It isn't What you do; it's Where you do it

It has been pointed out that there are huge geographic variations in medical practice. Likewise what is usual and acceptable in terms of administrative practices varies tremendously, depending on where you are.

For example, in my discussion of administrative fees I mention my success in implementing fees for the completion of forms without an associated office visit, primarily because most practices in my area were already charging them. DrFlea, on the other hand, points out why they won't work for him:

I can't charge to fill out camp and school forms. My colleagues don't do it, and the Medicaid folks can't/won't pay.

There you have it. I was able to because others already did. Flea can't because no one else does. Take-home lesson would appear to be that it doesn't pay to be an early adopter.

On the other hand, someone has to be first. Here's hoping I have the resources -- in terms of patient goodwill and recognition of the excellent services I provide that aren't actually medical care -- to pull it off.

The Ears Have It

Or: "You Can't Make This Stuff Up"

Part the First

Around Valentine's day, I get a report from my local ER that a 4-year-old patient of mine was just there because she had put candy hearts in her ears. I chuckle and file the report.

A few hours later her mother walks into the office with some kind of form for one of her other kids. I see her, remember the report I saw earlier, and burst into hysterical laughter. Upon suddenly realizing this could be construed as rude, I went over and explained that I had just read about her daughter's ER visit. Not only was she unfazed, she added, "That's not even the funny part."

Uh oh. What was the funny part, I asked.

"On the way to the hospital, she said, 'After they take them out of my ears, can I eat them?'"

Part the Second

7-year-old girl comes in with an earache. No swimming; no drainage; no URI symptoms. I ask the kid and the mom, "Has she been putting anything in her ears?" Both say no. I look in her ears -- first the good one, just like I was taught. Then the bad one. No pain with tugging on her outer ear. I peer through the otoscope.

I take it out of her ear. I look at the kid; I look at the mom. And I declare definitively, "There is nothing naturally occurring in the human body that is that shade of pink."

The kid looks at the mom. The mom looks at the kid. And then she (the mom) says "Oh yeah!" -- in the tone I have come to expect from my teenagers when asked if there were any calls while we were out despite the dearth of written messages. "She was putting Play Doh in her ears."

Mining the Comments

Regarding my plan to refuse Medicare patients during the nine days Medicare won't be paying, a paleontologist (what else to call someone with an interest in dinosaurs) writes:

I'm still so far away from having to deal with these types of problems and I just keep hoping that more and more people stick to their principles like you're doing here. Try to have the whole medical reimbursement issue handled before 2015, if you could.

No problemo. Nine years. Plenty of time to get it all fixed up.

I think.

Unless I'm swimming in the tar pit by then.

The Hardest Thing

A I tell new parents in my practice: the hardest part of parenting is keeping a straight face.

Sometimes it's also the hardest part of doctoring, and I'm usually pretty darn good at it. Not today, though:

For several weeks, I've been trying to care for a 15-year-old girl with abdominal pain, and her family. The pain has been intermittent, has no relation to eating, stooling or menses. It hasn't affected her appetite or activities. Her physical exams have always been completely normal, and frankly I haven't felt that extensive lab and imaging studies were warranted. The pain began when her parents left her with family members while they went on a "second honeymoon" to Arizona. Somehow, this 15-year-old's parents had never left her before, and it eventually became clear that the pain was mainly attention-getting behavior.

Finally I tried to reassure the mother as tactfully as I could. "You know, 15-year-old girls can sometimes be a little dramatic."

The mother drew herself up to her full height of 5'5", planted her hands on her hips and shrieked at me, "Dramatic? Dramatic!? My daughter is not DRAMATIC!"

Gardasil: The Argument Against

For anyone who happens to have been hiding under a psychedelic mushroom for the last year or so, there is a new vaccine recently approved for the "prevention of cervical cancer" called Gardasil. This vaccine is administered as a three-dose series, costs about $120 per dose, and is being marketed for girls and women ages 9-26. So what, if anything, is wrong with this picture?

Just this: The American Cancer Society estimates that in 2006 there will only be 9,710 new cases of cervical cancer, and only 3,700 deaths. I am not disputing that these are horrible deaths, as are many other cancer deaths. But with a total female population of just over 147,000,000, that translates to only about one in 2,500,000 women dying of cervical cancer. At a cost of $360 dollars for the full 3-shot course of vaccine, that comes to about $900,000,000 to prevent one death. One. I'm sorry; no matter how horrible a death, it's not worth 9/10ths of a billion dollars to prevent just one.

