How Will Doctors Handle Uncle Sam Health Care?
Among federal Medicare regulations -- which are over 130,000 pages long -- there is more than ample room for confusion and some humor. After a long search for traction weights (those five pound blocks of metal used to pull fractures out to length) I found them propping open doors to patient rooms in the ER. It is a punishable offense under Medicare regs if the hospital is caught propping open these doors because they are fire doors.
In 30 years, I have never seen nor heard of a significant hospital fire. However, patients suffer every day by being inadequately monitored. Keeping these “fire” doors closed means the nurse sitting at her desk outside the rooms cannot visually monitor the patients. But, to comply with regulations, all those little rubber doorstops were thrown out. Fortunately, given a choice between poor patient care and ignoring a government mandate, most nurses care more about the patient than about the wishes of a bureaucrat in Washington. Ergo, the nurses commandeered the orthopaedic traction weights. In case of a pop inspection, traction weights at least provide plausible deniability.
Medical "quality" gurus of the Center for Medicare Services are convinced that certain abbreviations are dangerous. After over 100 years of clinical use, we can no longer write MS for Morphine Sulphate because it may be confused with Magnesium Sulfate -- two drugs with totally different indications. Neither can we write MagSO4 for Magnesium Sulfate, even though it is the technical chemical name for the drug. We cannot write ‘cc’ (an abbreviation every junior high science student understands) because it might be confused with ‘i.u’.-- international unit. And, we can't use ‘i.u.’ because -- you guessed it -- it might be confused with ‘cc’!
Like good gulag inhabitants, doctors complied for a while, then some (no one I know, of course) committed little acts of defiance such as making up their own abbreviations because the government watchdogs simply cannot enumerate all the outlawed terms -- though God knows they have tried.
As Medicare decreased reimbursements, physicians found ways of being more efficient while maintaining quality -- presumably the kind of behavior any third-party payor would want. In my case, I used a physicians' assistant to help gather routine data during a new patient encounter. He would do the routine part of the history and physical, and I would do the complex part, utilizing my time explaining the problem and treatment options to the patient. But this quality care was not to be. Medicare decided it would pay me approximately $94 for a new patient visit if I did it all myself (but I would waste much of our visit doing the mundane part of the exam) or it would pay the PA $94 if he did it all himself, as long as I was present to sign off on his plan. That option would have been more lucrative, but a clear compromise of care since I would have been signing off on a plan without first-hand patient knowledge. The quality solution which we had at first implemented would also have been $94 and superior in every way, but this was deemed illegal, subject to a $10,000 fine for being a "split consult" -- we both can’t see the same patient the same day and bill as one.
After four years of medical school, five years of residency, and usually a year or two of fellowship, orthopaedic surgeons are the most qualified people to apply splints. Up until last year, I did so. But now, Medicare has determined that only those physicians who are "certified" may do so. Who will certify me, you may well ask? A group of orthotists -- people with no medical degree and (relative to orthopaedists) much more limited experience and training? And this certification would have cost me over $3000 -- a cost exceeding the revenue for placing splints on Medicare patients in my practice.
So, now, these older patients, when taken out of a cast, must travel to another facility, to have a less qualified provider give them a vastly more costly splint. And, the physician can not oversee the process to insure correctness of the application. Medicare is paying more for less quality. (I guess the orthotist lobby is more powerful than the orthopaedic lobby.)
These are not isolated incidents, but emblematic of a daily clinic in Medicare Absurdistan. A psychiatrist once told me that we need three things to remain sane -- the ability to deflect criticism, the ability to laugh at oneself, and the ability to accept the absurd. Until it kills us, government run medicine should provide no end of practice.
Lee Hieb is an Orthopaedic Surgeon, in solo private practice. Her first-hand experience in medicine began in the 1950s, when she accompanied her father on his housecalls in Iowa.