"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.