Merck (the vaccine's manufacturer) of course uses different numbers, coming up with a much greater benefit by calcualting how many CIN2/3 (abnormal/precancerous paps) were prevented, according to the following statement in their package insert:

CIN 2/3 and AIS are the immediate and necessary precursors of squamous cell carcinoma and adenocarcinoma of the cervix, respectively. Their detection and removal has been shown to prevent cancer; thus, they serve as surrogate markers for prevention of cervical cancer.

Here's the fallacy: yes, every cervical cancer began with a CIN2 or 3, but not every CIN2/3 will go on to an invasive cervical cancer. And of those, only about a third of those patients (in aggregate) will go on to die. But the real catch-22 of the situation is that the women overwhelmingly more likely to die are those who never get a pap test.

Thus we have a huge paradox: those who come for cervical cancer screening, even relatively sporadically, are not going to die of it. The vast majority of cervical cancer deaths are in women who have never had a pap. Not ever. Even one lifetime pap reduces the already very small chance of dying of cervical cancer from tiny to ridiculously miniscule. Those who die are those who do not get screened (for whatever reason, be it financial, cultural, socioeconomic, or other access issues.)

So no; I am not going to recommend Gardasil to my young female patients. (We're completely ignoring the role of males as reservoirs of HPV infection, but then females have historically been on their own dealing with the consequences of sex; but I digress.) We are also not discussing the overall global burden of HPV disease, which is considerable. None of the above analyses apply to women in Africa, where horrible cervical cancer deaths are sickenly common.

What could change my mind?

If Merck were to donate 2 free doses of Gardasil to women in Africa for each dose sold here (which would still net them a ton o'cash) then I would push it like a street-corner crack dealer. But I'm not holding my breath.

Administrative Fees

There's been some talk here (and elsewhere) about charging extra "administrative" fees to patients for things that aren't strictly medical in nature, such as filling out physical exam forms for children's sports or camp, and insurance forms. Some also want to charge for expedited referrals, and other administrative services.

I agree in principle (hell, I'll agree to anything that smacks of actually getting paid for what I do instead of having it "bundled" with office visits that often don't ever occur) but I'm having trouble with implementation.

Many offices in my area already charge for completion of forms outside of an office visit, so putting that one into effect went relatively smoothly (except for the lady who demanded her kids' records instead of paying the $25 for three different forms, then sweetly called back a week later, checkbook in hand) but I'm afraid much beyond that won't fly. For now, that is.

In order for an annual "service fee" to work in the context of private practice, it must become the rule and not an exception. If more and more offices (other than "Concierge Practices", which don't do anything different from what I'm already doing without getting paid) were to charge some kind of service fee -- even if only a nominal $20 a year -- I think we'd be on to something. If large practices (those with the least to lose) become "early adopters" they would pave the way for the rest of us. Either that or we --GASP -- work together and all do it at once.

Pros? Cons? Comments?

What should I do?

Starting September 22nd, the government will not be sending out Medicare payments for nine days. (Really.) No interest; no late fee; no nothing. Just no checks.

What do you think would happen if I just decided not to pay my office rent until the 10th of the month when it's due on the 1st? What if I didn't pay my electric or phone bill? Do you think the credit card company would bat an eye if I dropped them a note telling them my September payment was going to be nine days late and not to bother charging me extra? Do you think pigs can fly?

My landlord would be at my door daily; my phone and electric would probably be cut off after a week (a bit of exaggeration given my stellar credit rating) and the credit card companies would cheerfully ignore my protests that I had told them all about it ahead of time.

So it would appear that in the world of business, service stops when not paid for. I can do that.

Between September 22nd and October 1st, I will refuse to see Medicare patients in my office. If they need care urgently, they can go to the ER. I shall also tell them exactly why I am imposing a moratorium on caring for them. And if (when?) this happens again next year and the year after that, I'll just be that much closer to the brink of opting out of Medicare entirely.

I'm not dead yet

They say the solo practitioner is extinct; gone the way of the dinosaur.

Close, perhaps; but not quite yet. I am still here; taking care of patients one by one, day in and day out, closing in on the end of my second decade in the solo private practice of Family Medicine.

Truth to tell, things are very tough. My income has declined in each of the last four years, so I don't know how much longer, realistically, I'm going to be able to continue.

So come along and watch as one of the last dinosaurs meanders along, trying to avoid stepping into the tar pit while worrying that it's already knee deep in it.