
     "Is it gonna hurt?" she asks in a timid voice.
     "Not really," I say.  My nurse is standing next to me and nods. "We'll freeze your skin so it shouldn't be a big deal."
     "I be scared," she admits.  "I don't know if I can do it.  I hates needles."
     "I hate needles, too," I tell her.  "Everyone hates shots."
     Suddenly her situation reminds me of the past.
     "I remember your grandma!" I blurt out.  "She'd be in so much pain, coming in with her gouty toe or knee, begging for a cortisone shot.  Do you remember?  You'd bring her in sometimes."
     "Oh yes!" Mrs M. says, brightening up.  "She loved you!  She always said, 'Dr. C. is the best!  God bless her!  Dr. C. is the onliest one can fix me!'"
     Her ninety-nine year old grandmother had suffered from weak kidneys, which predisposes one to gout, a terrifically painful condition caused by crystals that shift like broken glass in the joint spaces.  Cortisone shots are nothing short of a miracle for this condition.  Every few months she'd arrive in a wheelchair with one or another of her large, dutiful family, asking for "one of them wonder-shots."
     "Remember how she'd shout, just as I injected the medicine, 'Dear Jesus, forgive Dr. C. for what she be doin' me, for the suffering she be causing me...for she knows not what she does!"
     "Oh, I remember," Mrs. M. laughed heartily.  "She was somethin' now, Big Momma was, wasn't she?  That was one tough lady!"
     "You're tough too.  You're all made of the same stuff.  In fact, you remind me of her."
     "I couldn't be strong without the Lord Jesus Christ," she says.  "He's my Cross, and he's my Savior!"
     "I understand," I reply.  "I hope he guides my hand as I give you this shot."
     "We don't do nothin' without God!" she exclaims, and a rather stern look crosses her face, directed at whomsoever might harbor doubt.  "And I mean nothin'!"
     "Please God, help me to do this properly, and to get Mrs. M. out of pain so she can praise your name this Sunday in church," I pray out loud, as the nurse sprays ethyl chloride onto the skin just below Mrs. M.'s left patella.
     "Hallelujah!  Praise God!" she is now singing out, carried away by the Spirit.  "We don't do nothin' without Jesus!  I'm so glad my doctor knows that!  Thank-you-Jesus-for-my-doctor!"  She is looking upward and smiling radiantly when I finish the shot.
     "All done!" I tell her as I place the syringe in the sharps container on the wall.
     "You finished already?" she exclaims.  You already done?"
     "Yes, I am."
     "I didn't feels a thing!  Not one thing!"
     "Isn't that great?" I remark, as I finish writing the note in her chart.
     The nurse helps her from the table to her feet.  "I don't feels the pain!" she announces.  Perhaps the lidocaine I used with cortisone is starting to be effective.  Who knows?
     "Wow," I say, smiling with her and sharing the moment of collusion.
     "Now, listen here," she says as I get up to open the exam room door for her.  She puts her two hands on my shoulders, looks right into my face, and speaks with authority. "You see how God works?  You see?  He performs miracles!"
     "Praise be to God!" I say.
     "And don't you forget it!  We don't do nothin' without Him.  Nothin'!  Praise the Lord!  Praise be to God!" she exclaims, walking without a limp down the hallway to the check-out counter.

