Thursday, December 6, 2012

The Government Made Me Do It

     Left lower quadrant pain, nausea, vomiting, weight loss.  A colonoscopy earlier this year revealed the tiny, balloon-like outpouchings of diverticulosis.
     "My son told me to come here because you can do everything right in the office," the patient said, distress casting a pall on her face.
     Tenderness, rebound, guarding, negative guaiac, no fever--all the signs of early diverticulitis were present.  Diverticulitis is like appendicitis:  an area of the colon gets inflamed, perhaps by infection, and the mucosal wall thins out, threatening rupture.  Antibiotics administered orally and by IV prevent such a catastrophe, but the patient needs careful attention.
     This is a diagnosis family doctors make, and it's something we can treat, most of the time, in our offices if we are willing to hire nurses trained to do IV's and accept responsibility for the patient's condition.  Given the prevalence of terrible infections circulating through hospitals--MRSA, c. difficile, TB--most patients are safer at home, where their stressed immune systems aren't likely to succumb to another contagious illness carried unwittingly by hospital staff from room to room.  In addition, the news about "mistakes" made in hospitals is frightening--I'd only go to the hospital if it were a matter of life or imminent death.
     Therefore, I refrain from recommending hospitalization to most of my patients when they have infections, heart failure or other ocnditions that can be treated effectively in the office.  Most patients appreciate this.
     But the woman with diverticulitis had Medicare--a government insurance which is not covering any "procedures" in my office, regardless of the patient's condition or medical necessity.  Perhaps someone at Medicare doesn't feel like paying me for keeping patients out of the hospital.  The government officials who enacted the raid on my office most certainly are behind the scenes--I'm sure they know a whole lot about good and bad medical care, aren't you?  As things stand, it's these administrators who are making decisions about patients' treatment these days, not doctors.
     Once again, I had to ship a Medicare patient to the hospital by ambulance.  The cost to Medicare of an ambulance:  $500 or more.  The three or ten day hospital stay:  thousands of dollars a day.  The CT scans, heparin doses, blood draws and other tests likely to be performed, more thousands of dollars.
     The cost of IV's in my office for three days:  an office visit, $66.18;  and IV $38.10/day for three days; and oral antibiotics from the pharmacy:  sulfasoxazole-trimethoprim, free at a local Publix, and metronidazole, $20.
     And the cost of complications or medical errors in the hospital, which statistics have shown occur in one in three patients--that depends on how much you value your life.
     The government made me send this Medicare patient to the hospital, and I will continue to have to do the same with others, against my better judgment, rendering my experience and know-how useless.
     Why can't Medicare authorities do this simple calculation?  It's cheaper, safer and better for patients to be treated in a clinic for a few days, and go home afterward, than it is to admit them to the hospital.   And if a doctor is willing to assume this level of responsibility, the charges to Medicare are going to be a little higher than for one who acts as an insipid gatekeeper. 


  1. People who are convicted of crimes give up privileges afforded to citizens; innocent people do not. The presumption of innocence means that the burden of proof belongs with the government.

    You can and should disown any fault. To my mind, the root of the problem you’re strapped with is someone else’s feel-good delusional disorder along with self-serving moral justification for overstepping boundaries of decency in order to get money for the government even when it leads them to lie or steal. It is something akin to Hilter’s craziness. It is a strange psychosis that does not allow the disturbed person to be empathetic or to even consider that the person they are persecuting is a victim of false witness as is your case.

    I’d wager that your attorney knows of prosecutors who have clung to the notion that an arrestee was guilty even when there was no evidence to support the allegation. Some prosecutors have been caught up in crimes by either fabricating evidence against defendants or hiding evidence that exonerates when their need to convict overtakes common sense. Of course, that conduct ruined their career. Mind boggling to try to figure that one out.

    FYI, there’s some innuendo posted online that US Attorney Pamela March of Tallahassee is an unethical person. It apparently has to do with her employing Stephen Kunz after he was punished for deplorable conduct in his unwarranted prosecution of Stephen & Marlene Alsenberg. Can a pattern of behavior be established? This is the second person we’ve stumbled across who has prosecuted someone when it wasn’t warranted while employed in that criminal division. May just be the tip of an iceberg revealed.

