Sunday, March 18, 2018

Thousands of High School Students Protest Gun Violence - Should We Give Them a Free Pass?

This past week high school students across the country walked out of school for 17 minutes to show solidarity with the 17 fallen Florida students and their families. There is not a human being among us who disagrees with their mission, except for a few deranged and cowardly murderers.  These kids are crying out for more restrictive gun laws.

Although I will offer a controversial view below on the walkout, let me say with clarity and sincerity that I am proud of these kids.  Since the horror in Florida, I watched them speak to us with passion, poise and eloquence.  While many of us may not agree on the best path forward, we can all agree that we have great kids in this country.

These kids are right and have a right to demand to be safe. Schools have always been an oasis for our children, places where they are to be nurtured, educated and protected.  I know that there are many teachers who would serve as a shield for their students in any situation, as they have so nobly demonstrated. 

Safe in School

Some public and private schools have  authorized the demonstrations, assuring the kids that no disciplinary action against them would be taken.  Moreover, Yale, MIT, Dartmouth, UCLA, Harvard and other colleges have announced that no high school protester’s college application would be adversely affected by their participation. 

Many high schools have differing views on the propriety of the protest.  Here’s my concern.  If colleges and high schools are taking a permissive stance on this protest, because they support the cause, have they opened a door that will allow future students to walk through?

My personal view is that students should not be permitted to leave the school during school hours without permission in accordance with established school policy.   Students, like the rest of us, are free to protest and express themselves when school is not in session.  Why must the demonstrations occur during the school day?  If school policy is violated, then violators should be prepared for the consequences, which should already have been codified and known by all those concerned.  Many students opted to protest and were prepared to be held to account.

What if the students' message was not for more gun control?  Would we expect equal treatment?

How would high school administrators, school boards, teachers, students, parents and colleges react to the following protest themes?
  • Students walk out demanding that teachers be armed.
  • Students walk out demanding that an NRA spokesman be permitted to address the student body during assembly.
  • Students walk out protesting against teachers who have been advocating for stricter gun control during class time.
  • Students walk out to express their pro-life view and demand abstinence education.
  • Students walk out demanding an end to standardized testing alleging they are racially biased.
  • Students walk out demanding changes in the curriculum reflecting a more multicultural approach.
  • Students walk out protesting the FBI and law enforcement who missed so many opportunities in Florida to intervene and prevent a horror. 
I don’t think we should have an elastic policy that stretches when we support a cause but contracts when we oppose it.  True fairness is when we have the same tolerance regardless of the content.  Free speech, for example, doesn’t mean free speech only when we agree with it. 

How do you think the Academy, high school leadership and the press would have reacted if high schoolers poured out during the school day carrying signs and shouting in unison, Build That Wall!  Do you think that colleges and universities would be racing for the microphones to give these kids encouragment and a free pass?

Sunday, March 11, 2018

Insurance Company Denial of Emergency Care - Part 2

Last week, I opined about a decision by Anthem to deny paying for Emergency Room (ER) care that it deemed to be non-emergent.  My point was that insurance companies should not be obligated to pay for routine, non-emergent care, recognizing that we need a fair and reasonable method to define a medical emergency.   In my view, payment should not be denied to a patient who reasonably believes he needs ER care, even if the symptoms are (hopefully) found to be innocent after a medical evaluation.

For example, if a patient develops chest pain at 10 o’clock p.m., and is worried about an acute cardiac issue, he should call 911.  If the ER determines that chest pain is simple heartburn, it would not be reasonable for Anthem to deny payment for this ‘non-emergent’ condition.   We’re all a little smarter after the fact once we know the outcome.

Some medical complaints, however, are never medical emergencies.  If you want ER care for a runny nose, a cough or a sore knee, and you proceed to the ER, explain why you think your insurance company should pay for this. 

Coronaviruses Cause the Common Cold 
True Emergency?

Emergency Rooms must accept every patient who seeks care there by law.  A patient cannot be turned away regardless of how trivial the medical issue is.

One approach would be for every ER to have two tiers of service – Tier 1 for true emergencies and Tier 2 for all the rest.  Some ERs have such a system, but I think this should become the standard of care.  The Tier 2 facility could be equipped to provide efficient, low cost care for appropriate medical issues.  ER personnel are already highly skilled in triaging patients and could direct incoming patients toward the correct Tier. 

