The Government Stole My Patients' Medicines

     The daughter of an elderly patient called me at home over the weekend.
     "Can you help my mother?  She's running a fever--and she's not eating."
     "I haven't seen Mrs. M.  for a year," I answered.
     It's unfortunate, but we stopped taking Medicare patients at my clinic when the government (we presume) instructed Medicare to stop paying us for our work.  It took six months of zero payments for us to realize the Medicare--the insurance carrier for people over sixty-five-- had no problem letting us see patients for free, forever.  (Is that legal?)
     "How has she been doing, otherwise?" I asked.
     "It's bad," the daughter said.  "She broke three bones in her arm last week.  They couldn't do surgery, and sent her home.  Now she has a fever."
     We had been treating Mrs. M.'s osteoporosis with yearly Reclast--administered in our office through an IV.  The treatment is quick and easy--and an exceptional way to reduce fractures in older patients.
     In fact, data on bisphosphonates like Reclast shows a thirty to fifty percent reduction in fractures in people treated the first year.  The trouble is, patients won't take oral bisphosphonates:  the pill causes reflux, it's hard to remember the dosing schedule, and the restrictions about not eating or lying down afterward are annoying--especially for older people, easily confused.  But patients will come to the office once a year for Reclast.  It's a fantastic product, except for the cost.
     Medicare pays doctors to administer Reclast, as it should--but its reimbursement for the medication is $200 less than the cost to buy the medication.  (IV Boniva is similarly under-reimbursed.)  I told my nursing supervisor--who maintains inventory--that if we couldn't find Reclast at a break-even price we wouldn't be able to administer it to patients.
     She did her research and found a reasonable price for the product at Northwest Pharmacy.  We were able to buy two other important injectable medications from Northwest at prices that allowed us to use them in the office:  Synvisc, and Boniva.  For the first year at Colasante Clinic we gave Reclast (and the other two medications) to patients whose medical problems justified its use.  I believe these medicines prevented fractures--and saved lives.
     I have been using Reclast for six years.  The fracture rates for patients in my practice plummeted after we started administering it.  Patients would take calcium and Vitamin D, have their kidney function checked with a lab test, get Reclast in our office--and get on with their lives.
     It's a fact that in Family Practice we don't get credit for most of the good things we do.  Patients love us, but they don't come back and say, "Hey Doc, Thanks--I haven't had a fracture!"  They don't appreciate that they didn't get pneumonia or the flu after we vaccinated them, or that they didn't have an unplanned pregnancy after we inserted an IUD.  It's hard to register the absence of a problem.  But we know we're doing the right thing for people, and that's what matters.  I knew that giving IV Reclast was saving my patients from having fractures, just as I had observed that putting them through vestibular training would correct the balance-related falls so common in older folks.  Patients don't write me notes saying thank-you, they haven't fallen.
     Today a patient came to see me, and started crying as soon a I sat down and looked at her.
     "You know my husband died six weeks ago?" she told me.
     No, I hadn't known.  I hadn't seen Mr. B. for more than a year--another Medicare patient.  He, too, had been getting Reclast--until we stopped giving it.
     "What happened to him?" I asked, feeling downhearted.  I was remembering how Mr. B.  had always stood up when I entered the room, and given me a little bow.  I remembered that he was freshly shaven for his appointments, his shirt was tucked in, and his hair neatly combed.
     "He fell and broke his hip," she answered.  "He died seven days later."
     One-third of the patients who sustain hip fractures die within six months--of something.
     Why did we stop giving Reclast?
     Because the FBI took our entire stock, during its raid of my clinic on June 16, 2011.  The agents took all the Boniva, too, and ninety IUD's, aas well as the Synvisc we were using for patients with disabling knee arthritis--people who were grateful for the treatment because they could not undergo surgery.
     The medications taken by the FBI in their rampage on my clinic totaled $100,000.
     As it turns out, the distributor for these medications, Northwest Pharmacy, is located in Canada.  The products were brand-name, made by the original manufactures (e.g., Merck), sealed in their original packaging, checked and approved by U.S. Customs officials at the border (the boxes officially stamped, according to nursing staff)--then shipped to our office.
     Providers don't order medications, nor do they open boxes of supplies.  I signed off on the orders, which were handwritten by my nursing staff on our purchase order forms.  The nursing staff has always been excellent in my office--high caliber individuals with great integrity.  They want to do a good job.  I was glad they had found the products my patients needed at a price we could justify.  My practice management magazines caution doctors against "doing everything yourself because you don't trust anyone in your office." They say it's bad not to delegate.  I trusted my nursing staff--and why not?
     Is there something wrong with products shipped from Canada?
     Or is there something wrong with a government that has made it acceptable for the pharmaceutical industry to price products out of reach for the people who need them in this country, and illegal to purchase them at a lower price from another country?  If it's illegal, why doesn't the American government tell the Canadian government to stop selling American products to Americans through Canada?
     Do the products come from Canada?  Or do they come from the United States, where they are manufactured?  In truth, most pharmaceuticals are manufactured abroad, but they're still "from America" unless they've been sold to another country.  At a meeting with my lawyers one of them looked at his bottle of Prilosec--purchased at CVS.  "Hey!" he interrupted us. "It says, 'Made in India'--right here on the label."  Is that legal?
     Isn't half of everything we buy in this country made in another country, or shipped from another country?  Isn't Reclast--"American-made"--made by non-Americans. in another country?
     Are you confused?  I am.  And I don't know how many more booby-trap rules for doctors I can stomach.  American physicians must be the most regulated human beings in the world.
     I never saw the website for Northwest Pharmacy, but I saw some of the faxes they sent us every day, advertising their competitive prices--and they didn't say, "Canadian products."  In fact, their flyers said these were American products, and they had more than 50,000 American doctors as customers, as well as hundreds of  thousands of satisfied clients.  I thought they were trying to reassure doctors that they weren't some hole-in-the-wall place in, say, Timbuktu.      
     My lawyers are confused, too.  They investigated the situation surrounding "Canadian medicines." Everyone knows that for twenty years Americans have been buying the American medicines they need from Canada at 30% less than in the United States.  It's a crime to do this.  But my lawyers tell me that the government has decided not to intercede when individuals buy Canadian medicines.  They'll "decide" whether and when to arrest doctors, however, on a case-by-case basis.
     It's against the law to buy Reclast from a Canadian pharmacy, I'm told.  It doesn't matter if it comes in its original, sealed packaging from American pharmaceutical companies (which it does), or that the chain of custody can be traced with exactness.  We physicians are required by law, if we wish to treat our patients appropriately, to purchase what they need at $200 more--in the case of Reclast--than we will be reimbursed by Medicare.  And it's illegal for patients to pay the difference (as many have offered to do)--Medicare "sets" the prices we're allowed to charge, Medicare pays whatever it likes, and the government makes it a crime for doctors to do anything except take a loss.
     Oh...we can also withhold treatment from the patient.
     I know the government doesn't care about my patients, the ones who are now suffering fractures and accepting this as part of old age.  If it did its FBI agents would give back my patients' medicines, which were ordered for individual patients, and let me make the decisions about medical care. Osteoporotic fractures are not a fact of aging, not if patients have access to the medication they need--and I want to help them. 
     But since the raid on my clinic and attack on my character by the FBI, I'm beginning to wonder if I can help anyone at all, any more.
  
    

"You Are All Vermin"

     "Do you want to know what FBI agents and other law enforcement officials think of regular citizens?  They think you are all vermin."
     This is what a retired Chief of Police told me.
     It is so far from a what I consider a normal, humanistic perspective that it borders on insanity.
     Is it necessary for our public officials to be inculcated with loathing, the way military recruits "need" to be purged of doubt or the capacity for affection in order to decimate entire towns?  Isn't this what makes torture and extermination of large sectors of humanity possible?   The war in Bosnia, ethnic cleansing in Darfur, the horrible tortures inflicted on people in Burma--these and all crimes against human beings are possible because a state of unfeeling has been fostered, and feeds on the poison of apathy.  Screams of pain become a form of amusement.  Sadism is unleashed from places the rest of us keep locked up.  In this state, the suffering of others doesn't matter.  It doesn't even register.
     What does matter to people who have been trained not to care and to go after others like hawks  driven by instinct to swoop and snatch the necks of their prey and swallow blood?
     Is it the need to reinforce an already entrenched mindset of attack and cruelty, to guard against the germination of a single seed of tenderness?  Are kindness and sympathetic thought impossible if you're guarding the city gates against marauders and destroyers?  Do you yourself need to become a destroyer?
     Is it power--an elixir so addictive that one can never, ever get enough?  Does power make people ruin everything around them in the hope of sustaining their personal positions?
     Or is it pure laziness--an unwillingness to discriminate, which surely must be the highest human function, the most admirable form of intelligence?  An intelligent mind discriminates good from bad, certainly, and the subtle gradations of good and bad, as well as the circumstances in which actions and their ethics are enacted.
     But a truly intelligent mind also separates personal, neurotic interests--including pride, envy, power and the desire to avoid shame (motives which operate below the surface of consciousness and take courage to isolate)-- from decision-making.  Intelligent people don't see, everywhere they look, danger (which would be paranoia), or criminality (which would be misanthropy)--they don't think of everyone as vermin.  They may, on the contrary, be able to see vermin, in context, as a good thing.
     In Plato's Republic the task of discrimination is considered the domain of the wisest men of all--and these most intelligent of human beings are accorded the greatest power:  they are the ones who keep order in society.  If the most authoritative people in the land fail to act with strength and wisdom, the social order falls apart.
     The Republic is Plato's esteemed work on the proper governance of people.  Socrates and Glaucon use logic to ascertain who, among human beings, should be permitted the lofty task of ordering and guarding the state--and what qualities they must demonstrate for the state to survive.

