The BMI of the Chicago Teachers

Last week, when I was looking at the news and the Chicago Teachers' Union strike showed the teachers on parade, on strike, it was striking how THEY ARE ALL OBESE. Not just a little chunky, a little zaftig...OBESE.

The devil in me thinks that the marching maybe did their health some good. Certainly not for the children...they were babysat and fed as per the Board of Ed. rules regarding school lunches (and breakfasts). Has it gotten so horrible in America that kids have to go to school to be fed? If you have kids, don't you have the commitment to feed and clothe the child? Oh wait, silly me, such a concern is downright Victorian. FDR fixed it.

Secret Shopper

One thing I really love to do is to be a patient and not say one word to anyone that I'm a physician. I want to see/feel/hear how regular patients are treated, and I don't want to be subjected to the hallway consults of dermatological issues that other patients in the office are having--and this has happened to me--once I was getting a physical and my doc asked me about a patients' rash in another room--I told him to have the patient call my office :-)

I went for a flu shot at a local walk in clinic. I perused their glossy brochures by the front desk. They have 3 MD's --older white men, medical school grads of the 70's--and 9 staff  "ARNP" with so many letters after their names I was wondering if they wanted to print an alphabet soup. CSH, ARNP, MSM, WTF?? What is all of this crap?
Now, I do not for a minute minimize nor belittle what RNP's do. However, to have a walk-in medical clinic staffed with them nearly 3 to 1, something is wrong. I thought all RNP's had to be supervised and present each patient's case to a licensed physician. I don't know what the regs are currently and I don't care. I do know that the vast horde of America believes that a white coat=doctor. You could be a janitor, or excuse me, "maintenance specialist" and if you're wearing a white coat people will fall over themselves to get your attention and curry favor. This clinic is clearly ramming thru 3 times the volume of patients for each MD, because each MD is the one that bills insurance. I do know an ARNP cannot be free standing and bill Medicare directly, they must do it under a physician's license number. So the clinic "pumps and dumps". They conveniently have an on-site pharmacy, lab, and x-ray. All geared to squeezing the most out of each patient encounter.

I hate that.

So I was just a regular, Joe Schmo patient getting my flu shot. No questions, no inane comments about my chosen specialty, and no nervousness afoot. I sense that if they know I'm a doctor, they get nervous. I don't want nervousness, I just wanted to get the damned shot and get out. I was treated well and had no complaints about the whole show.

Unlike an a&^&*%e last year who called my office declaring he was doctor-such-and-such and he demanded to be seen. When I interviewed him, the guy had a PhD in biochemistry and worked for a pharmaceutical company his whole life. A**&&**&! You're not a doctor to me. HA!

Remember kids, Safety First!

I rememder some slogan from my 1970's elementary school experience that went "Safety First" or something like it. My impressionable young mind retained this slogan till the present day. I look both ways when I cross a street, I wash my hands a zillion times a day, I'm hyper-aware of all the stimuli around me. It gets exhausting.
But now, to maintain my board certification (that's right, for those of us unlucky enough to be born in the 1960's and afterwards, we have time-limited board certification) I must take a "Patient Safety" online course. No matter that doctors practice in a myriad of ways, from concierge to hospital-only; the course is the same. What's worse, it's the same course for every kind of doctor, whether a psychiatrist, pathologist, or a trauma surgeon.
Now, the thing is, what this is TRULY about, is paying $25 (it's helpful that they take credit cards online)  to an unheard-of entity to take a mind-numbing online course extolling to virtues of root cause analysis for medical errors.

Into this bag of responsibility also falls the fact that I am responsible for reminding or notifying a patient that he/she has a follow up appointment.

When was my career as a physician saddled with the task of appointment manager?

When you hurt, and you have a doctor's appointment, you keep the appointment in the thing known as a CALENDAR and now they even have them in smartphones and they go **ping** when you have an appointment....and I think it's fair to say that if you aren't even sufficiently invested to keep your appointment, how are you a good risk for me to take? How are you a compliat patient? How are you a patient that deserves my time and effort?

The simple fact is, you're none of the above. You're a flake that NEEDS to be discharged.

I'm not talking about people who are overscheduled, forget, and call us the next day full of apologies and excuses. I'm not talking about the people who had other crises erupt, or who had a death in the family, etc. and missed their appointment only to realize it days later. I'm willing to give those the benefit of the doubt. I am more than happy to reschedule anybody who apologizes and who WANTS to come in.

I'm referring to those who never call, never show up, and just fade off the planet. We've gotten onto the merry-go-round of phone calls to disconnected phone numbers, not-in-service cell phones, and I've just given up the excessive waste of time and energy that it takes to be an appointment babysitter.