Thursday, June 28, 2012

A Brief Introduction to Coding

     Starting in the 1980's Congress created and has been adding to a mountain of rules that dominate every aspect of a doctor's business.  Medical coding is one of the government's obsessions.
     Coding is a way of converting verbal descriptions of diseases and procedures into numeric or alphanumeric designations.  It amounts to an entirely new language that health care providers must learn.  It started in the 1950's as a way of tracking mortality on death certificates.  In the 1970's the HCFA (Health Care Financing Administration) began requiring that codes be used for billing.  Soon they were attached to reimbursement rates.  Since then, via dozens of updates, the initial array of codes has multipled like weeds into formidable fields of digits, and now there is a pandemic of numbers that has taken over communication with insurance companies.  No one knows what to do about it.  Every "fix" results in thousands of new numbers being added to the code books.
      Doctors like me who need to get paid have started thinking of patients in terms of their diagnosis codes instead of their human qualities and needs. This happens for at least part of the precious time relegated to the office visit.  Everything we say or do with patients must be converted to these numerical symbols. If it isn't done correctly, or if the numbers look suspicious, or if an insurance company wishes for its own reasons to postpone payment, the doctor isn't remunerated for services.
     It's as though the office visit, the illness, the patient, and the special nature of the encounter have become irrelevant.
     If a patient tells me he has a cough my first thought is, unfortunately, "786.05." Then I begin to wonder, "Is this 465.9, or 466.0, or possibly even 162.9  (a cold, bronchitis, lung cancer)?  And is his headache (784.0) a migraine (346.01), sinusitis (461.0), or neck strain (723.1)?  If I do a chest x-ray (71020) or spirometry (94010) will it be covered with the office visit (99213) if I attach a modifier (-25) with the cough code (786.05) or do I need a symptom of chest pain (786.59) and an additional modifier (-59)?   
     All day long my head is full of these numbers, thousands upon thousands of them, and I spend hours each week looking up more because the coding manuals are constantly being revamped, and I am never truly proficient.  There are diagnosis code books, office visit and procedure code books, medical supply code books...we buy updated collections every year, to supplement our electronic coding resources.
     Somewhere along the line I may recall with a start:  There's a patient here, it's a human being, and he is asking for help.  A little crack in the armor I've donned to deal with insurance companies opens up in that moment and I reach out to touch the patient.  I am thankful that I am still able to do this.  I think it means I'm still a doctor.  But it seems not to be a requirement for the job.
     Codes get in the way of patient care, especially when there are frightful numbers of them, as is the case with the 2013 version of the diagnosis code book,  ICD-10--a quantum change from older versions.  It does away with the previous twelve years of numbers and starts all over, quintupling the number of cryptograms doctors must master.  Once this new volume becomes mandatory all the codes I have in my memory bank will be rendered obsolete.  Insurance company computers won't recognize the ICD-9 codes.  And they certainly won't recognize English.
     Have any people who actually practice medicine day after day participated in the compilation of these codes?  If so, they must have sadistic motives.
     Why haven't we doctors rebelled against such an absurd system? 
     Consider the possibility that one of my employees, whose job it is to enter these codes into a computer, might get a number wrong?  The office visit may go unpaid;  the insurance company, if it pays, may recuperate the money months later;  or the claim may be rejected until the office note is sent to the insurance company by snail mail, after which the charge may be deemed "fraudulent." The physician is held liable for everything staff members do, and could ultimately be charged with a crime.
     It is so easy for errors like this to occur that in my office I have installed "macro codes" to prevent mishaps. My billing employees no longer work like Bartleby the Scrivener by entering thousands of numbers, but have single keystroke entries that expand into the diagnosis and procedure codes representing our most common services.  (Most small offices, including mine, have more billing personnel than providers.)  Whereas the current ICD-9 manual has 25,000 codes, the newly released ICD-10 manual  (optional now and mandatory by October 2013) has 148,000 different codes, necessitating that I revamp my macro system, a job that will take months.
     To speak any language, one needs about 3,000 words.  Why, then, do we need 148,000 codes to tell insurance companies what we did with patients in order (maybe) to get paid?
     Let me illustrate the situation with an example. The most common medical condition in Family Practice is high blood pressure. There are hundreds of different codes for high blood pressure:  hypertension with renal, cardiac, or ophthalmic complications; malignant, gestational, accelerated, antepartum, intraocular, pulmonary, or necrotizing hypertension; hypertension with liver disease or heart failure; postoperative, puerperal and psychogenic hypertension...the list goes on and on, with fourth and fifth digit's mind-splitting.  Worse still, doctors have to know which diagnosis codes will support the "procedures" we do.  Will a hypertension code cover a urine dipstick test?  Or a renal artery ultrasound? Will longstanding hypertension allow me to order an echocardiogram to look for cardiac enlargement?  Billing personnel need to look up these "compatibilities" for every procedure, and for every different insurance company, because they vary.  There is no consensus among insurance companies about which procedures doctors should be allowed to do based on a patient's symptoms.  It's guesswork, and doctors are forced to care more about whether a diagnosis code supports something we want to do than whether that service is best for the patient.
     You can see how much less time is available for thinking about the patient's medical condition, lifestyle, and future health during office hours.
     When ICD-10 is in place I will need to change all the problem lists in my patients' charts so that new codes for their afflictions replace the ones I painstakingly recorded over the past decade.  It will take months.  This wouldn't be so bad, except that coding is only one of many areas of government and insurance regulation, and when they're all put together the practice of medicine becomes untenable.
      Since passage of HIPAA in 1996 federal and state investigators have been given license and funding to investigate and prosecute "health care offenders" (physicians) for many "offenses" including those related to not having mastered the staggering number of codes required to represent medical services on charge sheets.  It can be a serious violation if a doctor doesn't link the codes correctly to procedures, or if written documentation for each patient visit isn't comprehensive enough to satisfy the insurance auditors' standards.
     I keep wondering if the government raided my office because something went awry with our coding.  Despite my compulsive efforts over the years to educate everyone in the office about accurate coding and documentation could we still have stumbled, and sent codes that weren't exactly right for a patient's condition? 
     "No, no," my lawyers reassured me. "That can't be it."
     "Why not?"
     "Your case is a federal case.  Coding problems wouldn't be federal charges, they'd be civil charges."
     I took a deep breath and let it out.  The two lawyers glanced warily at one another.
     "It's likely that you will have both federal and civil charges," they continued..
     "What?  What do you mean?"  Now they were telling me I could have several crimes on my hands.
     "Maybe they won't be able to find a federal crime.  Then they'll drop it down to a civil suit," the lawyers went on.  "But the civil charges are almost as bad, because the government's fines ($10,000 per error, plus three times the amount of the payment, extrapolated to every patient) can add up to hundreds of millions of dollars 'owed.'"
     "And this is all for coding errors?" I asked.
     Then I was told about a doctor whose fines added up to $1 billion.
     I looked at my lawyers with eyes that must have been the size of golf balls.  They looked right back at me, nodding their heads.

Today's Little Events 6-27-12

      This morning I did a live interview about this blog and about the FBI raid on my clinic one year ago.  It was recorded at the radio station WSKY/WKTK and will be aired on Saturday and Sunday June 30th and 31st, at 11 pm.  The host, Doug Clifford, had seen my blog and requested that I be on his show.
     "Your blog is three weeks old and already has 1,900 pageviews?!" he exclaimed.  He speculated that "the plight of the solo physician" might be a timely accompaniment to this week's Supreme Court decision on Obamacare.
     In my e-mail today an undisclosed attorney, whom I haven't met,  sent me several admonitory messages after reading my blog.
     "I have no doubt you are innocent of any charges where criminal intent is required," he wrote by way of introduction. "But I strongly urge you to dispense with your blog immediately if it remotely discusses anyone at the U.S. Courthouse."
     "I'm simply telling my story," I wrote back. "I harbor no ill-will toward anyone at the Courthouse.  But I'd like to understand what is going on.  Perhaps someone who reads the blog will have an idea."
     He answered with apparent confidence.  "False, contrived testimony from the prosecution is the foundation of every USA 18 USC I know.  These tactics are part of U.S. Government official operations guidelines."
     I told him that I thought I might be the victim of "false, contrived testimony" by individuals who hope to win a bounty from the government, but that I had faith the truth would prevail.
     His last piece of advice was to "confine comments to the appropriate forum, such as legal pleadings, and/or official complaints to the appropriate government agency."
     That reminded me of a period last year when I thought "appropriate government agencies" might help me.  After all, I abide by the law, pay taxes, vote, and love my country.  I know I have rights, but need help locating them in this particular instance.  I appreciate that I am still permitted to drive wherever I wish, shop, work, eat, and breathe.  But these days I feel sort of terrorized.
     I wrote a letter with a synopsis of the raid and forfeitures of my clinic, and asked for assistance.  I sent it to thirty-eight government officials, including local state representatives in the Florida legislature, my U.S. Senate and House of Representatives delegates, the Governor, Mayor, State Court, Attorney General...even President Obama.
     Only four of my elected public representatives responded--with form letters, all instructing me to find an attorney to give me advice, and wishing me the best.
     I contacted the Civil Liberties Union.  My case was not the type their agents prefer.
     I contacted newspaper journalists, but they wanted to know if there were any other doctors in the same situation.  The Wall Street Journal and New York Times seemed interested, especially if there might be a pattern of government intrusion on medical clinics.  I contacted the Huffington Post and the Galen Institute, but didn't know how to pitch what was happening.  I ran out of places to register "official complaints." 
     When I got to the clinic after the radio interview my billing specialist requested a private conference with me.  She had received a strange call from a prior employee, someone who had quit one month before the raid at Colasante Clinic...therefore someone who may have been one of the government "informants" suggested by the e-mailing lawyer above.  She identified herself as Shanna Owens, and said she was returning a call about her bill.  
     It's true that when Shanna left she never repaid a loan of several thousand dollars I had tendered, at her request, to help her family through an emergency.  Shanna had worked five years for me and I was happy to help.  But the shaken employee said Shanna didn't mention this loan, and had confabulated the reason for the call.  She felt certain Shanna was scouting for the FBI, trying to see if my billing specialist had quit, hoping for another "witness" on their side.
     It seems likely that an ex-employee could be so tempted by the possibility of a whistleblower fee that she would say things to an eager FBI agent to make him think he had a big case to chase.
     A few minutes later one of my x-ray techs said that an FBI agent, Robert Murphy, had gone to her house this morning and spoken to her father.  This is the name of the FBI agent who had spearheaded the raid on my office in June 2011.
     "He flashed his badge, said his name was Murphy, and wanted to speak with me," she said,  visibly disturbed.  
     "What did your father say?"  
     "He told the FBI agent I was at work and would be home tonight."
     I got busy doing clinic work, occupying myself fully with my patients' galaxies of symptoms.  I didn't have time to surmise about the FBI's motives.
     When office hours were over I went to the track with a handful of my employees, as usual, and ran two miles.  I didn't want to foster a sense of uneasiness in my heart .  But when I got home I couldn't log onto my blog.  The host said, "You currently have no blogs on this site." 
     My first thought was:  "The feds have taken my blog!"  
     Around the time of the clinic raid last year my e-mail account was hacked and erased, sending into cyberspace years of files and contacts.  Could the FBI have been responsible for that?
     In fact my blog is still intact.  It turned out to be a log-on aberration.  "I must be getting paranoid," I thought.
     Then I remembered what one of my professional friends said a few months ago:  "You have every reason to be paranoid."