    Get out from underneath the pile right now. Just put it in your mind to do it. Hold your chin up because the stress is unwarranted. No worries! Your attorneys are competent

  2. It is no secret that construction and related industry was set back a few years ago. Projects slowed and competition increased as the industry collapsed. What is obscure is whether or not the industry will ever again be as robust as it was during the boom. While work is still slow in many areas overall business is improving. What is interesting is how business owners dealt with the crisis. Managers sought after other income streams. Many reinvented and modernized their businesses to meet current needs. Most businesses are smaller.

    Have you considered seeking out a different income stream? Obamacare is all about people becoming insured (larger customer base of insureds in theory). If the age of eligibility is raised to 67 for Medicare recipients the length of time people will be insured will be longer, which presents a larger customer base of insureds.

    You obviously understand that it is good business to fire employees who subtract from the equation but do you know that it is permissible and even necessary to fire clients? One thing I would not do is to work for a client who refuses to pay me for my efforts. If someone sent me a check for fifteen percent of what I billed for along with a nonsensical letter of explanation for stiffing me, not only what the ‘honeymoon period’ be over but also we would be in divorce court—get me? Rather than allow Medicare to frustrate me, I would instead get Medicare out of my life. In fact, I would buy a black Sharpie and rubber stamp that said ‘Return to Sender’ and on any future correspondence, such as; code changes, advertising, solicitations, received from Medicare I’d stamp the front of the envelope then I would turn the envelope over and write on the back in big letters ‘F.U.’ and take it back to the post.

    Not only do you understand Patrick Henry’s ‘Give me Liberty, or give me Death’ speech but you now know why people like Pamela March sends any correspondence through the attorney instead of directly to the defendant.

    You don’t have any responsibility to deliver health care to Medicare recipients. If there are no doctors serving their clients it is of their own making. Get ahead of all the other clinics that will opt out of servicing Medicare patients by marketing yourself now to clientele who can afford the care that you want to provide. I’m sure you can take care of your own valuable employees by making a few changes.

    The message that you have to deliver about health care is much larger than a local flyer can convey. Your message needs a movement.
    Keep writing your blog, go ahead and write your “Best Seller” by a primary care physician, then contact Dr. Oz and Montel to promote your book. Use key words in online advertising and patients will flock to you.

    The best revenge is your success.

  3. Thanks for your endorsement and advice. I am not leaving medicine because I'm failing--in fact, the clinic is doing very well. I'm leaving because I don't want to practice medicine in a system where government officials can use their power to steal from successful individuals without having to justify themselves in public. I AM quitting Medicare, along with every other insurance.

    1. I know you said you’re leaving medicine because you’re disgusted. You also said you feared making an error in judgment due to distraction. I fully believe that you are disgusted but I don’t believe you’re afraid of making a mistake. Strange thoughts cross everyone’s mind from time to time but those kinds of thoughts are usually fleeting.

      I’m trying to nudge you past focusing on what some idiot is doing…It has no pay-off. I may have understated my feeling about continuing any relationship with Medicare. This is the time to move any accumulated funds to safety.

      Your disgust is not going to let up; in fact you are going to take it with you wherever you go. I like thinking about a particular quote from H.L Mencken, “The most dangerous man, to any government, is the man who is able to think things out for himself…Almost inevitably, he comes to the conclusion that the government he lives under is dishonest, insane, and intolerable.”

      I am not saying that your decision to quit medicine is wrong… I’m suggesting that you make sure that you are not throwing out the baby with the bath water.

      God speed with whatever course you set.

    2. Thanks for your background info. Very interesting intersection with some of my experiences. I have to have a relationship with Medicare until I get paid what they owe me. I'm looking for a lawyer so I can sue them for unpaid accounts. If you think I should dissociate from Medicare altogether, and not even collect unpaid accounts or get a reasonable explanation for non-payment, I'd have to know your reason. Are you proposing that a certan degree of paranoia is appropriate when it comes to Medicare, since it's government-run and therefore rife with corruption, therefoe a real danger unless I cut all ties?

    3. In my view, there are several reasons to stop seeing Medicare patients that I will discuss in the following paragraphs:

      1. It grates upon the nerves when requests for payment are in dispute for most, if not for all, people who are in business for profit. Clients who short check are expressing dissatisfaction. In denying payment for services received, your client is challenging you. Medicare seems to be saying to you that you are a cheat and they know it, therefore, they are taking the lead in correcting you until you can prove them wrong. To begin with, it is like getting a slap in the face every time you go through your inbox. You pick out an envelope anticipating being rewarded for your effort but instead you find a short payment or a nonsensical explanation for non-payment.