             It becomes our task, then, it seems, if we are able, to select which
          and what kind of natures are suited for the guardianship of a state.
             Do you think, said I, that there is any difference between the 
          nature of a well-bred hound for this watchdog's work and that of a
          wellborn lad?
             What point have you in mind?
             I mean that each of them must be keen of perception, quick in
          pursuit of what it has apprehended, and strong too if it has to fight
          it out with its captive.
             Why, yes, said he, there is need of all these qualities.
             And yet we must have them gentle to their friends and harsh to
          their enemies;  otherwise they will not await their destruction at the
          hands of others, but will be first themselves in bringing it about.
             True, he said.
             It may be observed in other animals, but especially in that which
          we likened to the guardian.  You surely have observed in well-bred
          hounds that their natural disposition is to be most gentle to their
          familiars and those whom they recognize, but the contrary to those
          whom they do not know.
             I am aware of that.
             And does it seem to you that our guardians-to-be will also need,
          in addition to being high-spirited, the further quality of having
          the love of wisdom in his nature?
             Yes, he said.
             The love of wisdom, then, and high spirit and quickness and
          strength will be combined for us in the nature of him who is to be
          a good and true guardian of the state.
             Let us so assume, he replied.

     Our social order is patterned after the Ancient Greeks, and the model of that world has been given to us by Socrates.  The Republic outlines the principles underlying our constitution.  I keep trying to match it up against the reality of my day-to-day experience of American politics.
     I would like to believe that now, twenty-three hundred years later, we have inched ahead--in the manner Socrates advised--toward the ordering and guardianship of society by intelligent, high-spirited individuals with a capacity for discrimination--with philosophia--the Greek word for love of wisdom.
     Our "guardians of the state," the highest in the land, are our legislators--and our law enforcement officials. They should be ferreting out crime, not attacking citizens like me whose work serves as a foundation stone for the maintenance of a healthy republic.
     Let us all hope our country is being safeguarded by people who know what they're doing.
  
           

The Hawks Are Circling

     This morning as I hurried down the Tennessee flagstone walkway from the front door to my car I saw twelve hawks and nine vultures making circles overhead.  It seemed as though they were aiming for me, ready to yank off my head, pick the flesh from my bones, claw my liver, and slurp out my eye sockets.  They are ruthless, gory creatures.
     Then I saw the poor chicken, my defenseless friend, who produced eggs for my son's giant chocolate birthday cake yesterday.  It was torn to pieces and bleeding on the ground a few yards away.  The predators were very close--just above the tree line--so I knew they couldn't be frightened by me, an unarmed, soft-hearted human whose trek to the car to make it to work on time was a minor annoyance that delayed their carnivorous gratification.
     I wasn't surprised, then, upon arrival at the office, to be told that three of my staff had been contacted by the FBI over the weekend.  One was a student who worked for the clinic part-time through high school as a file clerk and nursing assistant.  She had just started college courses in Tallahassee:  the FBI agent said he'd meet her on campus for questioning.  She doesn't have to talk to him--but she doesn't see what harm it could do.  She told us she'd been honored to work at Colasante Clinic, and she cried when she left for college. 
     Perhaps she and I are both as naively innocent as my chickens, pecking dirt with characteristic American industriousness to meet the basic requirements of life, not realizing people can be after you.  She may not be aware of what many lawyers have told me, that federal agents pick and choose from among the elements of their interviews in order to splice together a story they want to tell.  The story elevates them:  they have caught a criminal red-handed, the FBI is heroic, Americans can be glad their tax dollars (all $8.1 billion of them, in 2012) are being spent to defend the public in a mighty way.
     The FBI agent drove to the home of one of my nurses over the weekend--and his IRS cohort blocked the driveway with a second vehicle.  They questioned the nurse for twenty minutes on the back porch, while a catahoola-leopard-hound-pitbull-mix barked wildly in the background.  "I could have let the dog loose any time," the nurse said, "and he'd have torn them up."
     "Why does Dr. C. do aortic ultrasounds?" the agents demanded to know.
     "If one in a hundred has an impending dissection," the employee answered, "think of what we've saved?  You've got to understand:  aortic aneurysms are silent--patients don't have a single symptom.  How are you going to find one, if not with an ultrasound?"
     A dissecting aortic aneurysm is an excruciating but quick death in one out of three cases.  The aorta ruptures like an overblown balloon.  Blood explodes into the abdominal cavity--and that's it.  But before the patient dies, emergency surgery and hospital costs can wrack up charges of $100,000.
    What will Medicare pay a doctor to perform for an ultrasound to prevent such a catastrophe, in patients with multiple risks?  $81.
     Are the FBI agents upset about that $81?  Are they upset that my clinic posted profits in the years before their raid ?  Do they think I shouldn't have spent $70,000 on ultrasound units?  Should I have left tests like that to the hospital?  Should we solo docs turn everything over to hospitals?
     The hawks are circling.  They're picking the brains of everyone in my vicinity.
     Does the FBI know anything about medicine?  Or are its agents just playing the numbers?
     No matter...they need a victim.
     Will I be next?
     There had better be a good reason, because I am not a chicken.
      

