Goodbye 2011, hello gorgeous 2012!

Well, I've just been exhausted by this year. Seriously bone crunching exhaustion. Medicine is hard work. Whoever thinks it's all glamour and gliding doesn't know shit. It is backbreaking and long hours on your feet, long hours being smooth and suave, and doubly difficult if you're having a bad day and faking it. Arthritis is developing and I have a new found respect for the elderly. Ice packs, anti-inflammatories and stretching through yoga are my new saviors.

I really hope the old garbage from 2011--the uncertainties, the corruption, the inconsistencies---go away. I'm ready for a positive uplift. I want goodness and gladness and seriousness. It's a good time, like the Roman Janus of old--half looking back, half looking ahead--to examine where you've been and where you want to go.

Here's to an abundance of health and prosperity for all  in 2012!! Cin-Cin!!

Groundhog Day every end of year

http://www.moneynews.com/Economy/Payroll-Tax-Medicare-Cuts/2011/12/22/id/421833


Well, once again, they hung the guillotine over our necks and they averted a nearly 30% pay cut for those of us in the trenches doing the work.
This charade happens every year. I am completely sick and tired of this annual ritual. CMS halts the processing of Medicare payments for the first 14 days of every January to give Congress "time to find ways to avoid the pay cut". CMS knows there would be a massive walk-out/revolt by doctors if the cuts came through. We still don't know what the fee schedule for 2012 will be, nor what the deductible will be. They'll figure it out well into 2012, with all of us scrambling to program billing software with the new fee schedules well into the new year. Their (Congress')  incompetence, contempt for the citizen, lack of knowledge of what it's like to be working in America today....(grumble grumble) GGGRRRRRRRRRR.

In a bizarre way, I actually want the cuts to happen. It would force their hand to restructure a bankrupt government entitlement with ever increasing Medusa-like growth.

Seasonal Nostalgia

Like many people this time of year, I find myself a little sad thinking of my childhood Christmases. The dreaming of Santa Claus arriving in the night--Ma, how he does he get into our apartment if we have no chimney? The family gatherings, and missing those who aren't with us any longer. The snow and the dark days ( I grew up in NJ). Now that I'm in a warmer climate and have real world, adult pressures, the season can be fraught with have-to-dos and responsibilities. I still look for Santa and believe he's around. It's easy to feel that you're missing that "magic" in all the sappy commercials this time of year.

I was reminded of a simple gesture by a patient's daughter. My patient passed away a few weeks ago, and his devoted daughter always came with him to his appointments. She came to bring me a thank-you card in the midst of her grief, thanking me for the support and the help I had given her father, and how he absolutely trusted what I thought. It brought a knot to my chest and I had to keep it cool in the middle of a busy clinic morning. Her gratitude reminded me what's most important for us to remember at all times--being kind, mindful of the golden rule, and just aiming for your best everyday, despite the headwinds!!!

In an earlier post I talked about bikram yoga, how deadly hot it was and how it wasn't for me. I truly love yoga and I persisted, I found a studio that offers "power yoga" in a room heated to 85 degrees, so you sweat but don't die. The studio is clean, smells good, has big windows facing a garden courtyard with lots of open space around it. I really feel that your surroundings impact your practice, your work, your life.
I was sold. I've been attending "power vinyasa" classes, a faster paced sequence of challenging poses in a heated room for 60-90 minutes, and it's wonderful. I really like how we begin and end each class with a long powerful "OM". There is a wisdom to this ancient practice of fitness, and I am much more flexible, limber, stronger after a few weeks. I can already do a partial tripod headstand! OK so my legs aren't straight and I can only hold it for 5 seconds, but it's a victory at age 43. Physical fitness is so important, it sets the pace for everything. Growing old, obese, weak, winded, and full of elevated lipids and diabetes and high blood pressure, NOT for me. I wish my peers and patients would listen to me when I suggest this. They are sooo behind the times, they think I'm crazy when I push for exercise, yoga, biking, swimming, etc.

Have yourselves a Merry Christmas and a healthful new Year!!!