      Every short check you receive requires more action on your part. Medicare is aware that you are losing money by protesting payments in dispute. How many reasonable explanations concerning non-payments have you received from Medicare, would you say?

      Your billing covers materials, labor, burden, overhead, than a reasonable amount of profit is tacked on. So your client pays fifteen percent. If profit was figured at less than 85 percent, you paid out of pocket to do work. I would much rather be standing out in a stream somewhere wearing my waders than to pay to do work.

      The cost of recouping money doesn’t have a code, does it? Those costs depend upon the outcome of taking legal action, which leads to the second reason below.

      2. So after a long wait that makes you feel harried, you finally get to plead your case and try to recoup unpaid accounts. The defense attorney could say that you had a duty to mitigate damages but you failed to do it. You could have simply cut ties with Medicare but in fact you NEVER did. You had Medicare patients right up until you closed the doors on your business.

      3. Medicare recipients must find their own voice or they could potentially end up with a worthless entitlement of substandard care. Recipients will not find their voice until doctors refuse to participate in their care. Medicare will not change their policies as long as recipients are receiving care. German doctors strike when management refuses to negotiate terms of care and wages but getting to that point other doctors have quit medicine or found work out of country because they felt disgusted.

      I would continue to do my best to collect all unpaid accounts, send in all required documentation, and request explanation for non-payments; to include hiring a law firm to assist me to that end.

    4. I agree with what you have said. I did not withdraw from Medicare because my lawyers said the prosecutor said there was no reason they could think of to explain why I wasn't getting paid. In answer to your question about how many legitimate denials have come through, I would say...close to none. There are no billed procedures or services that were not necessary or not provided. There may have been one or two tests, like a urine dipstick, ordered but not done because the patient left early and the nurse, billing assistant and I all failed to recognize that the test was billed but not actually done. We're talking about very few $3 tests--errors like this occur on both ends. E.g., insurance companies also forget to pay for some tests, and we end up not being compensated. In fact, I don't know of any tests we billed and didn't do, but present this as a possibility. We are very compulsive about correct billing and accurate, thorough documentation in our office. But patient care comes first, not documentation--unfortunately, government and insurance comapanies (and lawyers) would like documentation to be our first priority, not the actual ailing human beings who present for care. This, in a nutshell, is the absurdity of practicing medicine these days. Your advice is sane, and I am taking it under consideration.

  4. Rinker, I can't find anything with Pamela Marsh and Stephen Kunz in a google search. How can I locate the story to which you refer?


      Is US Attorney Pamela Marsh of Tallahassee ethically deprived?

      More about the Alsenberg case is found under:

      US attorney Stephen Kunz of Tallahassee; ethical dwarf

      It is posted on the committee to 'Expose Dishonest and Incompetent Judges, Attorneys and Public Officials'. Comments about Pamela Marsh are also on other sites and goggle will bring up several links for us to browse.

      Did you know that you can report corruption and patterns of abuse by law enforcement agencies to the FBI? Isn't that a hoot?

  5. Rinker, Do you have your own blog? If so, please direct my readers to it. I'd like to reciprocate the favor you've shown by reading my posts and commenting.

  6. No, I don't have my own blog. I really enjoy your posts, especially the recipes. I have downloaded all of them and we are trying each one. We garden and do some canning. I have raised chickens for as long as I can remember. The description of your pond brought childhood memories to mind.

    My grandfather, a medical doctor, was my guardian from the time I was 18 months old. He was also an avid fisherman who wrote articles for Field and Stream magazine. He would meet professional fisherman at lakes and streams for an official outing (event to be published). One day when I was about five years old he couldn't find a babysitter so he decided to take me along to meet up with an "important group of men" as he called them. When we got to the stream the men were already there so he left me standing on the bank and joined the men in the water. I watched him fly fish for trout downstream for a time. But after what seemed like an hour went by I began playing at waters edge. I came across some crawdads and while playing around one pinched onto my finger and wouldn't let go. I let out a bloodcurdling scream and splashed through the water as I ran to my grandfather with the crawdad stuck to my finger. Right away someone said something about "scaring the fish away" and "we might as well call it a day". I can still see my grandfather standing there on the bank wearing his waders with a pole in hand wishing those men well. He was so gracious.

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