An Open Invitation to the FBI

Dear FBI:
     You are the guardians and protectors of America.  You are seekers after truth.  I don't believe the things other people tell me about your agents, because everything they say is bad, and that simply can't be true.
     I know that your boss, the head of the Department of Justice, is under the gun and this may make all of you feel uneasy and defensive.  My office staff and I understand what you're going through because we, too, are upset about being under the gun by you.  Your raid and forfeitures, and your continuing investigation, are disturbing to all of us at Colasante Clinic and make it difficult for us to focus on patients, who need our full attention.
     Therefore I would like to provide answers to all your questions.  You no longer need to circle the office like wild animals stalking prey, scheduling clandestine meetings with my staff, questioning my patients over the fences of their yards, calling the homes of my employees and ex-employees to glean information that might, if cut and spliced, be used against me.
     You do not need a subpoena:  I will accompany you without resistance and give you whatever information you need.  Please present your questions and accusations, and give me the opportunity to respond to your confusion.  You will see that there has never been any wrongdoing in my medical practice, and certainly no attempt to defraud insurance companies--in fact, my efforts have been focused doggedly on representing what we do for patients with accuracy.  My knowledge of billing and coding surpasses that of most physicians--as it must for solo doctors--and my intent to help patients by clarifying their symptoms with the safest available technology is sincere and based on science.
     Several of my staff have disclosed that your questioning of them has focused on tests and procedures performed on my patients within the confines of my office.  The tests that seem to bother you most are ultrasound studies.
     Have you ever seen ultrasound images?  Have you noticed how informative they are?  Do you know that ultrasound is a technology that is safe, non-invasive, and free of radiation?  It is my opinion that every physician's office should own an ultrasound unit, and it should be used every day as an extension of our eyes and ears. Ultrasound is like a stethoscope with eyes:  it sees into the body, and its shadowy images identify pathology that other more dangerous, high-tech equipment (like CT scans) cannot.
     You must realize that patients who schedule appointments with us have symptoms.  They don't visit the doctor when they feel well or are pain-free.  A great number of patients describe abdominal, pelvic and chest pain. They come to my office, in particular, because we have a reputation for doing diagnostic studies on site, circumventing the need to refer them to multiple other physicians.  They come to my office instead of going to the emergency room.
     The ultrasound is a superb tool for identifying those who might have a gallstone blocking the common bile duct, a coronary artery that weakens movement of the heart's powerful left ventricle, or an ovarian cyst which, if oversized, can cause disabling pain.  We have found small thyroid cancers, large liver hemangiomas, uterine masses, and prostate nodules.  Putting a patient with chest pain on the treadmill and performing an echocardiogram (a type of ultrasound) right after exercise is a good technique for determining whether that patient really needs to see a cardiologist.  We have been able to save patients the time and expense of specialist visits by using this technology.
     Perhaps the problem, from your standpoint, is that Medicare pays us too much for ultrasound studies.  Even if I agreed, I couldn't change Medicare's fee schedule.  Medicare sets its fees, and other insurance companies copy the government.  Remember, it takes specialized training and a lot of experience to read ultrasound studies with accuracy.  It's important to look at the cost-benefit ratio.
     Yes, our total charges to Medicare add up to more than the average family physician's office because we do diagnostic work-ups on patients in the office, we follow up on all their symptoms, and we require specialized staff.  Consider, however, the money we save Medicare on CT scans, specialist visits, emergency room doctors in the middle of the night, and MRI's?   Think of what we save society by offering patients the reassurance of a normal test, followed by personalized counseling that inspires them to change their lifestyles.  Then think of how much is saved--somewhere down the road--when these same patients don't have heart attacks, gall bladder infections, kidney stones, or hepatitis from fatty liver infiltration.  Would you like a list of the cancers we have detected--using ultrasound--at such an early stage that patients were cured with minimal treatment, never needing expensive chemotherapy or radiation?
     Furthermore, you must not underrate the diagnostic value of a normal ultrasound test.  One of the basic tenets of melanoma diagnosis, for instance, is that for every melanoma a doctor identifies through biopsy of a skin lesion, he should have done twenty biopsies that come back normal.  Otherwise, he's not doing enough biopsies, and he's likely to miss a cancer by making assumptions that turn out wrong. This precept extends to ultrasound studies, too.  When patients have pain, it's invaluable to be able to do an ultrasound study--on the spot--which shows whether that pain (as patients fear) represents cancer or not.  Can you imagine the relief a patient feels, knowing I actually looked at the place that hurts?
     If you had abdominal pain, wouldn't you want to know it wasn't something serious or life-threatening?  When you have chest pain--as you may, some day, given the statistics in this country--do you want your doctor to shuffle you around from hospital to specialists over a period of weeks, or will you want a study now, to find out what you really need?
     The problem, as I see it, is that most doctors are not using ultrasound units in their offices--not that I am using it.  Perhaps their reasons for eschewing such a valuable tool has something to do with the problems I'm having with you:  your attack on my judgment, your raid on my office, the allegations implied by FBI agents calling my patients and staff, the sick feeling created by your unwillingness to speak up, ask your questions, and get intelligent answers from me.
     Therefore I am offering you, again, the opportunity to meet with me--the target of your research--to talk about whatever lacunae may be left in your investigation.  I can give you some background on Pat McCullough, who so deftly pointed your suspicions in my direction and thereby succeeded in escaping scrutiny of her deplorable behavior.  I can explain the basic philosophy of my medical practice, which is based on science and has saved much pain and suffering for patients--isn't that the point of doctoring, after all?
     And perhaps I can provide you with whatever information you need to release me from the state of siege you have imposed, so that my staff and I may return our attention to the peaceful practice of medicine.  Then I might even be able to work on my other mission:  a farm residential community for adults with autism on property I purchased for this purpose in 2009.  "Carmine's Farm" now has official non-profit (501c3) status, but its development is paralyzed as long as you hold me hostage, psychologically and financially, with this investigation.
     Please contact me as soon as possible.  I will give you a tour of the clinic.  I can show you the magic of ultrasound technology.  Perhaps we can talk over lunch.

                                                                                      Sincerely,
                                                                                                  Ona Colasante MD


     

What is Fraud?

         Here are some of the "crimes" that constitute fraud in the medical field.  This is the federal government's list.

          1.  Having a billing practice that establishes a physician as a financial "outlier."

          2.  Incorrect coding.

          3.  Medically unnecessary services.

          4.  A pattern of upcoding.

          5.  Adverse patient outcomes.

          6.  Failure to provide covered or needed care in violation of contractual arrangements.

          7.  Delays in diagnosis and treatment.
          8.  Written or printed documentation in the chart that does not support the codes billed. 

     What do any of these terms mean?
     What is an "outlier"?  Medicare defines the term, but does not share information about "average" coding practices until after a physician has already "committed fraud" by being an outlier.  Physicians (like me) who purchase and use equipment such as ultrasound or stress test machines are likely to have more patients who agree to undergo testing because it's quick--therefore we are more likely to be outliers because we are able to persuade our patients to do what they need.
     What is "incorrect coding"?  In many cases coding guidelines differ from one insurance provider to another.  For example, if I perform a physical exam on a Medicare patient, I must code V70.0-G0438;  but if I do the same physical on a non-Medicare patient, I must code V70.0-99397.  If the patient is younger than sixty-five the CPT code may be 99396, 99395, 99394, 99393, 99392 or 99391--unless it's the patient's first visit, or he hasn't been to the office in three years.  Then the codes change to 99387, 99396, 99385, 99384, 99383, 99382 or 99381.  If the patient is younger than twenty-one the diagnosis code has to change from V70.0 to V20.2.  The exact same service is provided for a patient, but the codes for billing that service depend on the patient's age, insurance company, or status as a new or established patient.
     To make matters worse, specific aspects of the physical exam must be coded separately.  For example, if I perform a Pap and pelvic as part of the yearly physical, I must also submit to the insurance company, V72-31-Q0091 if there are no signs or symptoms, V76.2-Q0091 if the patient is low-risk, and either 622.1, V15.85, or 795.1-Q0091 if the patient has risks for cervical cancer.  There are hundreds of other options--all for the exact same service!  If the patient's insurance is Medicare, the procedure codes change to P3000 or P3001, and if the insurance is Medicaid 88164 must be used instead.  The pelvic exam, as separate from the Pap, is coded as V72.31-G0101, depending on the patient's situation, or it could be V10.41-G0101, V10.43-G0101, or V10.48-G0101.  A rectal exam must be coded as V76.11-82270, but only if the patient is over age 50 and doesn't have Medicare.  If the patient has Medicare the codes may be V76.11-G0102 or V76.44-G0102, unless the patient has symptoms or it happens to be the second rectal within a 365-day period, in which case a specific code must be selected from a long list of other options--whichever exactly represents the patient's problem.  For example, if a rectal is done because of new constipation, the codes may be 564.10-82270.  Even with exact codes Medicare is not likely to pay for this charge--its computers say that a rectal can't be performed more than once a year, and only on patients over age fifty.  Exceptions are impossible to justify--we're talking to computers, not people.  Most insurance companies will not pay for a Pap or pelvic exam if performed on the same day as the rest of the physical exam--in order for a physician to get paid for a Pap exam the patient must return to have it done another day.
     In addition, all these codes must be appended by "modifiers".  The office visit must be submitted as V70.0-99396-25, the pelvic exam V72-31-G0101-59, and the rectal V76-41-G0102-59-51.  If modifiers are submitted to some insurance companies, the services won't get paid, because those insurance company computers don't "recognize" modifiers.  But if -25 and -59 aren't appended to charges for other insurance companies, the charges won't be paid.  There are dozens of different modifiers for various uses, and no consensus among insurance carriers about when and how to use them--only denials of payment or allegations of fraud if they aren't used "correctly."
     My office provides many services on-site.  Each service is complicated by a Pandora's box of coding rules that vary across insurance companies.  Errors in coding are inevitable, given a system which isn't centralized and involves so many variables.  Coding and billing have become entrapments for physicians, none of whom can master the ever-changing rules contained in hundreds of thousands of pages of "updates."  Therefore we are all vulnerable to charges of fraud--and can easily become targets of stupendous fines for breaking the rules.
     What is a "medically unnecessary service"?  Who should decide whether a patient needs an EKG or a chest x-ray?  The insurance carrier?  The doctor?  If I decide to obtain a chest x-ray on a patient with low sodium (a condition that suggests a pulmonary abnormality) it probably won't be "covered," because insurance companies cannot think this way.  Therefore, the chest x-ray would be considered fraudulent, whatever my medical reasons for obtaining it.
     Since "adverse patient outcomes" and "failure to diagnose a patient on time" are examples of fraud we're all in trouble.  All patients die, eventually--and death is an "adverse outcome."  A medical malpractice article in the August issue of Family Practice Management states that 75% family physicians will face a malpractice lawsuit before age 65, and of those 77% will be for "failure to diagnose a patient on time."  Ten years ago statistics showed that a family physician is likely to be sued every seven years.  Given the government's definition of fraud, physicians who are sued for failure to make a diagnosis on time or for an adverse patient outcome could also face charges of fraud.
     Failure to document what is said and done for a patient is the biggest physician land-mine.  Is it really possible to represent what happens between a doctor and a patient on paper?  The malpractice article says, "If your note doesn't indicate how you arrived at a differential diagnosis, you're asking for trouble," and tells us that writing, "risk-benefit assessment discussed" is no longer adequate protection in a malpractice case--nor is it enough for insurance companies.  "Boilerplate notes"--or computer templates designed to meet documentation requirements for insurance companies--constitute red flags for auditors.  Physicians tell same patients the same things all day long--but we can't use forms to document this.  We have to write individual essays in their charts explaining in excruciating detail what we said, why we said it, and the process by which we made one diagnosis rather than twenty others.
     My codes for a test--for example, 786.05-71020-59 means we did a chest x-ray because the patient had a bad cough--aren't enough in the way of explanation.  I am required to give a description of the cough, duration, triggers, and associated symptoms, as well as the patient's history of a similar cough, contact with others who have been sick, travel outside the country, exposure to tuberculosis, and particulars like cough with sputum, or cough with blood, or paroxysmal coughing...all described in detail.  If not, I might not get paid for the office visit.  If the chest x-ray still doesn't seem legitimate to auditors, the I may be accused of fraud, fined, banned from seeing patients covered by that insurance company, or reported to the government.
     "The federal government uses the threat of prosecution and arbitrary penalties to collect excessive settlements from doctors 'guilty' of clerical errors.  Federal officials [have] developed a crude system to extrapolate fines on doctors and hospitals," says Grace-Marie Turner in her article, "HIPAA and the Criminalization of American Medicine.  She goes on to say:   