Wednesday, June 27, 2012

The Goal of Federal Prosecutors at an Emergency Hearing

     The goal of federal prosecutors at a Hearing, which they did not call for their own benefit, is to say as little as possible.
     In my case the Emergency Hearing for return of my property and an opening of affidavits, held on September 14, 2011, was my idea.  I had a right to have a Hearing, but I did not have a right, it seems, to find out anything about the raid on my clinic on June 16, 2011 or the bank forfeitures on August 6, 2011, both of which were ruining my life.  The FBI had a right to invade my medical clinic and transfer all the money fom my bank accounts into theirs, but were not required by any law on the books to explain why.
     In fact it seemed almost mandatory that the prosecutors at the Hearing use the fewest number of words necessary to show respect to the Court.  Could it be that they would suffer demerits if they were to use language that carried meaning?  Perhaps a loss of points every time something was said that might reveal to me what they were up to?
     It was like a game of poker, only they weren't bluffing.  I had the feeling that this was how they always were, it was part of the training for this high-level position.  Someone like me would never have made it this far in such a profession.  I would have had to have been brainwashed.  I would have had to have all the animation power-blasted out of me a long time ago.  Some of us just aren't designed for that degree of self-possession.
     It's a good thing no one had ever said to me growing up--as I was jumping rope, riding my bicycle through Pennsylvania cornfields, picking wild mulberries, lying in meadows with books by Emerson, Thoreau, and Whitman, canning hot peaches in cinnamon syrup, dreaming my young girl dreams--"Hey, Ona, you really ought to think about becoming a Federal Prosecutor!"  Impressionable as I was, I might have taken this seriously...and now be on the other side of the courtroom, unable to speak.  
     How can people stand not to say what's on their minds?
     I think Prosecutors Corey Smith and Bobby Stinson did a very good job on that day.  I mean, they did the job they set out to do, the job required of them by their station in life, and they were trying their best to protect The United States Government.  They said not one thing of note in the entire six or seven hours reserved for my Hearing.
     They protected their case against me as though it were made of the most delicate, ephemeral substance and one little breath might blow it away like dandelion puffs.  I hardly breathed myself when one of them stepped up to the microphone in the courtroom and said a few words to Judge Jones:  "Yes, Your Honor," "We don't think so, Your Honor," "Our desire is to protect the witnesses, Your Honor."  I was hoping to catch a wisp of meaning in these precious communiques, a bit of meandering intent fraying ever so lightly from the very ends of the prosecutors' muffled syllables.  But there was nothing, not a trace of a feather of a thought that found its way to my sensibility.  The air in the courtroom was empty of meaning.
     Except for what was obvious, and had to be impressed that day onto my consciousness:  You are in deep trouble.  You are the Defendant.  You may not speak.  You have no rights, none at all, not right now, maybe never.  Your petty little doctor-life is irrelevant in our world. You think you're a big shot?  We'll show you.  Wait and see.  You're on our time.  We have power.  We have a lot of power.  Don't mess with us.

Tuesday, June 26, 2012

"You Can Get the Same Healthcare in Costa Rica"

     "Work for change, but have an escape route."  This is Ron Paul's advice.  Many fifty-somethings are doing just this.  Or they've given up on change and are planning their expatriate futures.
     One of my friends has a plan to move to Spain.  The cost of living in the Spanish countryside is half that of the United States, and he can get health insurance through an American company, United Healthcare,  for $68/month in Spain.  He can use this insurance in Spain, the United States and throughout much of the European Community.  The same insurance company won't issue him a policy in the United States.
     Another friend is building a house in Costa Rica.  "One can get the same quality medical treatment in Costa Rica for a lower total out-of-pocket cost than insurance co-pays in the U.S.," he informed me.  One dentist in Gainesville routinely refers self-pay patients to Costa Rica for extensive dental work, including implants.  I have seen the results of Costa Rican dental work:  it is excellent--and one-twentieth the cost.
     I just returned from an educational conference in Switzerland.  What a shock to meet so many Americans who have decided to settle permanently in Switzerland, despite the high cost of a work visa!  Each one gave me a variation on the same theme:  it's frightening to live in the United States these days.  Our country is out of control, they say, having turned over the reins of decision-making to big business, lobbyists, and politicians whose tenure depends on campaign contributions.  The story of the FBI raid on my clinic  and the theft of my clinic's hard-earned money corroborated for them the auspiciousness of their decision to relocate.  Many are thinking of giving up citizenship in the United States in order to stop being required to submit tax returns, but the paperwork is voluminous.
     While I respect their decisions, I love the United States.  I want to stay on the rural farm I have improved with wildflowers, palm trees, butterfly gardens, and fruit groves.  I have formed deep connections to my patients and employees.  It's true that the powers of political hegemony seem insuperable and that I could be facing prison time for--please remind me--for what?  I don't even know, and my lawyers can't surmise.  Are we in a fascist state?  This is what some of my emigrant friends believe.  I am under assault... and it's unbearable, a staggering fact of my life and a sad commentary on my many years of education and devotion to the medical profession.  But my roots are here.  I feel sorry for political refugees and all those who have been displaced from their birth homes.
     The temptation to relocate to Bali or France--or to join my friends in Equador, Spain, Costa Rica-- is, nevertheless, powerful these days.  When my lawyer instructed me last year to turn over my passport to him so that, "If the FBI comes to your house to arrest you, I can tell them you aren't a flight risk, I have your passport, they should release you on bail," I suddenly felt as though all my freedom had been usurped.  I took back my passport this month to go to Switzerland.  The lawyer returned it to me it without hesitation, saying, "I don't know what the Feds are doing.  Go wherever you want."  I am confused.
     Meanwhile I go to work, I pay taxes, I cast my vote in every election, and I provide health insurance for all my staff.  The premiums are close to $600 a month per person... an astounding sum by the standards of any other nation, but for all this I get to live in America.  I'll do what is required for the privilege of abiding in this country, which is trying so hard to be great.