Yet, in this Safety Course, it was harped on again and again. Why? I don't know. I understand that medication errors occur, chart errors occur, etc. but since when does a missed appointment fall under the purview of a physicians' duties as a safe practice?

Because it's an easy clerical task that can be called upon in a court of law. Nothing to do with actual medical delivery and medical duty.That's what I believe.

The Foundations in Patient Safety course was entirely geared towards hospital based medicine. That's where the big money, risk, and federal oversight is the heaviest.

My dentist informed me that they get annual recommendations from the ADA to discharge the bottom 10% of patients that are, in his words, dead weight. I always marvel at how dentists have managed to avoid being called health care (we all know that periodontal disease and abcesses are quite lethal) but they are completely outside of this system. Fascinating.

Tighten the screws

Increasing numbers of patients are calling about whether we'll participate with PPACA. WTF? I have no clue how the "program" will be administered. It hasn't been stated, anywhere, how the nuts and bolts of doctoring will work in the new system. Much hand wringing about insurance exchanges, Medicaid, and that "you can keep your doctor"....HAHHAHAHAHA! As what, your personal nursemaid? People won't be allowed to see doctors, that's my feeling. They'll be shunted to NP's and PA's first to do the triaging. One hospital CEO has been quoted in the WSJ as stating that the "volume" will more than make up for the decreased reimbursement. Just churn them thru, "doc" and shut up. Who knows how specialists will be handled. None of this has been made clear, not even a little bit.

It's not about health care. It's about health payment and taxation. You heard it here first.

"Just bear with me, one moment please..."

I was on the phone with various Humana agents for about 45 minutes, being ping-ponged from one to another. They do not have an HMO presence in my geographic locale but as a "provider" I may accept their Medicare Advantage/PPO members and bill the insurance company without any contracts. Or so they say. The current issue I am facing is that I am being treated as a primary care provider when in fact I am a specialist, a dermatologist. The copayments are different. I trained as a dermatologist and my claims need to be processed as such, not by a random high school dropout who sees my claim and does the automatic rote thing. I fight daily for such small humiliations to be removed from my hair.

For those of you who do not know, Medicare Advantage plans were all the rage in Florida as the new kid on the block about 4 years ago. They were "rushed like a fraternity in September" because they promised senior citizens zero out-of-pocket charges and they tossed in little goodies like gym membership discounts or prescription plans. In sum, seniors get Medicare premiums docked from their Social Security checks. Yes, that's right, what you "paid into" all those years as a working stiff is no longer enough, you must continue to pay for it even from your Social Security check. Then they are subject to a $140 calendar year deductible and 20% copayment of the allowed charge for all outpatient, or Part B, services.

When the retiree joins these Advantage plans, they no longer get the Medicare premium docked from their Social Security check. The Medicare Advantage plans get government grants, in a lump sum, to cover the senior citizen, and then they "deliver" services at a bundled rate. Part of that sum goes towards advertising and promotion, so government is funding non-medical activities in this method, by feeding a private sector entity. Patients pay a flat copay at office visits, somewhere between $15-50 depending on the plan they choose. Specific drugs, labs, etc must be used, and only doctors who accept the plan can be seen by the retiree. A doctor does not have to accept the plan even if they are a participating doctor with Medicare. There is a different fee schedule (LOWER OF COURSE) and more restrictions on types of services covered.

The controversy came in when fast talking salespeople came to town and offered seniors free coffee and donuts to get them to switch to their HMO-like system. You all know that people would sell their souls for a jelly donut. The insurance agents got huge commissions and bonuses for signing seniors up in bulk. The rude awakening came when plans over-promised and under-delivered. The infamous "Any Any Any Plan"-- literally that was the name of a certain Tampa-based plan-- got shut down by the feds for not paying doctors and hospitals and they went bankrupt. I refused to accept that plan many a time (simply because of their absurd name) and I faced harsh words from my patients who were on this, only to then hear their lamentations when the plan got busted. Sorry Charlie. If you yell at me I won't be your doctor.

In any event, I'll wait and see what happens with Humana. If they can't correct the glitch in their system that doesn't recognize what I do, I'll refuse to deal with them any further and drop it. I had long standing patients switch to their Advantage Plan and I took it and billed it, got paid within 14 days, and all was fine, until I read the fine print and saw they weren't able to code me as a specialist for mysterious reasons. We shall see if they will fix it. I'm not holding my breath.

Update on 10/15/2012: Not one letter, phone call, nor follow-up to this situation has occurred.  They haven't done one thing. I'm tired of this BS so I'm dropping it. Stick a fork in me. I'm done.