          Civil actions have become lucrative for law enforcement 
          agencies....The government can seek $10,000 in fines for each
          violation, plus three times the amount of the charges in question.
          In this inquisitional legal climate, doctors fear their livelihoods
          and financial security are at risk if their office assistants happen
          to make errors on federal forms.  Even if they can withstand
          the financial losses, doctors are particularly terrified of
          reputation-ruining fraud charges.  They often feel it is safer to
          simply pay heavy fines than to fight the federal government.
   
     The federal government--and other insurance companies, who adopt the government's policies--invent their own definitions of terms like "outlier," "incorrect coding," "medically unnecessary," "adverse patient outcomes," "failure to provide care," and "correct documentation." Using these definitions, virtually any doctor may be found guilty of fraud.  If the government wants a doctor's money, it points a finger and takes it.  "Crimes" are easy to find, using the wide berth the government has given itself via dozens of statutes--once a doctor has been raided and robbed, as I have been.  
     How is a physician supposed to survive in this environment?  Why would any physician want to?

    

     

The Statin Wars: What's a Doctor to Do?

     Private industries, especially Big Pharma, are so greedy for money that they will stop at nothing to propagandize people--using dishonest "science" and "research"--into buying their products.  Now we know beyond a shadow of a doubt that even the so-called "double-blind, placebo-controlled, large-cohort" research studies supporting the recommendations doctors are required to make in treating patients are so often bogus that most of us don't trust research studies at all any more.  I know I don't.
     The statin scam is an example.  For ten or fifteen years we physicians have been presented with one  medical study after another "proving" that most adults should take a statin.  Statins are drugs such as simvistatin (Zocor), lovastatin (Mevacor), and atorvastatin (Lipitor).  At medical conferences there is always a lecture about cardiovascular disease and stroke insisting that we physicians are committing malpractice if we don't prescribe statins to nearly all patients over age fifty.
     Now we know that all but one or two of these medical studies was funded--without mentioning the source of funding (that's illegal!)--by pharmaceutical companies who stood to profit from the sale of statins.
     Here's the line that medical studies--and pharmaceuticals companies--fed us all:  "Statins prevent stroke and heart attack, reduce the risk of developing Alzheimer's Disease, and extend the lifespan of people with diabetes by three years even if those people don't have high cholesterol.  Statins might even prevent cancer."  Who wouldn't want to take a miracle product like that?  Never mind that until recently most of the statins cost $200 to $300 per month.
     Here's the truth.  The FDA just added diabetes and memory loss to a lengthening list of side effects caused by statins.  Isn't that terrific for the makers of statins?  First their secretly funded studies tell us everyone with diabetes must be on a statin.  What they don't tell us is that statins can actually cause diabetes.  It's a self-sustaining profit system.
     More of the truth:  Statins cause memory loss, mood disorders (including suicidal thoughts), sexual dysfunction, muscle breakdown, and congestive heart failure.  But wait!  I remember the statin sales representatives telling us that statins were important adjuncts in the treatment of patients with heart failure.  In addition, we were told that statins might reduce or reverse narrowing of arteries supplying the heart as well as other organs--even sexual organs.
     Hundreds of millions of statin prescriptions have been filled, adding up to $15 billion in sales worldwide.  Statins have been recommended for children with lupus.  Cholesterol-lowering medicines have been touted as the "standard of care" for almost everyone in our overweight culture.  If a physician didn't prescribe a statin, and a patient with risk factors for heart disease had a heart attack, that physician could be sued for failing to advise the patient to take the "heart-healthy" product.
     What's a doctor to do?
     The longer I work in the medical profession, the less faith I have in anything except my own observations and experience of patients.  This is not how medicine is supposed to be practiced.  We're supposed to be objective and science-based.  Yes, I still read medical journals every day--and I try to ignore the heavy-gauge paper used to make sure advertisements are the first thing readers see when opening the magazine.  We physicians are supposed to rely on double-blind research studies.  But until the government regulates the runaway pharmaceutical industry, putting a halt on dishonest research reports, forbidding advertising by prescription drug companies, and ending all the lies fed to the FDA as well as the perpetual lobbying of legislators, I'll prescribe medicines only when it's a matter of life and death.
     I am discontinuing statin prescriptions for almost all my patients who take them.  The high cholesterol myth is over.  We've always known that the brain is composed almost entirely of cholesterol, and so is the myelin sheath around all our nerves.  Our hormones are built on a cholesterol base.  How could eliminating cholesterol be good for the human body?  Why did doctors fall for such trickery?  How many patients have been harmed in the process?
     Statins may not be completely worthless--after all, they're almost exactly like red-yeast rice (no longer available in this country, though saponins are sold under the same name).  Their main effect is anti-inflammatory.  Inflammation causes coronary disease, not cholesterol.  Lowering inflammation is the key to a healthier life.  But we don't need statins to accomplish this--diet and exercise are much more effective, and so are some key nutrients such as omega-3 fatty acids (fish oil), coenzyme Q-10, magnesium, folate, flax seed, and vitamin C.  Taking care of our teeth, and eliminating cavities and gum disease go a long way toward eliminating heart disease and vascular inflammation in this country, too.
    Better than any drugs or supplements is a lifestyle that includes daily exercise, whole grains, and two-thirds of every plate covered with vegetables and fruits, preferably home-grown.  Being obese is an inflammatory condition, therefore maintaining a healthy weight with a modicum of muscle can do wonders for longevity.
     And love--being in love, loving life, loving one another--has a calming, restorative effect on every organ system, reducing rates of illness.  Dr. Dean Ornish proved this in his 1999 book, Love and Survival:  The Scientific Basis for the Healing Power of Intimacy.  When was the last time your doctor told you to fall in love?
     How many fads have we seen come and go in the past two decades?  The Adkins diet, the South Beach diet, the militancy against cholesterol and trans-fats, high-fructose corn syrup, Noni juice, spirulina, memory and libido-enhancing supplements, "superfoods"--it's depressing for a doctor to be asked about these crazy obsessions.  We don't need miracle cures, we need common sense--save your money and your passion, and spend it on an ordinary, obsession-free  life.  Let's all eat foods that we cook ourselves in pots and pans on our own stoves.  Let's all plant a few fruit trees and vegetables plants, and buy our food from the people who grow it.
      Our primate relatives are constantly exercising and making love.  They eat foods straight from nature, and they don't take statins.  My reference point from now on is going to be monkeys, nature, my patients, the wild world outside my door--not corporate dogma, not nitwitted legislators, not lies. 