Monday, June 25, 2012

Why Solo Docs Should Not Sell Out

     Solo Doctoring is a special calling.  There is a bit of The Loneliness of the Long Distance Runner in it.  Here you are, all by yourself in the foggy morning with the patients, with your staff, in your cluttered little office, with your bag of tricks.  You travel a labyrinthine road with each patient for years and years;  it's toilsome, full of calamity, beset by the perplexities of transference and countertransference, but there is joy amidst the heft and storminess of that hundred and fifty-six miles, the joy of having made something happen.  Your patients need you.   They don't come to see you when Pandora's Box is tightly shut, when they feel terrific, or if they've just won the lottery.  And frankly, they aren't interesting people when all the charms of life have showered down upon them.
     The solo doc gets more of the provocative patients, the ones who suffer but are also agents of change.  This is my prejudice, but I am imagining a patient in deep distress wishing to find a fellow traveler on the backwater road to understanding himself.  Doctors in large corporations are not those lonely souls, at least not on the surface.  They are protected by the group, saved by a bulwark of lawyers and accountants who stand at the helm and vouchsafe their jobs, saved by other doctors who "cover" for them when they go on vacation.  You can no more get "coverage" for your patients when you go away than you can for your marriage.
     Patients are provocative when they have a venue to be so--when there is room to move around and bring out their performances; when there is time for the doctor to imagine who is making the puppets dance, and why; when the doctor finds it all irresistible, joins in the drama, and tenders the magic potion.
       Despite the fakery of HIPAA the patient's darkest woes can't find true sanctuary in a gargantuan corporate office.  Are the secrets recorded in the typewritten note really safe from the curious meandering eyes of the hundreds of clerks who handle the thousands of charts every day?  No clinic, however small, is free of employees but if the few staff members have been there for years and greet you like family it feels secure.  When a patient trusts everyone in the office, when the doors are sealed, when the doctor is another lonely soul trekking his way toward the dark end of life, untold stories surface from the black muck of the past;  in that space there are divulged feelings that many doctors would rather not contain because they take too much time.  But in the environment of the solo doc patients experience catharsis, and restoration of health.
     Of the many doctors I've met among the growing subset who sold their little private offices and moved into conglomerates, none seems truly happy.  They act like amputated versions of their old selves.  They don't have the peculiar mannerisms and quirky ways of expressing themselves that you see in solo docs, especially the old country docs.  There's a defensiveness about them, too, in their saying over and over, "I'm really on my own, it's just that the company does all the paperwork and insurance stuff, and they hire and fire..." and "I have more quality of life."  It's as though they have been so thoroughly hypnotized by the recruitment lullabies that they repeat them as facts.
     "You're not happy!" I want to shout, pointing out to them that they've grown lumpish and wan.  But how should I know?
     I do know that a complacent doctor well-protected by corporate bureaucracy doesn't provide "hooks" for the patient to grab onto, and hooks are what allow for relatedness.  My patients are always asking about my life, or making assumptions about me based on idiosyncrasies in my presentation, the artwork I've chosen for my walls, or the jokes and information sheets I hang on bulletin boards.  While I say very little about myself, over the course of many years patients come to know or deduce things about me that allow them to feel comfortable in my presence, even to consider me a fellow-traveler.  This is conducive to their well-being.  It's true that many corporate-owned practices set up doctors in small private offices that simulate those of solo docs.  But this is a deception--it belies their awareness that solo doctoring is best--why else mimic it?-- and I don't think it fools patients.
     My mother's long-time solo cardiologist sold out to a hospital several years ago.  He's the same doctor on the outside, but she has mentioned to me on numerous occasions that he's really not the same, he seems resigned, he has lost his verve.  And she isn't the same either, when she's with him.  She can't confide in him;  she hides her symptoms;  she doesn't want to waste his time.
     There are subtle problems with the doctor-patient relationship in the corporate "delivery of medical care" (a phrase not invented by a solo doc).  My mother's cardiologist isn't in charge any more;  as a result his patient care has gone gray.  Corporate advocates would laugh and say I'm pointing at a specter in the dark.  There's no difference, they'd insist, hiding in the wings while the doctor does his gentle curing, and grabbing the monthly profits from his pockets like burglars.  There is a difference, and I think it alters the patients' well-being and the doctor's.  It's destroying the last bits of what used to make American medicine great.
     The main reason solo docs should not sell out is because maybe we're  happier in our independent orbits than we've been willing to admit, and once we sell out it's hard to turn back.  Even if insurance companies erect roadblocks and the federal and state governments have turned into tyrannical parents, we solo docs manage to do well.  Imagining that life will be simpler when someone else takes charge is like turning our cars over to chauffeurs or allowing a cook to decide every meal we eat.  Like wild animals whose forested habitats have been devastated we can adapt more readily to change than our soft, salaried counterparts.  There isn't a year in solo practice when I haven't had to shift my strategies, add new skills to my repertoire, memorize new codes, analyze documentation requirements, or drastically amend my relationship to insurance companies.
     There is a heart in solo doctoring, and it shrivels up when we sell out.  Solo docs are completely invested in what they do.  Our personalized decisions have immediate effects on the practice, unlike those in larger groups where pyramidal administrations sink new ideas into procedural quicksand, and change is a last resort.  We lone doctors can remedy problems in a day, or we can keep doing things the old-fashioned way when our broad understanding of patients tells us it's for the best.
     I do not understand the incursion of corporations into private medicine.  It's an insidious takeover, an attack on humanity, a blasphemy--and I'm down here in the trenches waving a red flag and shouting, "Help! Help!  Are there any real doctors left?"