Excuses, excuses

I love it when a non-compliant patient (a teen) does not show up to appointments and does not follow any of the prescribed regimens, which are reached to via consensus, and then oh, 9 months later, when said teen is away at college, everybody wonders why his acne is out of control. I actually received his mothers' rebuke TO ME for not "feeling" the stress he's under and not renewing his meds, sight unseen. I set her straight, no compliance from you, no more renewals from me, this crosses over into medico-legal land. I also urged them to find a different dermatologist who would suit their needs. I was already the third one he had seen in a year, "because nobody is helping him". Well, most of the time, you have to put in some effort, and help yourself. I am only a guide, not a magician with Merlins' wand to wave over the acne and have it disappear.

You can't always get what you want

Along the same lines as my previous post, a patient no-showed yesterday and called today to chew us out for not calling to remind him of his appointment. No nanny works here. My policy is, and has always been, that you are an adult and if you have an appointment, you keep it. I will not hold your hold and remind you like an alarm clock. There are a bevy of items in the marketplace--beepers, smartphones, calendars, etc. to do such a thing. It clearly said to me that he's not ready for the cosmetic things he wants done. He had no concept despite all the education, flyers, and information I gave him at the consultation 10 days ago. I advised him to seek treatment from a different doctor. Unmotivated, rude, diffident patients are not welcome here.

Rating Websites=Jerry Springer's forums for the disgruntled patient

A doctor friend recently shared her frustration with Yelp!, one of the many doctor-ratings websites in existence, where patients can anonymously post whatever they want about a doctor. The disgruntled patient railed against the doctor and called her competence into question because his insurance didn't cover certain things (quel surprise!) and the patient gave her a one-star rating out of five.

Here's the thing: you aren't a success until you have people who love you as well as the people who don't. With this in mind, this is how people conduct themselves with respect to insurance fraud. 

KA-CHING. The attitude is, "hey! it's not my money, let the insurance figure it out. I've already paid enough and I'm not paying any more". Think of all the people who have boasted of a generous payout on their auto accident claim, or flood claim, etc. In America today, insurance fraud is a way of life, and one of the biggest reasons why the cost borne by the consumer keeps increasing.

Third party medicine makes the exam room too crowded--doctor, patient and insurance company. You not only have to be a superb physician and have a warm bedside manner delivered with a painted-on smile, you also have to know every copay, code, modifier and deductible in advance. And these change weekly, sometimes entirely cancelled and replaced by new bureaucratic codes. The situation is not sustainable and is doomed to fail. It will only get worse with increasing regulation and bureaucratic red tape--hello, HIPAA 5010 updates? PPACA? 

Many physicians have gone cash-only, opting out of insurance/Medicare/Medicaid completely and I can only see the trend increasing.  BCBS and UHC have online real-time plan look-ups where you can see at registration what the patients' copayment or responsibility will be, and if they have a $5000 deductible, we tell them so, and collect payment on the day of the visit. You forgot your wallet? Reschedule. Everything else? Cash/Visa/MC/Discover accepted.  "Here is your superbill so you can send it to your own plan. "

I will also say that sometimes it makes more sense to limit the scope and volume of a practice. You can't be everything to everybody. I briefly contemplated interviewing patients before deciding to accept them into my practice. Pragmatically, it didn't work. But I am mindful of the patient interaction from the beginning, from the phone conversation in booking an appointment to their behavior in filling out a new patient registration sheet. My staff tells me everything, as bad behavior with front-desk staff predicts inappropriate behavior, nearly always. I've had patients refuse to sign the financial responsibility sheet and then I've refused to see them. The doctor-patient relationship is a two-way street, we are not technicians repairing a flat tire. This is a personal service involving vulnerability, for both the patient as well as the physician. 

Doctor review websites are a reality. Physicians have zero legal recourse in addressing those defamatory statements, I think HIPAA even makes it illegal to respond. Some physicians have patients sign contracts that are basically gag-clauses, where the patient must consent to NOT post on these websites. Frankly, I think our core mission is being diluted in all of this crap. Let's just be doctors. Reject third party medicine. Attacking the doctor because insurance didn't pay will only reduce access to doctors in the future. 