1:24 am

     Why do doctors work so much?  Or do they?  I can only speak about my own doctor-life.
     It's 1:24 am.  I just returned home from work.  If I hadn't had to make sure all the documentation in the charts was satisfactory, representing everything my staff and I said and did for the many patients we treated today, I would have been home at a reasonable hour, maybe 7 or 8 pm.
     Those of us at the clinic don't need ninety percent of the documentation we stuff into the charts.  My staff and I know our patients well and remember most of what we do--the rest could be notated in a few lines.  We write reams of explanations for people who don't care one bit about our patients:  why we did this, why we recommended that, what advice we gave, what exactly we told patients about how to lose weight or quit smoking...and how many minutes we spent counseling them about their health as a percentage of the total time spent in the exam room with them.
     It's a long day, taking care of patients.  When the last one checks out it's another full day, writing copious, elementary notes in a format legible and comprehensible to billing clerks who live at insurance companies, who might read them, and who are assigned the job of determining whether we deserve to be paid or not.  If the clerks can't read my handwriting, they don't have to pay.  If my signature isn't legible, they don't have to pay.  If they can't understand why I performed an echocardiogram on a patient, they don't pay. We don't get a second chance.
     Who are these people for whom I write so much data?  They are clerks hired to "save" insurance companies money.  I doubt if they have more than tenuous connections to the medical profession.
     Two months ago I gave myself a cortisone shot over the right third metacarpal joint:  I had a trigger finger from writing so much.  My nurse-practitioner needed treatment for carpal tunnel syndrome.  Computer software programs will not make this job easier.  We keep saying we have to stop this job.  The oppression from outside the medical field is too great.  Our bodies and souls are tired of fighting to justify our work.  We want our lives back.  If we're going to be at the office until midnight, it should be to take care of patients, not plead with insurance companies to recognize our work.
     Let's get rid of all insurance companies.  Let patients decide whether and whom to pay for medical care.  Give them a budget, and let them spend it how they choose.  This would restore the free market to medicine.  It would save a lot of money.  And it would restore doctors to the art of doctoring.  

Why Did the FBI Contact Me Five Times?

     Right before I sold my Hawthorne Clinic in 2009 the FBI contacted me twice.  Within nine months of the sale it happened three more times.  On all five occasions someone named "Special Agent So-and-So" telephoned me at home and asked for my help on a case.  The agents told me that lots of charges had been paid by Medicare for supplies never issued to patients in South Florida (300 miles from my clinic) and never needed.  In all five cases my medical license and clinic information had been entered as the referring physician.  Did I know anything about this?
     The FBI agents sent me names of patients in the Miami area, and next to the names were the amounts of money Medicare had paid on their behalf--millions of dollars--for nothing.  The federal agents acknowledged that Medicare had been scammed.  "All we want you to do is sign at the bottom of the list, confirming that you don't recognize the names of any of the patients," they instructed me.
     Medicare had made electronic deposits to invisible people's accounts for hospital beds, home ventilators, wound vacs, and the like--very expensive items.   Each time I was asked to review another list it showed that someone had received several millions of dollars in payments over the course of a few weeks.
     "What are you going to do about this?" I asked, as though I myself had been robbed--and hadn't I, really--and you, too--as taxpayers of our shared Medicare fund?  Isn't that why we have public servants and protectors like the FBI?
     "Oh, we'll never catch them," the FBI agents replied.
     "This is a huge problem!"  I exclaimed.  Then, in my medical problem-solving way, I made a series of what must have seemed like amateur suggestions about how the perpetrators of these scams might be found and brought to justice.
     "By the time we get the news from Medicare that there have been bills for services that weren't provided, the scam-artists are paid and gone, probably out of the country," they said each time they needed my help.  "We're just trying to close out the case."
     Were  the agents pretending to be apathetic?  Did they have another agenda altogether?  Was I "helping" them, or was I their real target?  The possibility that the feds were hiding another purpose, or that I might have been exploited, or framed, didn't occur to me.  At that point I still had faith in our justice system.  I knew I was a good citizen.  It didn't cross my mind that someone else might not think so.
     Pat McCullough, the buyer of my clinic, had been given access to my office records--patient ID numbers, and provider license information--for more than a year before the sale was finalized.  It is customary for business records to be reviewed by a buyer during the due diligence period--which means Pat had the same information that con artists use to send fake claims to Medicare.  It's possible that Pat had been selling my patient and provider information through subterranean networks, to be used by other scammers.
     Sending fake charges to Medicare is big business, and easy money.  The payments are far in excess of what actual doctors receive for their work.  A lot of Medicare fraud losses could likely be explained by such well-executed insurance heists.  My conversations with the FBI agents didn't give me confidence in their ambition to track down these criminals--but of course they may have been covering up their real intentions.
     Attacking doctors, who are visible--and fairly puny when it comes to fighting--is easier than unraveling high-caliber fraud--and maybe it's better publicity.  Besides, doctors usually end up settling with the government before a case gets expensive to defend--so it's easy money.
     I told the FBI agents in 2009 that I suspected a scam, with Pat as a peripheral participant.  They weren't interested.  They took down my information, as agents are required to do when a citizen reports a suspicion, and they said they'd contact me again--but I never heard from them.
     Do government agents have any respect for doctors and ordinary citizens?
     "They consider you vermin," said an ex-police chief who entered a comment on my blog.  When I read what he wrote I found myself feeling hopeless.
     What has happened to honor and justice?  If you and I are vermin, what does that make the friendly,  peacemaking "men in blue," our policemen?
     Animal trappers?  Zookeepers?  Exterminators?
     

Jerry's Warning

     Just as I am placing the glass jar with home-made peanut butter cookies on my desk and reaching for my white lab coat, Jerry, my billing clerk, scurries in and shuts the door behind us.
     "Dr. C., I need to talk with you," he says, all the words rushing together.  "Please, please, if you don't do anything else for me please do this one thing."
     "What is it?" I ask calmly, in the way one person attempts to balance another's extreme emotional state.
     "Dr. C., you've got to get rid of that post on your blog!"
     "Which one?"
     "Th-th-the one, you know, about the F-F-B-I," he stutters.  He is bug-eyed and a little shaky, but I can see he means to be sincere.
     There are a lot of posts about the FBI," I reply.  "In fact that's my problem:  the FBI."
     "You know the one I mean, "he insists, as though I am pretending to be dense.
     "Is it the one about the FBI agent falling off the roof?"  This post got a lot of hits, and I am still trying to figure out why.  Do people like the image of a policeman falling off a roof?
     "Well, that's not great either," he asserts.  "But I'm referring to the one about"--and now he utters the words under his breath, "how to scam Medicare."
     "What's the matter with it?" I want to know.  Did Jerry not appreciate the tongue-in-cheek writing?
     "Oh, my God, Dr. C., you can't be serious!" he says with exasperation.
     We'd forgotten about Tom, the nursing assistant who was sitting in the corner of the room doing research on the computer.  He's an over-polite college student who works part-time at the clinic, and perhaps I hadn't given him enough credit for having the courage to speak his mind.
     "It's a satire, Jerry," he says.  "I think everyone gets that."
     "But what if the FBI reads it?  They're not going to think it's funny!"
     "Jerry," I say placatingly.  "Let's give the FBI a little credit.  I'm sure they would see the post as a message about the state of Medicare.  I'm trying to show that doctors aren't the culprits."
     "Dr. C.," Jerry replies, and I realize that he thinks I am feigning indifference.  "You have got to understand that telling people how to commit fraud is not going to go over very well with the government. You're making them look bad."
     "Isn't it obvious to you that the piece is a spoof?"  I ask.  "I'm not giving people an instruction manual for defrauding insurance companies."
     "You're mocking them," Jerry tells me, and now he is crossing his arms in front of his chest.  "The FBI doesn't take kindly to that."
     "How do you know?" I ask.
     "I used to work for Medicare," he says authoritatively.  "You can't challenge the system.  You're going to get yourself into a whole lot of trouble."
     Tom chimes in again.  "Jerry, you've got to look at the entire blog.  She's just telling her story.  People have a right to do that.  Dr. C. isn't insulting anyone."
     "Dr. C.," Jerry says firmly, as I slump into my chair and look for my stethoscope.  There are patients being triaged for me in exam rooms up and down the halls, and I am feeling restless.  People don't like to wait for the doctor.
     "Please, Dr. C.,"  Jerry leans over me, his hands gripping the edge of my desk, his knuckles turning white.  "Do this as a favor to me.  I'm just trying to help you.  Please take down that post."
     "Do you think I should stop blogging?"  I ask.  "Because I don't want to stop."  The writing is like a form of rehabilitation--and it helps to have an audience.
     "Can't you just write a John Grisham-type novel?"  he wants to know.  Finally there is a smile moving like the shadow of the wing of a dove over his face.
     "Can't you just write a bestseller?" he continues.  "I really don't want you to get in trouble.  I just want us all to keep our jobs."
     "Okay," I say.  "No problem.  One bestseller coming up."
     Then he opens the door, releasing me to my day.
    
     

Twelve-Egg Cheese Souffle

Better than the ones in France.  (I hope I'm not excommunicated for saying this.)  Use your backyard chicken eggs for the lightest, most delectable souffle in the world. Adapted from The Silver Spoon, the recipe book given to every bride on her wedding day in Italy.