Sunday, June 24, 2012

Why Are Solo Docs Selling Out?

     Solo docs get tricked into thinking someone else can do it better.  Doctors are sensitive. This is good because they need to register the little messages patients are always transmitting below the radar.  But they are too sensitive to the corporate messages, which amount to advertising and can be subtle or in-your-face.  The corporate propaganda has this theme:  Let us handle the business of medicine so you can do what you do best, doctoring.  Aren't you tired of late nights and burnout?  Come with us and we'll guarantee you a high quality of life.                      
      Doctors feel offended by daily auditing of their medical records by insurance companies whose intention is to intimidate doctors into under-coding for their work and offering their patients fewer services so that insurance companies can increase their profits.

      Because they are threatened, year after year, by large Medicare pay-cuts and are made to feel personally responsible for the mismanagement of all the money tax-paying individuals have entrusted with the Medicare program.  Starting in July or August of every year doctors are warned that they will have to accept lower pay, despite the escalating costs of running a practice.   This year the projected Medicare pay cut was 29.5%.  Every medical journal seemed to make it a top story.  Then, as has happened every year this decade, in March or April we were told, "Congress Averts Doomsday but Medicare Pay-cut Still Looms."  Is there even a sigh of relief in these headlines?  Medicare and Medicaid face $320 billion in cuts over the next ten years.  (What if your boss told you he probably couldn't sign your paychecks much longer?)   For some reason doctors think their corporate employers will fare better in this environment, and they sell out in order to shut out the din of threats.

     All insurance companies regularly decline to pay for services performed by the doctor, and the procedure for appealing the decisions is preposterous.  It involves an interchange of forms and electronic responses;  human beings seem to be absent from decision-making by insurance companies;  explanations for non-payment are on the order of "the documentation doesn't support the need for service;" and insurance companies spend 100% of their time eroding the doctor's stamina, whereas the doctor is spending most of that time seeing patients. 

      Doctors have inherited a long tradition of self-sacrifice, working long hours and ignoring their bodies and souls.  They are still not very good at making time for their families and friends.  They think corporations can solve this problem for them.

      Patients have also inherited the tradition of expecting doctors to sacrifice themselves and have unwittingly acted as partners in the doctors' self-destruction, for example by calling and saying things like, "You shouldn't be up at 10 pm taking care of patients...but could you tell me what's wrong with me before you go?"  Doctors think the corporations will bully patients into better behavior.

       Every job--especially a job that is a calling--requires a measure of self-sacrifice, and doctors don't want to admit this.

      The federal government, heavily influenced by lobbyists who stand to rake in big profits for their corporate employers when Congress acts on their behalf (from which profits the corporations will make tidy behind-the-scenes campaign contributions),  is mandating changes in doctors' office that don't make sense for doctors or patients.  First it was the use of tens of thousands of numerical codes to explain to insurance company computers how a doctor diagnoses and treats each patient;  then it was expensive billing software requiring constant maintenance; then it was HIPAA compliance;  then it was OSHA, CLIA, AHCA agency regulations;  then it was E-prescribing software, often duplicating handwritten prescriptions and doubling the doctor's work; then it was quality-control reporting;  and now it is electronic health records (price: $30,000 to $150,000, plus one to two years of transition costs).  These mandates don't improve efficiency in most offices.  They get in the way of patient care, and they don't  acknowledge the deeply personal methodology of doctoring.  Coding a visit,  for example, is akin to synopsizing Wagner's Tristan and Isolde to five lines, converting it to numerical codes, and attaching a dollar value to it.  While some translation must occur now that patients don't pay for their own services, what  really happens in the exam room is lost in this process.

      Doctors are afraid to bow out of the insurance system, thinking they won't have enough patients.  Because patients think insurance really is a "benefit" and are afraid to bow out too, paying their own way, saving premiums, staying healthy.

       Patients are incited by insurance companies to report their doctors when they think there is "over-billing."  Most doctors don't over-bill and are not criminals, but patients are led to believe otherwise.

       The threat of malpractice lawsuits still hovers over doctoring, not because so many doctors commit malpractice (they don't) but because, as a lawyer once told me, "when the economy is down people look for any way to make money."  Malpractice suits feel demoralizing to doctors, but they are easier to bear if they can be shared with a big corporate daddy.

        The federal government is criminalizing medicine, raiding and impugning innocent doctors like me with the intent of amassing money through intimidation, to keep the big machinery of a bankrupt government going a little bit longer.  The government is more apt to attack a doctor who works alone and is vulnerable than one who is ensconced in another kind of machinery with layers of protective armor, the corporation.

How to Grow Potatoes

     There is a complicated way and there is an easy way to grow potatoes.  The complicated way is goof-proof, but the easy way is, well, easy.  You simply throw potato peelings onto your compost heap.  Sometimes potato plants spring forth with no help at all.
     One must always have potatoes in the pantry bin.  For a doctor getting home late at night it's a quick meal:  microwave three potatoes, drizzle olive oil, sprinkle salt, and serve with a glass of buttermilk.   A good night's rest will follow.
     If the potatoes waited for you too long,  they will have generated sprouts.  This means they are alive!  They haven't been sprayed by a packing house with chemicals to deter sprouting.  The places from which the sprouts grow are called "eyes."  Before they sprout they look like a little child's fingerprints  in the body of the potato--they challenge the potato-peeler.
     You need soil.  Sandy soil is best because it drains well and allows the tubers to expand freely, hence it yields larger potatoes.  Plant them when spring is around the corner.
     Take potatoes that have begun to sprout and cut them into pieces about the size of big marshmallows, making sure each piece has an eye.  If you buy seed potatoes at the feed outlet or hardware store they will be a strain resistant to viruses.  It was news to me that potatoes are vulnerable to viruses, like people.  Then my son informed me that humans have 99% of the same DNA as bananas.  Either the last 1% counts for a lot or we need to be kinder to plants.
     Pull the weeds and grass out of the soil.  If there aren't any it's not good soil, the plants will suffer, and the potatoes will be malformed.  You can augment soil with compost, preferably made from your own kitchen and yard waste, or with dry manure from chickens or cows you have known personally.  Do not use commercial fertilizer.  The potatoes will absorb the organophosphates and deliver them directly through your GI tract to your living cells.  Any quantity of synthetic organophosphate fertilizer is unhealthy.
     Dig a hole in the soil and drop one of the potato cubes into the hole.  Cover it with soil.  Make several rows,  spacing them one foot apart.  Mound the soil over the potato cubes as though a gopher had just been at work in the vicinity. Make a shallow drainage halo around the mounds and spread hay on top to keep out sunlight.
     Water the potatoes every day or two if it doesn't rain.  Sandy soil will allow excess water to drain off.  If water pools around potatoes they will rot.
     In two weeks the lush crinkly green leaves of the plant will emerge.  In six weeks the potatoes underground will be like golf balls.  They are delicious washed and boiled for 10 minutes, with nothing added.  In four more weeks they will be as big as fists.
     Burying your fingers deep in the soil below the potato stalks and discovering these magnificent prizes renews one's faith in the earth, sunshine, rain, the power we have to regenerate life, even our own wretched lives, from the most ignoble of places, with meager raw materials, and a measure of patience.  When I dig potatoes I think of lines from Louise Gluck's "The Wild Iris:"