Penn State Horror Show

I'm not going to add to the copious analysis about the Penn State child sex abuse horror. My gut feeling is that the entire administration, athletic dept. staff and athletic donors need to be subpoened and prosecuted, then summarily fire those involved and prosecute. The NCAA needs to shutter the football program, or at least close it for a year to re-evaluate the whole institution. They've done it for far less, Ohio state players selling autographs and shirts, and they won't do it for this?
If the football program goes down, it goes down and ends. It's OK. There are bigger things than this, people. Our societal mores and the core of what constitutes ethical action are both at stake.

My current loves

Here are my favorite things right now:

1. Books
Alan Cohen, I Had It All The Time. A self-exploratory aid to reconnect with your inner spirit.

2. Music
Gipsy Kings, Bamboleo. An oldie but a goodie. Such great energy.

3. Jewelry
The large lapis and bronze cuff from Paige Novick. Bold, colorful and cheery.

http://www.paperdolls-style.com/wp-content/uploads/2011/07/Paige-Novick-Lapis-Medallion-Cuff-565.jpg


4. Makeup
Laura Mercier Shimmer Bloc and Bobbi Brown (new larger-sized) Lipgloss.

Kinda dangerous bikram yoga

When visiting my sister recently, she persuaded me to take a bikram yoga class with her. I had no idea it was as challenging as it turned out. They're all 90 mins. long, with a set sequence of yoga poses conducted in a heated room--min 105F. Needless to say, after about 30 mins. I was sweating profusely as well as others,  dripping sweat all around. I didn't do the poses I simply could not do, I attempted my own modifications just to try them out. Afterward I felt really stretched and oddly relaxed. I din't feel any problems during the class, I saw some folks in there just sitting on their mats at own point, clearly overwhelmed but exhorted to "not leave" the room. This is such bullshit.

However, I decided to look into this when I got back home, and I tried a bikram class locally. The room had a low ceiling and it was quite crowded, about 30+ people were in the class. Unfortunately I didn't hydrate properly beforehand and towards the end of the class I was nauseous and had palpitations, which scared me. I got up to leave, and the instructor follows me out, "where are you going?" I murmured with as much decorum as I could muster before vomiting right there on the carpet, "I feel like I'm going to vomit". She then asks, into the microphone, with the best of the Seattle-granola-earth-mother intonation as you can imagine, "Are you going to vomit?" I ignored her and scurried out to the coolness of the locker room. I splashed cold water all over me, changed out of my shirt, had some dry heaves and then calmed down, and drank some cool water. After 10 mins. she comes into the bathroom to check on me, and exhorts me to come back to class. I say no no no. Forget it lady. I'm done for the day. She left me alone, mercy be to God. I was able to drink more water and checked my pulse, back down to around 80. When the class let out 10 mins. later, I crept into the stinky room and gathered my mat and towels and went home.
I started to recall that incident in the "sweat hut" in Arizona, I think, a few months ago, where some people died of heat stroke, and that led to me hightailing out of there. These instructors can't be following people around or insisting that they stay in the room. I should have said, lady you're not equipped to handle any kind of heat stroke here, do you want me to have a seizure? I was in no shape to think clearly. I followed my instinct to leave a dangerous room and stuck to it. I don't think I'll do this again. These devotees are sometimes cult-like to their own detriment, that's a huge turn-off to me.

Required Reading

I was given a heads-up about the existence of the Mises Institute, an economic think-tank/foundation in Auburn, Alabama. Fantastic Publications and a world of alternative economic thought, i.e the Austrian school, as developed by Ludwig von Mises. His book, "The Road To Serfdom" is incredible, written in the early 1940's after he arrived in Great Britain fleeing Nazism, where he was horrified to find the fashionable elites extolling the virtues of Hitler and Stalin. This happened. It is completely applicable to today. I am about halfway through it. In it he expounds on the confusion surrounding the conceptualization of socialism vs. totalitarianism, and the conclusion is, they are one and the same. FREEDOM FOR INDIVIDUAL THOUGHT AND ACTION IS DESTROYED AND THE COLLECTIVE, OR THE GOVERNMENT, MUST RULE AND CONTROL ALL ASPECTS OF LIFE. A must-read. The parallels for today are mind numbing.