     4 quantities of Bechamel sauce (recipe below)

     1 pound Emmenthal cheese, sliced into thin strips

     12 eggs, separated

     1 tsp salt

     Bechamel Sauce

     1 cup butter

     1 cup flour (gluten-free works great)

     1 quart rice milk

     2 cups whole milk

     1/8 tsp grated nutmeg

     1/4 tsp salt

       Melt butter.  Whisk in flour.  Pour in all milk, whisking constantly until boiling.  Continue to whisk

       and boil for 20 minutes.

For Souffle:

Preheat oven to 400 degrees.  Grease souffle dishes with butter.  Make Bechamel sauce, add Emmenthal cheese and stir until melted.  Season with salt.  Cool a little.  Beat in egg yolks.  Stiffly beat the egg whites and fold in.  Spoon mixture into prepared dishes 3/4 of the way up, and bake for 20-30 minutes (if individual souffles) or 40-45 minutes for large souffles.  Then lower the heat to 350 degrees and bake until tops are high and brown, 10 or more minutes.  Serve immediately.

Patient #8: Max

     "I'm only doing this for you," he tells me, stepping onto the treadmill.  "I'd rather go home."
     "You're doing it for me?  But you don't even know me," I say, looking up at him with surprise.  His height is accentuated by the six inch elevation of the machine.
     "I know you well enough," he answers.
     Max doesn't complain of chest pain--so I shouldn't be doing a stress test.  It isn't "allowed" by any insurance companies if a patient doesn't have symptoms or a condition to justify it.  There isn't a code for gut feeling--but I recall this term being used a lot in medical training, when it was considered a good enough reason for doing a test.  What happened to the merits of a doctor's instincts?  They've been nullified by insurance edicts, but I'm still practicing old-fashioned medicine.  I'm making decisions about patients as though I failed to get my share of indoctrination into the linear thinking of insurance companies.  When the-one-who-knows at the back of my mind whispers, I just don't feel good about that guy, I act on it.  No wonder I'm in trouble.
     Max and I don't have a longstanding relationship--I just met him yesterday.  Despite his protestations that he's fine (his girlfriend made him get a check-up "because she says at fifty-five I need a doctor") he has agreed to undergo a chest x-ray and stress test.  He wouldn't do the stress test yesterday, claiming he needed a shower, but swore he'd come back.
     The chest x-ray isn't good.  It's true he doesn't have symptoms to justify that test either but it turns out the films disclose a spiculated mass in his left lung--a telltale sign of cancer.
     "But I feel fine!" he objects.  "Are you kidding me?"
     We look to the right of his heart silhouette on the viewbox film, and the hazy white star in his left lung is unmistakable.
     "Are you gonna help me?" he asks as I fill out the referral request for a CT scan.
     "Yes, I'm your doctor now, and I will take care of you.  I'm here for the whole ride," I say, placing my hand on top of his.  "Thanks for letting me do the stress test."
     "My heart's okay, but who am I to tell you doctors what to do?" A nervous smile crosses his face.  I remind myself that he hasn't seen a doctor in twenty years, and therefore don't ask him about smoking, diet or exercise.
     The treadmill starts.  I explain the Bruce protocol we'll use for assessing his heart function, and Max walks as though he's raring to go.  His baseline EKG, which is used for comparison during the test, is normal.  But within fifteen seconds three of the tracings look scary.  There is sudden ST depression-- like a floor dropping out from under us--a sign of a cardiac crisis.  I stop the test, have Max lie down, and signal the nurse to call an ambulance and recruit assistants from the nursing station.
     "I'm fine," Max says, but now he is breathless.  Another nurse hooks him up to oxygen and inserts an IV as I put nitroglycerine under his tongue.  Then he swallows four pills meant to limit heart attack damage--an ACE inhibitor, beta-blocker, Plavix and aspirin.
     Max's blood pressure is low, and he has started sweating. "What's going on?" he asks, beginning to panic.  I drop another nitro under his tongue and cast a glance at the defibrillator, just in case.  Max's EKG is not getting better.
     "You need to go to the hospital," I tell him calmly. "Your heart is in trouble."
     "I'm fine," he says.  "Just give me a towel to wipe my face and I can go home."  I have the feeling that he is saying these things out of habit, because he doesn't make a move to get up.
     Then the ambulance arrives and three stalwart men with a stretcher hurry to his side.
     I tell Max that I will be here waiting for him when he gets out of the hospital.  I also say that I think he's going to be fine.  I am aware of his tenuous hold on life, but the little voice that knows pronounces these words anyway.  I think you'll be fine, Max.  He looks at me to make sure I really mean it.
    How has Max been getting by with such complete blockages of three coronary vessels?  How did he survive this morning's shower, which surely required more exertion than his brief time on the treadmill?  Why did he save his heart attack for me?
     Six weeks later he's back at my office with the midline scar of a triple bypass.  "You saved my life," he says, raising his brow.  "The surgeon said I arrived just in time--no damage to cardiac muscle.  Isn't that great?"
     "What about the abnormality on your chest x-ray?" I inquire.
     "You were right," he reports. "The CT scan showed the white thing too, and they said it's cancer--95% likelihood.  I wouldn't let them biopsy it," he adds, shaking his head and looking at the floor.  "It's too soon after my heart surgery--I can't take any more, Doc."
     "I'll arrange the biopsy for a few weeks from now," I suggest, "when you're feeling better."
     "Can't we wait, Doc?" he pleads.  "Can't you recheck another x-ray here in a month or two?"
     I demur, but he is insistent.  He's been through a lot, I reason.  I'll give him some time.
     Three months later the mass looks them same.  He tells me that everyone at his girlfriend's church is praying for him, and so are all his neighbors.  He announces that he has quit smoking.  He still refuses a lung biopsy.
     Another three months go by and the mass looks smaller.  Max tells me that he and his girlfriend have decided, after five years of procrastination, to get married.  The wedding is in two weeks--and I'm invited.
     At his nine-month visit the mass on his chest x-ray is half the size, and a year after Max's heart surgery it's gone.  I am astounded, but Max accepts the information as a foregone conclusion.  "You're the one who did it," he asserts, and it seems unkind for me to contradict him.  "You saved my life and you cured my cancer."
     Eight years have now gone by.  Max has moved to New York, but he comes to Florida once a year to get medicines refilled and visit old friends.  Every year he waits patiently for me to read his chest x-ray and show him the films.  It's a little like "Groundhog Day."  His lungs look perfect.
     I have not stopped relying on my gut feelings, despite their insufficiency as criteria for ordering tests, and despite insurance company reprimands--when my charts are audited--that some of my procedures aren't "indicated."  These audits allow the insurance companies to take back payments for services I have already provided.
     I doubt if my medical colleagues have stopped using their gut feelings either, but we're exercising our instincts underground--and we're looking high and low for solid evidence to justify the studies we need on our patients.  The initial chart note for Max's visit would read:  "No complaints of chest pain, shortness of breath, or claudication."  The stress test would not have been permitted by his insurance company, and my act of defiance could be construed as fraud.
     I live a double life.  I am following a tradition that is at the core of the whole history of medicine:  using my medical instincts.  But I'm also struggling to report my decision-making in ways that make sense to insurance company auditors--people who don't have degrees, and who are awarded coding certificates after six weeks of classes.  I stay up late writing chart notes for these auditors.  I never document the real truth:  I have a bad feeling about this guy... or, He looks like someone with cancer...or, I bet if I put him on the treadmill I'll find something wrong--because who in the insurance world (the only ones who read the charts) would understand?