       ... It is terrible to survive
          as consciousness
          buried in the dark earth....
          You who do not remember
          passage from the other world
          I tell you I could speak again:  whatever
          returns from oblivion returns
          to find a voice...

Saturday, June 23, 2012

Solo Docs Are Selling Out

     For the first time in the history of United States medicine there are more doctors working as employees than for themselves.  The number of solo doctors has plummeted. 
     The reversal of the trend from self-employment to employee status was first noted in 2008.  Medical Economics says, "According to a 2010 PricewaterhouseCoopers report, nearly 2,910 physicians were involved in mergers or acquisitions in 2009, double the number from 2008."
     Medical Economics is a free journal sent to all physicians in this country.  It is full of advertising and contains articles purportedly advising doctors about how to make good business decisions.  The article just quoted does not explore the reasons for the trend from ownership to employee status at clinics--it bypasses this riveting question altogether in favor of catechizing physicians on how to sell their practices to hospitals.  It provides step-by-step instructions for making this "transition."
     First the article comforts physicians who are on the fence.  "If you're considering selling to a hospital or healthcare system, you're not alone."  Humans are herd animals--if everyone else is doing something the impulse to follow along is almost irresistible.  The herd instinct is visible at football stadiums and in front of television sets during playoffs, and in the drift of the S&P 500.  Now it's being capitalized on to manipulate doctors.
     "Doctors don't know anything about business," has become an annoying apothegm over the years.  There is a certain pride when a doctor says it, as though caring about patients eclipses everything ordinary.  There is scorn when an accountant, hospital administrator, or CEO of a corporate-owned physician group says it, fueling the implication that doctors should get out of the business world and leave all the profit-making to them, the rich businessmen.  No one expects doctors to care about money:  it's obscene.  But CEO's and the rest of them, they're already filthy with the mud of mercenaries.  Why not let them have it all?
     Doctors do know a lot about business.  We have been running our own businesses for centuries.  Moreover, we run them with compassion.  I, for example, have never found any use for collection agencies. If patients can't pay their bills up front, I don't chase after them from behind by using hired hands to batter them with threat-notices.  Money is important, but it's not The Most Important Thing where people are concerned.  This is a basic fact of human interaction, isn't it?--and something corporations, not being human but standing in as the greedy underbelly of humanity, do not respect.  If we turn our offices over to corporations, including hospitals, and if in our shrinking solo practices we imitate the habits of those cold-blooded entities, patients can no longer expect the benevolence and concern of the physician sector to translate into grace when it comes to unpaid balances, the need for a doctor in the middle of the night, and wide-open office hours.
     The Medical Economics article warns doctors about letting their emotions get involved when making the decision to sell.  "As difficult as it is to hear and remember, loyalty is not a financially tangible asset.  It may be an admirable and appreciated trait, but it can't translate into dollars and cents in an acquisition."
       Doctors!  the article reprimands us.  Start acting like the rest of the world!  Quit letting your feelings get in the way of your life!  The clear message is that what we considered priceless, our loyalty and our love, are without value in the real world.  "An emotional attachment to your practice might give you an inflated idea of its worth."  This is a cautionary note for doctors on the verge of selling out.  We shouldn't expect anyone to value our feelings, our attachments, or our patients' attachment to us.  Corporations appraise these at zero.  Sure, our patients may value these qualities.  But they don't matter...or do they? 

Lunch on the Day of the Court Hearing

     We were told by Judge Jones to take a lunch recess in the middle of the Court Hearing.
     I had not had a true lunch break in twenty years.
     Wow!  It was really fun!  We went to Emilio's and ordered amarillos, tostones, black beans and rice.  I sat with my employees and the four lawyers who were either representing or about to represent me.
     Taking a lunch break is a magnificent idea.  It allows a person to draw a deep breath, move from morning to afternoon, speculate about life, plan activities after work, and generally act like a human being, not a workhorse.
     In Switzerland, where the work ethic is intense, it's considered cause for dismissal when an employee decides to "take lunch at my desk."  The diligent Swiss people mandate lunch breaks either because they know it improves work performance or simply because they are a civilized race.
     In general I eat a few handfuls of buckwheat granola, a bowl of grapefruit, or some stir-fried tofu and vegetables left over from my weekend cooking for "lunch"--usually while I'm looking up ICD-9 codes or writing the copious chart documentation necessitated by insurance carriers,  in between doing office visits and surgeries.  Most days there are no breaks in the schedule and I skip "lunch."  I know it's wrong.  I just can't relax over lunch when I hear someone hacking up infected sputum in the next room, or I know there's a patient with acute abdominal pain in the wings.  Sometimes little kids are running up and down the hallway, and I know their mother's patience is wearing thin:  she wants to finish their immunizations and well-child exams and get out the door.
     On a few occasions I have taken lunch at a restaurant with one of my lawyers while listening to variations of the stomach-wrenching explanation for why my case isn't moving along:  "There's-nothing-we-can-do."  It's not what I would call "doing lunch."
     Except for doctors and providers, all my employees are required to take lunch breaks.  I tell them they need to leave the office and let work roll out of their minds.
     On the day of the Hearing it was refreshing to leave the courtroom and walk around downtown Gainesville in the sunshine with the wind blowing through my hair.  Even though the Hearing wasn't going very well I felt I had a number of good people on my side.  All of them were confused, nevertheless they were backing me up.  At the restaurant we aligned three tables and were squeezed together like old friends.  The lawyers laughed and told stories, and we laughed along with them.
     Then I said I wanted to get up and sit with the prosecutors and FBI agents, who were seated at another table across the room.  We had all chosen the same restaurant!
     "Oh my God, no you don't!" said my four lawyers in unison.  "You can't do that!"
     "I won't talk about the case," I reassured them.  "I just want to tell them a little about Gainesville and this neat restaurant, and suggest that they check out the Hippodrome."
     They grabbed my sleeve and forced me back into my seat.  "You're crazy," they said in hushed voices, looking around in every direction.  It was as though a terrorist had just been set loose.  "Don't you know what they could do?  They could take everything you say and twist it around until they think they can prove that you've admitted your own guilt."
     "But I'm not guilty."
     "They don't know that.  And they don't care."
     This was an important point on the maturation curve for me from naive, faithful, law-abiding citizen to paranoid, affronted, closed-mouthed defendant.  When I walked back to Court with everyone else the sun didn't seem so warm.  It felt as though I had cement in my shoes, and I was glad I hadn't chosen to become a lawyer.