First Day of Summer

Doctors are under assault by the patients, FDA, the Feds, CMS (OMG did I use the correct modifier? Am I going to jail?) and by insurance companies. This is all a given. What I'm finding more cheery is that doctors are repeatedly hitting back. The AMA no longer represents physicians, and there is open revolt going on with PPACA. Increasingly, physicians are acting in ways that would've shocked me 10 years ago. Examples abound, but not taking certain insurance plans, going concierge/cash only, and going to work for industry are increasing examples of why we're seeing more doctor shortages than ever before. It's not that there are less doctors, but there are less PRACTICING doctors. Doctors have multiple talents and lots of corporate entities find that the background intelligence and training that doctors can bring to the table leads to a distinct edge in being placed on corporate boards and such.

Anyway, it's the first day of summer! YES! Plans for trips are swirling. Here are my current three obsessions this month:
1. Whole Foods' Mixed Berry Cereal Bars. Nutritious, not full of unpronounceable toxic shmutz, and yummy.
2. Palomar Starlux Laser Corp. has provided zero friendliness after purchase, but I must say their customer service and ordering dept. is excellent. THANK YOU, you know who you are.
3. Arnica is really great for muscle soreness. You can get it at health food stores, Whole Foods, etc.

Let me just opt out. No Mail.

Today I went to check my mail at the medical center, where my office is located, and I found a big bunch of mail held with a rubber band, bundled in the mailbox in the driveway of the Urgent Care. On top, a handwritten note (on the same yellow/orange notepaper used to claim certified receipt notices) dated 5/31 stated that "the mail will be withheld until the mailbox is moved". I received no mail on June 1, 2, or 4th, until the situation was discovered.

I notified the "medical center operations manager" --really a data-inputting grunt--and thus the bureaucratic dance began.

The new mail carrier had a battle going on with the medical center staff. She refused to drive her vehicle into the driveway and wanted the mailbox moved to the "regulation of 3 inches within the curb" because in Florida, postal carriers do not walk out of their vehicles, they sit in the truck and deliver mail into mailboxes at the edges of the curbs. This is why they are all obese and full of varicosities and Type II diabetes. I know this because I treat some of them, as patients.  Oh and you, dear taxpayer, are paying for the most Cadillac-of-Cadillac-health plans to treat and correct these medical conditions, directly caused by the sedentary and molly-coddled lifestyle these persons lead.

The medical center manager went to talk to the postmaster. He was completely unaware of the withheld mail edict, apologized, and stated all mail would resume tomorrow. 

I am TOTALLY concerned about the fact that a mail carrier unilaterally decided to withhold my mail, along with the mail of the entire complex, in effect, holding it hostage. They have done this from time immemorial. Postal carriers steal mail, brightly colored birthday cards, welfare checks, you name it. They are underpaid grunts who can't be fired, handling our really sensitive documents, and it's enshrined in the Constitution. Sometimes they "go postal" and start shaking and shooting  or opening Pepsi bottles in WalMart aisles. And they wonder why they're going bankrupt. Any possible way that I can avert having to deal with the USPS, I follow. E-payments? Check. Email? Check. Electronic pathology reports? Check. Bloodwork results faxed? Check. 

But not everything can be handled electronically. The world is straddling the paper and the internet systems right now, and we have medical records coming in from Dr. Smith in Sheboygan, on paper. Mrs. Hunt sends in her copayment via handwritten check, via US Mail. And so forth. 

I am a physician trying to run a medical practice. I have bills, reports, payments, and sensitive mail that is coming to my attention, such as lab tests, pathology records, etc. This is clearly unacceptable behavior and crosses the ethical boundary of the mail carrier. What assurance do I have that no mail was comprised? How do I know if something was stolen, or lost, in this process? I need answers. 

Medicare has ruled that as a participating physician, I must have a physical address for mail, no P.O.Boxes are accepted. So that avenue is cut off. 

Can't I have what Kramer in "Seinfeld" wanted all those years ago, to "opt out" of mail? Seriously, why can't we just opt out? We can show an ID and pick up all the mail at a given post office. That's it. No carriers, no delivery. 

I will dance, sing, pour vodka over my head, turn cartwheels, and let fly all sorts of fireworks when two things happen. First, the USPS goes bankrupt and Congress overturns its monopolistic hold on First Class Mail. And second, Obama loses the election. Homer Simpson could be sworn in, and I'd be delirious. I just can't take the Stalinist "Forward" motto. It calls to mind "Pa'lante" (Castro) "Forward" (Mao and Stalin). 

http://www.theblaze.com/stories/forward-for-communism-is-obamas-new-forward-slogan-really-a-coincidence/