  
     "

"Outliers"

    I can almost hear the terror and hushed calculations of physicians reading this blog.  They dare not post comments to the blog itself, because it might spotlight them.  They are desperate to stay out of the accusatory gaze of the government.  We doctors are prudent people--we try to avoid trouble.  The government makes this impossible.  Every one of us could easily be "in trouble" for "fraud" by the current standards of Medicare--a set of rules comprising more than 200,000 pages and which are, finally, absurd.  These rules and "guidelines" offer no way to communicate effectively with the government (for example, English) about the Medicare payments it doles out (using money we have entrusted with the government for our medical coverage in old age).  The federal government's efforts to attack "fraud and abuse" are having no effect at all on the real fraud being committed by fly-by-night sham clinics and nonexistent "doctors" who scam the government by billing them for millions and disappearing before the feds know what happened.
     "Oh, my God," one physician wrote to me at my g-mail address.  "I would die if something like this happened to me."
     Then came her scared circumspection about my situation, ascertaining how she might avoid being similarly targeted.  "My husband thinks it was because of the Canadian shipments from Merck," her email went on.  "I think you were slandered and libeled by that angry person from your business deal.  Your life is changed and you will never be the same."
     When physicians read my blog they are wondering how to avoid doing whatever I did to invite the FBI to focus on me.  Physicians want to stay out of the limelight.  We want to be left alone to take care of ourr patients--but this isn't really possible because solo doctors, at least, are perpetually thinking about how to code and document in order to bypass the predatory scrutiny of the government.  This means billing in a "neutral" way, and documenting chart notes at the fifth-grade reading level for the so-called specialists who inspect office notes for coding errors--possibly in exchange for bonuses.  It also means ferreting out and dismissing patients and associates who might decide to exercise perverse power by reporting doctors to Medicare and the FBI.  These two government agencies welcome and even invite such reports as a way of justifying attacks on doctors whose incomes are high enough to make an investigation pay itself off in fines and take-backs.  
     In the absence of whistleblower reports, Medicare uses statistical analysis to identify doctors who are "outliers."  An outlier is a physician whose billing habits place him to the right or left of the bell curve for all physicians in his category.  Family physicians are one category.  I am a family physician.  I am also an outlier.
     The only way to avoid being a physician outlier is to do and bill services the average number of times other doctors bill the same services.  There would be no outliers (and therefore no physicians committing fraud, by Medicare standards) if doctors all did the same things and billed exactly the same way.  Physicians do not have access to information about the billing practices of their colleagues, so efforts to bill in an average way are based on guesswork.
     Even if a physician's billing practices place him at the median, however, he is vulnerable to fraud charges.  The government's computers may consider a middle-of-the-road "pattern" too perfect.  Therefore many doctors habitually under-code for services--their reasoning is that Medicare won't harass them if they don't ask for as much as they are owed.  But cautious coding flags doctors too (our practice management journals warn us: "Don't default to 99213  E/M codes!")--positioned to the far left of the bell curve we may be subject to government audits the same as physicians who do more and code for more. 
     There is an I Ching hexagram, "Chien," which denotes "a dangerous abyss lying before us and a steep, inaccessible mountain."  When I threw coins last fall and requested a comment from this ancient system of philosophy and divination the Chien hexagram returned to me.  It described my situation perfectly, then and now:  no avenue for escape from entrapments set by the government and Medicare  I am beleaguered by a system that prevents physicians from knowing what the government and other third-party payers want, a system so complex that it consists only, finally, of barricades.  It feels very dangerous.
  
               The king's servant is beset by obstruction upon
                    obstruction,
               But it is not his own fault...
               Thus the superior man turns his attention to
                    himself
               And molds his character.

Obstruction and fear are the hallmarks of the solo physician's experience, "surrounded by obstacles."  Richard Wilhelm interprets Chien, hexagram 39 in the I Ching's compendium of every possible human situation, as follows:

               In such a situation it is wise to pause
               in view of the danger and to retreat.  
               One must join forces with friends of
               like mind and put himself under the
               leadership of a man equal to the situation;
               then one will succeed in removing the
               obstacles.  This requires the will to
               persevere.

     Clearly I am looking for help from anywhere, even from a text that goes back to mythical antiquity, the Chinese Book of Changes, which served as the root for Confucianism and Taoism.  In its puzzling language I find comfort and a measure of hope. 
     I'd like to talk with my fellow physicians but we are divided in the ways that fear always divides people.  How can we join forces?  We are all on the same ground but we act like people isolated by confusion.  
     If we continue to struggle alone, like moles digging passageways in the dark underground, hoping to escape the ubiquitous creatures who intend to eat us for lunch, we will never be able to push back the behemoth of a government whose agents surround us like wild dogs.
     

What Does a Doctor Do for Fun?

     My favorite thing to do is nothing.  I don't have a lot of time to do this--my job and family still lay claim to most of my attention.  But once in a while when no one is around and I'm not hidebound to finish a task I go outside and sit in a lawn chair.  By the time I know what's happened three or four hours have elapsed.
     Next to doing nothing, I enjoy watching the chickens.  If you haven't had chickens you should get some.  They are endlessly fascinating.  Here's a fact for the pragmatist:  if one in three Americans had chickens we would put the entire poultry industry out of business.  If you know anything about slaughterhouses you can appreciate the urgency of this information.
     Backyard chickens have become such a fad in America that many cities are lifting their ordinances against keeping farm animals.  It's costing too much to enforce the rules, and maybe city officials want chickens, too--you can't blame them.  Yesterday I spent several hours with my twelve Barred Rock and Delaware's among piles of leaf compost under the Live Oak trees, where they scratched and pecked with energetic deliberation.  I observed that they prefer black beetles over fire ants, and thin green worms over wireworms.  How do they catch the frenetic moths buried in leaf mold, and what sixth sense tells the rest of the band when a colony of larvae has been unroofed twenty yards away?   Fetching brown eggs from hay in their nest boxes has to be one of the charms of my life, and last night's twelve-egg souffle completely made up for the week's frustrations. 
     My sons are grown and mostly gone, but sometimes we still hang out together.  It's not the same as the lively years when they were boys making a gopher tortoise "zoo," following deer tracks and building tree forts, but a day canoeing on the Suwannee River followed by dinner and some card games--concessions to make me happy (they'd rather be on their computers)--consolidates our feelings for one another until the next time we're in the same locale.  I've encouraged them to "follow their dreams" but didn't realize it would take them so far afield:  Vermont, China, Senegal, California, Chicago, the Netherlands.  
     Tennis, Scrabble and ping-pong are my other pastimes.  And hanging out the laundry.  There is something about seeing clothes and towels gyrating in the breeze that satisfies a deep, biological, longing, possibly a feminine one.  I like weeding the garden, planting herbs and flowers, and harvesting pumpkins.  In the evenings I read.  Looking at this list makes me realize that it should be easy for me to grow old.
     My doctor friends have other avocations.  Many of them dream about the time when they will not have to practice medicine any longer.  One left medicine to teach high school science.  Another is going to law school.  Many travel abroad in their free time, or ski, or sail.  The rest are calculating how little they need to retire, even speculating on land in cheaper and less politically charged countries.  But where are those countries?  Equador?  Costa Rica?  El Salvador?  Bali?  Are they really better than the United States?  And how do people pick up their roots and replant them in a faraway land?  What would I do with my chickens?   What would my chickens do without me?   
    

"Do Your Lawyers Know about Your Blog?"

     More than a dozen people have asked me this question, some of them more than once.
     "I know that it's a criminal offense to threaten or defame public officials," I answer.  "Have you read something in the blog posts that could be interpreted as a threat?"
     "No," they always reply.
     "Then why are you asking me?"
     "I just wonder if your lawyers have anything to say about your blog..." is the innocuous response, accompanied by raised eyebrows and pursed lips.
     So, what do they mean?  Is there another threat to my safety and well-being, aside from the looming investigation?  Are FBI agents and government prosecutors watching my moves, looking for a reason to step up their attack on my free American life?
     The days of feeling protected by our public officials are over.  How does it feel, for instance, for you to get a letter from the IRS?  Or to be pulled over by a state trooper?  Or to be audited by Medicare?  Do you feel as though you're being safeguarded by a ministry of intelligent authorities looking out for your best interests, keeping the world safe from attackers and defrauders so that you can live a calm, productive life?  Are the individuals in our public agencies concerned about protecting our rights?  Are they giving us information, helping us understand how best to meet our responsibility to society in exchange for the blessing of being American?  Or are they looking for glory, or publicity, or ways to fund their own paychecks via bonuses for proving that they can nail criminals, like me?
     I don't know how to answer these questions from the vantage point of my current life as someone under secret scrutiny by government agents who have been vested (by me? by the rest of us?) with authority to indict me and put me in prison.
     To whom are they answerable?  Isn't it us--whose taxes pay their salaries?  Does anyone know?  I wonder if I might not have paid enough attention in my high school civics class.  Did I elect the judge who told the FBI agents they didn't have to open the affidavits or otherwise explain to me why they raided my office and bank accounts?  Or did I elect the person who appointed the judge?   Was my vote somehow responsible for legislation that gave the government unprecedented power to attack its citizens without requiring sufficient cause?  Or was the legislation never formally approved, the door shut in its face...but its key elements let slide into law a year later like slime passing under the door sweep, behind which a witch's brew is always bubbling with gooey, unpalatable statutes?
     I believe I remember something like "innocent until proven guilty"--maybe it was taken out of context when I learned it?  I must have misunderstood.  In my case the punishment has preceded everything, even allegations.  I've asked my lawyers about this, and they say they don't know what to tell me.  The country has changed, apparently.  The laws have changed.
     Do my lawyers know about my blog?  
     I sent them the link a month ago, but haven't heard from either one.  I am not willing to ask them to approve every entry--think of the cost!  (I've noticed that lawyers can be slow readers.)  I refuse to be told to be quiet, which is what I expect some people would advise me to do--lay low like a possum, play dead, see if the predator will finally slink away.  Can I tell my little story or must I "shush" while the grownups decide what to do? 
     Is this America or not?  Are we free?  Are we allowed to speak?
  