Friday, June 22, 2012

Witnesses at the Court Hearing

     At my Court Hearing the Government had no witnesses.
     I had four witnesses, all employees:  the Clinic's bookkeeper, Nurse Practitioner, Billing Specialist, and Nurse Supervisor.  Two had been hired by me six years earlier, and two in the past year.  Each took the witness stand for about twenty minutes.
     The bookkeeper said she had known me for more than six years and been doing bookkeeping for me since that time.  She had never seen any irregularities in my work.  She thought of me as a person of upstanding character.  I was an asset to the community, she said, and very generous with my employees.  I was anxious to pay bills on time and meet tax deadlines.
     The Nurse Practitioner said I was an excellent doctor and had taught her much of what she knew about Family Practice.  She coded her own visits and was aware of the complicated coding guidelines.  She knew I reviewed every chart and every billing sheet before it was submitted to billing personnel for computer entry, and she had never known me to bill erroneously or over-bill.
     The Nurse Supervisor said she loved her job and felt we were doing a lot more to help patients than other practices where she had worked.  We were very busy and did tests and procedures that were necessary.  She understood the reason for everything she was asked to do and was learning a lot about sorting out patients' symptoms, because this was a teaching environment.  She explained how the office worked as a team to figure out what was wrong with patients and get them well. We offered many treatments on site, for example IV antibiotics, corticosteroid joint injections, IUD insertion, x-ray, ultrasound, bone density, skin cancer removal...and she knew this was more comprehensive than most family doctors, but patients were happy not to be referred out, which was why we were so busy.
     The Billing Specialist said she entered and submitted charges, understood billing procedures, and had worked at numerous other offices.  She had not seen or entered charges that seemed erroneous or fraudulent at Colasante Clinic, and she had never had any cause for suspicion.  She and other billing representatives were the only ones who entered charges to insurance companies, not the doctors or other employees.  When she thought a code was questionable, she would go over it with me, recommending a more appropriate one, and found me to be quite receptive.  When she reviewed payments there were none for services that she and the billing staff couldn't corroborate.  She considered me a person of high integrity with great regard for patients.  She knew we offered multi-specialty services which saved our patients the travel and inconvenience of referrals and thought it was an excellent way to practice.
     All the employees had referred friends and relatives to Colasante Clinic because they had confidence in the methodology and treatment protocols, and they knew providers cared about patients.
     The witnesses were sequestered in closed quarters outside the courtroom and were not permitted to hear one another's testimony. They were ushered in to take the stand, and ushered out when they were finished.  They were very nervous.
     I was not allowed to speak at any time during the Hearing.
     This was certainly for the best.

A Court Hearing To Petition for Relief

     My hopes for the Court Hearing were fatuous.  The proceedings made me ashamed of the judicial system and of the Federal Government, which is able to sidestep due process and common sense in the name of a fallacious national security.  A government that makes and alters its own laws without the amendatory input of its people is a totalitarian government.  A totalitarian government is corrupt because it serves its own private ends, not the ends of the population it is supposed to govern.
     After the Hearing Gilbert Schaffnit, who had watched from the citizens' benches and later became my lawyer, told me, "The Judge's hands were tied.  He wasn't allowed to do what he should have done because the law didn't give him any recourse."
     Is the Federal Government's right to invade and rob a family practice clinic, and to demolish a doctor's reputation, my reputation, so irrefragable that a judge can't, if he is shown a different truth, act on it?  Or didn't Magistrate Judge Jones see in my situation any truth except that of the Tallahassee Prosecutors Corey Smith and Bobby Stinson.  These prosecutors were the two federal lawyers  handling my case, acting on their FBI agents' unilateral conviction that they had a brazen criminal, me, in their clutches.
     I requested an emergency hearing not to establish my innocence--that would require an exposition of charges, wouldn't it?--and the FBI agents had "sealed" the evidence supporting their charges.  Their logic was that I posed a danger to society and the witnesses had to be protected.
     No,  the emergency hearing was my attempt to recuperate materials indispensable for keeping the clinic open for the sake of patients and employees.
     The FBI agents had taken all the patients' medical charts.  It is impossible to provide a high level of care to sick patients without their medical records.
     The FBI agents had taken all the cash from the clinic's bank account  and all the money crom  my two personal credit union accounts.
      The bank had canceled my only credit card.
      I could not borrow money now that my financial integrity had been insulted by the FBI's bank forfeitures.
     A clinic, like any other business, cannot operate without capital.  My employees needed their paychecks.  Their health insurance required me to make premium payments.  We had to pay for malpractice, unemployment, workers' comp, and general liability insurance. We bought supplies daily:  casting materials, splints, IV fluids, flu shots, suture material, anesthetic, needles, syringes, antibiotics, EKG paper, surgical trays.
     I filed an "Emergency Motion for Return of Seized Property and Documents, To Unseal Affidavits and for Immediate Adversarial Hearing and Incorporated Memorandum of Law" with the Gainesville Division of the United States District Court in the Northern District of Florida.
     This meant that I, Ona Colasante, was petitioning the court for urgent action in order to save my clinic from closing its doors.  The action I requested was that the Court order the FBI to return my patients' medical records and give back some of the clinic's money so I could pay the staff salaries, rent, utilities, insurance and bills for medical supplies.
     An Expedited Hearing was not granted because my lawyer at the time, Curtis Fallgatter, petitioned the court for a later date without telling me.  He went on vacation for several weeks--a trip arranged before I had retained him.  He had not mentioned it to me because I would not have retained him had I  known he would be gone during this crucial period.  That is a story for another post.
     I filed this Motion "Pro Se", which is legal language for approaching the court without a lawyer.
     The Court Hearing lasted all day on September 14,  2011.  Curtis Fallgatter and Mark Thomas were my lawyers.  In the wings were Gilbert Schaffnit and Carl Lietz who were lawyers watching the proceedings in preparation for representing me.  I had no money to pay any of them.  The federal government had made it impossible for me to pay for legal defense.
      FBI agents lined the left side of the courtroom, the prosecutors stood in front of them and everyone faced Magistrate Judge Jones.  No one made eye contact with me.  The aim of the prosecutors was to keep me from being granted access to the medical charts, clinic money, or affidavits. Their job was eminently easy.
     What happened?
     My lawyer told Judge Jones that we needed working capital to keep the clinic open, medical charts to provide good care to patients, and an unsealing of the affidavits to understand what the government thought I was doing wrong and then to stop doing it.
     The two prosecutors rose and declared that they should not have to return the money because it belonged to them;  they should be able to keep the patient records because they were needed for an ongoing investigation, and they had good reasons for keeping the affidavits sealed.
     Copying or scanning the charts was unacceptable, they said--they needed "the originals."  Giving the clinic copies of the records would cost the Government too much.  Allowing clinic staff to go to Tallahassee to scan records was too intrusive.
     The prosecutors divulged no specific allegations.
     "If the Clinic is billing erroneously, don't we need to know what it's doing wrong?" we asked.
     "Dr. Colasante should know," the prosecutors answered.
     "But Dr. Colasante insists that all her charges have been justifiable and accurate.  She needs to know if she's doing something criminal."
     The prosecutors and FBI agents conferred among themselves.  Then they gave the judge their argument.
     "Dr. Colasante just wants the affidavits opened so she can build a defense.  We don't think she should have them."
     Judge Jones ruled in their favor.


