“I’m on to you” – a patient who “only lied about one thing.”

“I’m on to you” – a patient who “only lied about one thing.”

Today I saw a young female patient with two children.  She supposedly has chronic pain after an accident. I "inherited" her after her last pregnancy. Her OB doctor maintained her on narcotics during her entire pregnancy, then discharged her. I have been seeing her for 5 months. She does have pain, but it is not pelvic.

Technically she should be seeing an orthopedist, but they won’t take her insurance. She has that "good insurance" (Medicaid). I don't participate anymore (you can all clap now) so she pays me CASH. I have been trying to get her to the University to see orthopedics since summer. She has had every excuse in the book.

She has been to the ER twice since she has been coming here. Both times there have been “issues”. The first time she was accused of child abandonment. Both times she was apparently inebriated.

Her story today about the injury that took her to the ER was different than what she told the staff and Doc there. I know for a fact that she was in jail for 7 days for domestic abuse since she was here. I had a call from child protective services yesterday about her.  They are concerned about her children and considering removing them from the home.

She has failed every urine drug screen since she has started here. On discussion today, she really doesn't like that Clonazepam. She just can't feel it. (She was on Xanax when she came here. I won't prescribe it to new patients). So she doesn't take it, and doesn't tell me she's not taking it. Her last two urine screens were negative for it. Others had other problems.  For non-medical people, Xanax is a medication that is used for “anxiety”.  It works fairly fast.  Apparently there is a good feeling with it.  Clonazepam is used for the same thing.  It is long acting, and has no rewarding “good feeling”.

I discharged her today in the office. Gave her 30 days of meds and sent her on her way.  My state requires 30 day notice before discharging a patient.  It’s a stupid rule in my opinion, but it’s the law.   She was shocked. "But I only lied to you about that one thing!" She tried to negotiate for staying without the Clonazepam. Then she wanted to stay "just one more month". Then she wanted to know if I would write her medications for her withdrawal when she got to the end of her prescriptions. 

I hate being manipulated and lied to.  She continued to try with a phone call about something after she left.  “I’m on to you!”

“Uncompensated” Medical Care - Charity

Back in the old days, doctors used to do a certain amount of what they called “charity care”.  They would care for people who were truly poor.  They knew that they were not going to get paid in cash.

Sometimes a church, a school or some other organization would raise money to help pay some of the costs of that care.  People paid what they could.  They paid in chickens or pigs or apple pies.  If you couldn’t pay with money, you might come by and mow the doctor’s lawn or do some other work that needed to be done. 

Martha who kept the doc’s books would kind of figure out when your bill was paid.  Everyone (except possibly the IRS) was happy.

Sometime after WWII, employers started offering “health insurance” instead of increasing employee’s wages.  Doctors didn’t mind, because they got paid what they charged in real money. 

Then Washington decided that the government needed to get into the insurance business.  Medicare and Medicaid were born.  The government decided that it was not going to pay the whole bill.  Instead they would pay what they wanted to pay. 

More and more people qualified for these programs.  As the cost of the programs went up, what the government paid went down.  Doctors at first made up for this by working harder, and by charging other patients more. 

Insurance companies decided they didn’t want to pay the whole bill either.  They started to demand the same discounts as Medicare.  Doctors worked harder.   Patients got less time for each visit.  Our hours got longer.  Your waits got longer. 

Medicare and insurance companies developed more rules and regulations like prior authorizations, formularies, preferred providers and ICD and CPT codes.  Did that sound like a bunch of garbage to you?  Until I started “doctoring” it did to me, too.  They didn’t teach you all that stuff in medical school when I went, either.

Doctors had to hire people just to do the billing and “chase down the payments”.  Then they weren’t payments, they became “reimbursements”.  “Patients” became “Insureds” and office visits and surgeries became “claims” and “procedures”.  Insurance companies started “bundling” all your care.  Surgeons get paid the same no matter how many times they see you in the three months around your surgery.  OB doctors get paid the same for the entire pregnancy and 6 weeks afterwards.  It doesn’t matter how many times they see you in the office or the hospital.  The only thing that increases the fee is a cesarean section.  Some insurance companies won’t pay extra for that. 

There isn’t enough room here to discuss what happened when the lawyers got their fingers in the mixture.  Besides, my doctor wants me to watch my blood pressure.  Let’s just say that a lot more testing goes on these days to keep from being sued.  It costs lots of money and doesn’t add much to the answers we get.  Lots of paperwork ensues. 

Patients – pay attention here – that’s you! – are now so far removed from what things cost that they don’t care about what tests are done.  They want the CT scan or the MRI.  They want all the blood work, all the nuclear medicine testing, and all the consultants.  The insurance is paying for it after all.

Not really.  If you have private insurance, your premium goes up if you keep getting tests.  If you have “public insurance” the taxpayers pay for it.  Either way, it’s busting our system. 

Ask people who don’t have any insurance.  I have lots of them in my practice.  You see, I don’t take insurance any more.  I have gone from 4 employees to 1.  We will give you the papers to submit your insurance, but we won’t fight it for you.  That saves us hours on the phone.  I don’t participate in Medicare and Medicaid.  I don’t have to take those huge discounts.  So I get paid for my time. 

I get to spend more time with my patients.  My overhead is a whole lot less.  So I don’t have to charge for all those people that used to work here.  We have time to help figure out where the least expensive place for an MRI is and help our patients find other doctors to help them.  I also found a lab that gives discounts for cash.  We also decide what tests we really need, not what insurance will pay for. 

This is what I went into medicine for. 

Here’s another blog with another version of this:

http://roadtohellth.com/2011/11/why-does-the-cost-of-healthcare-keep-going-up/

Based on One Test

Denial of services because the child is “no longer retarded enough”

I am acquainted with a family who is currently fighting a denial of further services for their autistic child.  This child has been getting social services for many years.  He is a pleasant child.  The family works hard with the child.  He has made amazing progress over the years. 

He did not speak when he started school.  He now does speak, but is not always understandable.  He has many typical autistic behaviors.  He has been working with a social service agency, social workers, special education teachers in school, speech therapists, and hard working parents.  He continues to make progress.

The psychologist changed tests at his last evaluation.  His IQ went up twenty points!  Some of his other “daily life activities” scores went up.  The parents tell me that the booklet they filled out about activities of daily life is being ignored because the psychologist won’t sign it.  He says it is because he wasn’t there when it was filled out.

Two people from the agency (which is located 500 miles away) who have never met the child have determined that he is no longer eligible for services.  This is based on numbers that have made a jump in the last year.  They are based on one test and are not consistent with testing done over the last decade or more.

The psychologist and physician both specifically state that he needs to continue services or go to a group home.  The social workers agree.  The parents want to keep him at home, but admit that they need help. 

There is an appeals process, but the parents are not hopeful that anything will be changed. 

What’s up with this?  One test?