  
        

I Know This Is Crazy, but...

     I know this is crazy but sometimes I wonder if there is a plot to put every solo doctor out of business.
     Although I am not a conspiracy theorist, I've been adding up the benefits to big business and politicians if all doctors were under lock and key.  If we were "owned" by large hospital groups, national corporations, or bureaucratic university systems, our ''freedom" to practice as we liked wouldn't be so free.  We might be seduced into believing we are free--the way people whose brains are injected with daily Fox-News media-bytes believe their thoughts are free.  But thought and regurgitation of thought are two different things.
     Doctors believe they're better at independent thought than pop-media-junkies.  We've been highly trained, after all.  We can navigate our way through the jungle of signs and symptoms to the bubbling spring of a diagnosis.  We untangle the intricate knotted silver chains of lab values, murmurs, and reflexes to establish a line of reasoning back to a causative agent.  We listen and doubt, listen and surmise, listen and predicate all day long.
     But we doctors are the victims of slick advertising too.  Maybe it's because we're human and our appetites for flattery and blandishments are huge.  Maybe we want to be sold a bill of goods that promises an easy life.  Although we're not the right market for Sugar Pops or condominium time-shares, we're a market nonetheless--for a slightly more subtle "product," the product of being a wage-earner, not a business-owner.
     Here's what's on this week's cover of Medical Economics--the physician's magazine for "Smarter Business, Better Patient Care."  The lead article is "Owner or Employee?"  The subtitle is "Keys to making the decision."  The background color is faded-out hospital blue, but there's a glow of white around the central image like the hazy halo that enspheres icons in religious paintings.
     The image--which occupies more than half the cover below the banner--is a keychain with two silvery attachments:  one is an ordinary key and the other is a detailed replica of the caduceus. The caduceus lies on top of the key, perhaps prevailing over it.  The key signifies "owner," but it also conveys the responsibility and drudgery of a business.  The caduceus--which is on the left side in the picture (therefore first, valued more, since our eyes move from left to right in the English-speaking world)--is a symbol.  Symbols carry a great deal more weight than signifiers.  A symbol is numinous, meaning it has the fullness of the sacred--it evokes reverence, it's magnetic, it is an enchantment.
     I stood at my mailbox separating the day's mail and glanced at this cover, making a lightning-quick decision:  I want the caduceus.  Who wouldn't want to be a doctor, with its magical connotations, the commitment to humanity, a higher calling?  My automatic response bypassed intellect--exactly as good advertising intends--and enthralled me with the symbol of my profession.  I felt honored, looking at the caduceus.  "Who needs the donkey-work of a business?" nudged a little voice at the back of my mind.  The key stood for all my boring, quotidian, business-owner tasks.  You're better than that!  the image told me, and the effect was total.  It was 10 pm.  Tired and depleted, I had just driven home from work.  The magazine was right--I didn't want the hassles of a business!  I wanted someone else--an employer!-- to assume my problems and liberate me to my sacred calling:  doctor.
     Today's polished, psychological advertising works like this.
     Why should the government or big business care whether doctors work alone or under the masthead of enormous enterprises?
     Whenever I ask--Why?--about anything that has political or corporate attachments the answer is always about money.  Doctors are big business.  If the powers-that-be own doctors they can tell them what to prescribe, how to practice, where to refer patient for procedures, how to funnel money for all these things into the pockets of avaricious CEO's--along with their insurance, legislative and pharmaceutical buddies, all divvying up the booty--who regard doctors as commodities, not sages, and certainly not saints.  As doctor-employees we become exploited workers.  We're not in sweatshops--that wouldn't look good!  But we participate in our own exploitation by falling for marketing ploys that stroke our egos and promise an easier life.  We're in glistening, clean, white-coat sweatshops.
     There are no easy routes to success.  I know that this is a platitude, but I have labored in my own business for twelve years and have basked in the freedom to practice, mostly, how I please.  It's not easy.  But I can't imagine selling out in order to take a salaried position with a government or a corporate-run clinic.  That would be falling for corporate sophistry:  because my calling is sacred, goes the message, I should devote myself fully to it.
     And the subtext?  Naturally, I should siphon all the rewards of my intellect and training to the moneymongers who flatter and cajole me, big bosses who have become so good at pretending that doctors are in charge they would exhort me to stand proudly in my caduceus-embroidered lab coat even as I give them my purse, my proprietorship, and my self-respect.

How to Defraud Medicare and Get Rich Quick

     First, you don't have to be a doctor to defraud Medicare.  In fact, it's probably easier if you're not in the medical profession at all--it's a distraction.  Remember, your primary aim is to make a lot of money fast from Medicare.  This has nothing to do with patients.
     Medicare is not a person.  Think of it as a whole lot of money sequestered behind a bunch of computers.  It's an advantage that the Medicare system is enormous, because it's as slow as a bunch of hippos.  You can steal a lot before the system catches up with you, and by that time you're gone.
     Throw out your conscience, if you have one.  You're not harming anyone--this is just about money.  You might as well take it, because if you don't someone else will.  The United States government is already in so much debt it won't even notice.
     The government has been given authority to go after "fraud and abuse" in the medical field--but don't worry, you're not in the medical field!   Federal agents are going after doctors because they're easy to find--you're not.  You won't have a clinic, and you won't have real patients.  The FBI's got the public geared up to think of doctors as thieves.  Their agents may know better, but they don't care about where Medicare is hemorrhaging cash.  They like publicity-- and raiding a clinic makes a good story.  They take money by imposing big fines on the doddering doctors they raid--enough to compensate for what you're taking behind the scenes.
     You can make a few million at a time, easy.  Set up some Medicare provider accounts by downloading Medicare applications.  Fill in the blanks with names and provider license numbers  (check out blackmarketdoctorIDs.com and use the CV, license, DEA, and hospital affiliations we provide for a small fee)--then send the forms to Medicare. 
     You may, instead, wish to invent the necessary information.  Forge a few medical licenses and specialty board certifications.  Consider primary care, since you can bill so many different codes under one doctor ID.  But surgery is your most lucrative field.  Or, fake a hospital--the money you can make is tremendous.  
     One of our clients hit the jackpot as a sham DME (durable medical equipment) supplier.  Medical equipment can be big bucks.  To bill DME you may have to put additional certification numbers in place, but it's worth it because Medicare pays without flinching.  When patients need ventilators or alternate pressure mattresses, they need them fast.
     Next, buy lists of Medicare patient numbers.  We can supply these through blackmarketpatientIDs.com--they're social security numbers with a suffix, usually "A."  Buy five hundred at a time, and bill out twenty or so a day for each doctor ID you've purchased--any more, and the system may flag you.
     Another option is to make an offer to purchase a clinic, which would give you the chance to collect valuable data on patients during the due diligence period.  Or, buy a clinic outright.  Don't worry about the initial costs--you'll make it all up when you clean out the clinic's A/R, borrow against falsified assets, and file Chapter 7 bankruptcy.  Then you can take the patient and physician numbers you amassed into your next scam.  It's data collection of a higher order--for experienced swindlers.
     Change all your data every few months, billing from new sham clinics with new ID numbers, and a different set of bank accounts each time around.  No one will know you aren't running a real medical practice.  Medicare reps aren't like bill collectors or inspectors--they don't want to go anywhere, and they aren't required to think.  Could it be that the administration of Medicare  is a hoax and there aren't actual representatives, just answering machines?  Try calling and see what we mean--no, on second thought, don't waste your time.  You're making money, you don't have time for games.  
     Figure out which Medicare CPT codes pay the most without triggering records requests.  Every few years Medicare changes the procedures it audits.  It used to be bone density testing, then sleep studies, then back braces--stay away from these codes for now.  You can make a mint by billing CT angiograms, however, and all interventional radiology codes.  Keep up with Medicare's audit targets by visiting our website dontbillthesecodes.com.  
      Medicare will automatically deposit money into your "clinic" bank accounts two weeks after charges are submitted.  The beauty of it!  No paper checks, no interaction with bank tellers.  it's just money-in and money-out.  Move the cash quickly to foreign countries--vault accounts in Panama are the safest and allow you to sidestep detection.  Avoid countries where the political structure is unstable.  You want to keep the money you worked so hard to earn, don't you?
     If you have a house, car, or telephone number keep them separate from your fraud enterprise.  Don't let anyone track you down--remember, you're invisible.
     One of our clients made $40 million in one year, and no taxes.  So get started today--it sure beats the daily grind!