Thursday, June 21, 2012

My Employees Care

     "Dr. C.!  You have to do these charts!  We can't let them pile up!  These patients need your help!"
     One of the front office personnel was hovering over my desk, looking down at me with a stern expression.
     Office hours had just ended. It was 8 pm and the she had just locked the door behind the last patient. She must have thought I was going to leave the charts until the next day and, in truth, the idea had crossed my mind.  Taking time off had made me realize just how different doctoring is from other jobs.  At least solo-doctoring.
     I had been away for a few days.  It's true, there were more than the usual number of charts with telephone messages, faxes, home health agency reports, reports from consultants, and office notes to review, answer and sign.  But I still felt the pull of the normal world, the lure of a nine-to-five job.  It seemed so healthy to get off work before dark, to stop at the grocery store, to take a walk or talk with a friend, and relax.
     Solo doctors don't know the meaning of the word, relax.  The commitment entailed in doing a doctor's work, caring about patients, laboring over them, wondering whether we've made the right diagnosis or said the right words to them, added to the long hours and administrative problems associated with running a small business makes relaxing a foreign word.  Or maybe we are constitutionally unable to relax, and choose this line of work because it suits our personalities.
     "Hey Doc, you'd better get to these x-rays before they get out of hand.  Let me organize them for you--you can't go home without reading them."  The x-ray tech was right;  there were three fractures, one kidney stone, and two pneumonias hidden in that pile and if I hadn't read the x-rays the patients would have had to suffer waiting for treatment.
     Last night I stayed at work until midnight.  I wasn't completely finished with the charts, but I was finished.  Before I cut back on office hours I would work until midnight or later about three days a week. Back then the clinic was open from 6 am to 10 pm seven days a week, we had two shifts of employees, and the waiting room was usually brimming with patients.  When my children were young they would loiter in the break room eating sandwiches, doing homework, coloring, blowing up condoms (which, by the way, make great water balloons) and importuning me, "Mom, when are you going to be finished?  Can we go now?"  These were the Fridays when I would take them to the beach for the weekend while other providers covered the office.  We'd leave at midnight, get to the beach at 2 am, and be able to wake up to the ocean. "Mom, how much longer is it going to be?"
     Now grown,  not one of my children  wants to go to medical school.  "Too hard," they say.  "I don't want to work that hard."
     And there's the matter of the raid, the investigation, the government's desire to repay its national debt by staging coups on doctors' offices, taking advantage of doctors' sensitivity, hoping for a "settlement" instead of an expensive, time-consuming, all-out court-battle.  The settlements add up.  The government claims it has "re-collected" hundreds of millions of dollars in its attacks on doctors, who mostly settle because trials are expensive and their sensitive natures--indispensable for the process of making medical diagnoses--are not able to withstand the negative publicity and pugnacious proceedings of court.
     Why would my children want to enter this world?  It doesn't matter how rewarding it is to care for patients, develop relationships with them, heal them, one by one.  No one wants to be attacked for nothing.
     Not me.  Which is why I think constantly about how to get out of this profession.  But it's part of my being.  I want to leave, but I don't know if I can.  I like the patients too much.  I like my employees.
     My employees care about me.  They care about patients.  They like their jobs.  The medical profession attracts people with strong feeling connections to the world.  This is true of my employees:  their sensitivity is their genius.  Without them I would not be able to do my job and the patients wouldn't respond to my treatments.  The entire office is the healing organism, the treatment. 
     It's 9:20 pm.  I have ten more charts to review and answer.  The nurse practitioner is laboring away at her desk, wearing her headphones, finishing her own stack of charts.  Soon I'll read the microscope slides from the week:  sputum gram stains to identify the organisms causing infection, vaginal wet preps for STD's, nasal smears for allergy-associated eosinophils.  Then I'll answer questions from insurance companies:  Why did you do an EKG on this patient?  What was the reason for the cortisone hip injection?  We won't pay unless we hear from you within 30 days.  We still might not pay, because we think you do too much.  We won't pay because we think we can get away with it. We won't have to pay because we know you're too busy to respond in the format and timeframe we require.  Ha, ha, ha, ha, ha.
     Okay, the insurance companies can laugh.  They can refuse to pay.  But the last laugh is ours, because we--my employees and I--have a special quality of life.  We have people on our side.  Our patients love us, and we love them back.  When we go home at night, however late, we can say to ourselves:  We did something good today. It was worth it.  It was worth every minute.