CMS did it again

My manager and I decided to submit our claims online through a clearinghouse to ease the burdensome headaches with the "upgrade" (upgrade for whom, exactly?) for HIPAA 5010 transactions. So today I got a message that many claims were rejected by Medicare, in particular those claims submitted after Sept 30. Closer inspection revealed the ICD-9 codes, which are going to be replaced in 2013 by ICD-10, have been CHANGED FOR 2012 and THE CHANGES TAKE EFFECT OCT. 1, 2011 FOR 2012 UPDATES!!!! Who decided this asinine course? A bunch of codes for skin cancer were DELETED and simply given a 5th digit but the old codes were thrown out, like the baby in the bathwater. So the code for a skin cancer in the ear was 173.2 but on Sept. 30 this ceased to function, and now an ever more specific code, 173.22 or 173.21, must be used if you want to get paid when excising a skin cancer on the ear. The definitions of these codes and the assignment of the new codes is not being divulged by CMS. You have to buy a book for that. Or do a quick couple of searches on Google if you're savvy....

So now, dear friends, it is not enough to operate, educate, explain, empathize, and just in general be a doctor. Now(and since LBJ signed his stupid legislation way back when) we have to play the bureaucracy game by updating all software and all printed materials in the office that have these codes, and pay for it, and do it with a smile :-). And it must be done overnight, 3 months before the new year. I cannot imagine how big clinics or hospitals are dealing with this, because there are a slew of other, newer, more specific codes that will be valid for only 1 year before they ALL GET TRASHED AND REPLACED BY ICD-10. WHY?????

The AMA is doing this to justify its existence. The AMA, in cahoots with the feds, come up with the barrage of diagnostic and procedure codes, and of course one can purchase a book from the AMA where all of these codes are "updated" yearly. Membership is way down and most doctors in America place no value on what this organization does or says; it merely mails out flyers offering new disability or health insurance just about every month, otherwise the AMA is a completely impotent and useless organization.

It would be so great to just see a patient, do what has to be done and prescribe what has to be taken for the illness to get better, have payment rendered at the front desk, and that's it. Instead we have this giant back-office operation where codes, bills, data, procedures, modifiers, etc have to be entered into a portal (which we have to pay for and we can't charge for doing this, expressly stated in the CMS mandate), and then wait at least 3 weeks to be paid. If at all.

I guess all those new employees in DC have to justify their existence. Codes! Modifiers! YES! WE WILL BE NEEDED AND NECESSARY FOR THE FUNCTION OF MEDICARE!!!

The Otter and The Cat

Welcome to my blog! I am an MD with a solo practice in the south. I have been employed by the government, academia, and HMO's in the past and have broken to one level of freedom by having my own practice. However, other challenges arise on a daily basis in this pursuit. This blog will attempt to chronicle them, and also provide a window into the harried, cumbersome, Kafka-esque level of regulation and government intrusion in my day to day life. I will also delve into matters personal, frivolous, and economic. I am a human being, too. "Doctor" is a faceless, anonymous, automaton-like term for who we are and what we do. We received a doctor in medicine degree after a painful, lengthy, expensive (more on that later) process. There needs to be a voice documenting what it's REALLY like "in the trenches".

I witnessed an act in nature along a river that I can't get out of my head. Standing on the riverbank one evening, I watched a river otter swimming, diving, and splashing about,  in what looked like fun water-play. After a few minutes of losing sight of the otter, he emerged onto the rocky banks with a fat fish in its mouth. He perched on the side of the bank, proceeding to enjoy his catch, blissfully unaware of my presence. Then he moved a few feet to the right with his fish. Then he jumped into the water again with his fish and came up a few feet farther down the riverbank. I peered more closely and I spied a stray cat chasing and harassing the otter, jealous of the otter's hard-fought catch. The cat wouldn't leave him alone and it kept pacing to and fro, jumping and hissing. Finally the otter got sick of this and dove into the river with the fish in its mouth. He swam upstream for about 150 yards to the other side of the river, where he emerged looking weak and exhausted, and after crawling a few feet up the other bank, he was able at last to eat his fish in peace. The cat wasn't able to get at him, and it eventually crawled back into the rocky crevices.

I know how that otter felt. I know how it feels to swim upstream, dive, work, and then work some more, all the while having the "cat" chase you down for your "fish". I know what it feels like to spend thousands of dollars in compliance manuals, ICD-9 books, software, CME, applying for more and more unique ID numbers, etc. and have it all for naught.