Here are the benefits.
  • Patients with minor complaints would be seen without waiting for hours while ER personnel attended to truly ill individuals.
  • Tier 2 facilities would be designed to provide lower cost care.
  • Tier 1 could operate more smoothly since patients with routine medical issues would be siphoned off.
  • There would likely be an overall cost savings to the health care system.
Ohio legislators are already threatening legislation to attack Anthem’s ER denial of care policy.  As a gastroenterologist, this craven political grandstanding nauseates me.  Politicians, who spend a career spending other people’s money irresponsibly, aim to lecture a private company who wants to exercise reasonable cost restraints.  Give me a break.

Would Anthem and her sister companies cover Tier 2 care?  Could they assert that since the patient was determined in the ER to have a non-emergent condition that the care should be on the patient’s dime?  I’m not answering this question, I’m merely posing it.  I do think that the present system when a patient expects or is entitled to any ER care being covered needs to be reformed.

When insurance companies pay millions of dollars for unnecessary care, guess who’s really paying for it?

Sunday, March 4, 2018

Insurance Company Denial of Emergency Care

We live in an era of demonization.  Political adversaries are not opponents, they are villains.  Commentary that contrasts with our views is labeled ‘fake news’.   Presumption of innocence?  R.I.P.  Civil discourse has become a quaint memory.  Why would one debate respectfully when today’s tactic is to talk over and demean your adversary? 

On the morning that I prepared this post, I read an article reporting that one of Ohio’s largest insurance companies, Anthem, is denying payment for non-emergency care provided at emergency rooms  (ERs).   In my view, this article was slanted, unfairly tilting away from the insurance company, an easy target to attack.   I think that a typical reader would conclude that the company was greedily trying to claw money away from sick customers.  An anecdote was offered describing a denial of payment for emergency care for abdominal pain that did seem improper, although there were no medical facts provided.

I felt that the journalist did not adequately present the insurance company’s motive and point of view.
Of course, I expect true emergency care to be covered.  And, I do not expect ordinary folks to reliably distinguish between a medical nuisance and an emergency.  Patients are not doctors. But, there should be some standard in place.  There should be a version of a reasonable person’s belief that an emergency is present. 

Insurance Companies are Easy Targets

Consider the following points.

  • Insurance companies are businesses and must be run responsibly, just like your business and my medical practice.  You may believe you are entitled to every imaginable medical benefit, but someone has to pay for it.
  • Many emergency room visits are clearly for non-emergent reasons.  This wastes health care dollars, leads to medical overutilization and clogs up emergency departments.
  • Insurance companies should object to paying for expensive ER care that could have been rendered elsewhere. 
  • A patient who presents to an ER with complaints such as a cough, a headache or stomach distress will likely undergo significantly more testing than would typically occur in a primary care physician’s office without an improved outcome. 
  • Do we expect an insurance company to pay for an ER visit for a splinter?
  • Do we expect an insurance company to pay for an ER visit to evaluate a child’s cold?
  • If a patient is offered an appointment at his physician at an inconvenient time, and he opts instead to proceed to the ER, should the insurance company be expected to pony up?
  • What would our position on this issue be if we were insurance company administrators?
I read (but cannot verify) that $40 billion are spent each year in this country on unnecessary ER care. Do you think there might be a better use for these funds?

It’s easy to vilify corporate America.  The pharmaceutical and insurance industries have large targets on their backs.  But, just because we can hit the target easily, doesn’t mean that our aim is true.

Sunday, February 25, 2018

The Americans with Disabilities ACT (ADA) and Food Allergies - Cleveland Enters the Arena

Reasonableness is like pornography - hard to define, but we know it when we see it.  (with a nod toward U.S. Supreme Court Justice Potter Stewart.)

It’s interesting how folks classify themselves on the political spectrum.  Most individuals regard themselves as moderate, independent and reasonable, regardless of their views and positions.  Try asking an extremely  partisan political conservative how he classifies himself and you will hear terms such as ‘family values’, ‘mainstream’ and ‘pro American’.   A politician on the far left is more likely to describe himself as ‘Progressive’, rather than as a 'liberal fanatic'.

The point is that unreasonable people believe that they are reasonable.

I read an account of an episode that occurred last week in Cleveland that hinged upon the legal meaning of the word reasonable.   A 16-year-old boy with various allergies joined several friends at an expensive restaurant.  Without providing advance notice to the restaurant, the young man started opening his own food that he had brought with him so that he might safely dine with his friends. The restaurant levied a $15 plating fee, which apparently is their policy and compensates them for the economic loss from a BYOF (Bring Your Own Food) patron.

The agiitated child texted his parents from the table which sparked a crescendo of anger and chaos.  Lawyers became involved in the contretemps, always a sign that tranquility is just around the corner.  Accusations of discrimination were hurled against the restaurant, who ultimately decided to waive the fee as a courtesy.  Everyone involved had a negative experience.  

In my view, all parties fumbled clumsily and repeatedly.  This dispute is similar to the childhood squabbles that we parents have resolved thousands of times in our kitchens and backyards.  Of course, the kid’s parents (or the kid) should have called in advance so the restaurant could be prepared and could also communicate and discuss its BYOF policy, which during this calm converation, might have been waived.  Surely, a phone call between two reasonable people could have resolved this riddle wrapped in a mystery inside an enigma.  (with a nod toward Prime Minister Winston Churchill.)  And, of course, the restaurant might have used a softer touch rather than light a fuse.

All Could Have Been Avoided With a Simple, Old-fashioned Phone Call

The Americans with Disabilities Act (ADA) requires an establishment to make a ‘reasonable’ accommodation to disabled patrons, visitors and clients.  We all support this law which has helped to emancipate and mainstream disabled Americans and others.   A reasonable accommodation does not mean any accommodation, however. 

The ADA would classify a serious allergic reaction as a disability.  Would the law require a restaurant to permit an allergic patron to bring in his own food?  Would a plating fee be permitted or might this be regarded as a discriminatory violation?  What if several diners with allergies came each day packing their own lunch boxes?  Would this be areasonable accomodation from the restaurant's point of view?   Could lactose intolerance or gluten sensitivity be claimed as disabilities?  (Don’t dismiss this possibility of DMC - Disability Mission Creep.  Recall, that a woman recently tried to board an airplane with her comfort hamster to keep her calm!)

I reached out to Mary Vargas, a Washington, D.C. lawyer, who was quoted in the newspaper article, and I am grateful for her patient explanation of some of the relevant legal points.  If there are any legal errors in my analysis in this post, they are mine, not Mary's. While attorneys perform a critical societal role, I suspect that Mary would agree that this issue should have been easily solved internally In a manner that would have satisfied all parties.

It’s not easy to screw up a situation where everyone should have emerged a winner.  But when you season a situation with anger and entitlement, be prepared to take cover.   

How would you have handled this situation if you were the restaurant?  What if you were the kid?  All reasonable responses welcome.

Sunday, February 18, 2018

Overuse of Colonoscopy - Scoping out the Reasons

In our practice we have an open endoscopy system, as do most gastroenterologists. This means that other physicians – or patients themselves – can schedule a procedure with us without seeing us in advance for a consultation.  Of course, we are always pleased to see any of these patients for an office visit in advance, but many patients prefer the convenience of accomplishing the mission in one stop.  This is reasonable for patients who truly need our technical skill more than our medical advice.

Our office screens these procedure requests in advance to verify that no office visit is necessary.  While this process works very well, it is not infallible.  There have been times when a patient arrives to our office poised for a colonoscopy with accompanying medical issues more complex than we had expected.

No vetting procedure is failsafe.  Have you seen the TSA statistics when they are tested in identifying dangerous items hidden in luggage?  Even though our trained personnel vet the procedure candidates, no process can capture every issue.  Also, sometimes patients forget about a medical condition or risk factor or medication, even when questioned about them. 

In addition, there have been occasions when patients arrive prepared for an endoscopic intrusion into their alimentary canal, when the procedure may not be truly indicated.  Keep in mind that the timing of a medical test often depends upon medical judgement.  For example, capable gastroenterologists may have differing opinions on whether a colonoscopy for a particular patient makes sense.

Colonoscopy - It's Alimentary!

Recently, a patient whom I had never met arrived for me to do a colonoscopy.   He had enthusiastically swallowed the liquid dynamite which had the desired cleansing effect.  I presume he took a day off of work and had a driver with him.   My review of his records demonstrated that he was about 2 years too soon for this procedure.  The reason he scheduled the exam is because his prior gastroenterologist’s office sent him a computer-generated letter that he was due for a colonic violation.  In other words, the patient was following his doctor’s advice.  

I speculate that the reason that the computer issued a Notice to Appear was that the prior gastroenterologist experienced a ‘click malfunction’ and clicked Return in 3 Years by error, rather than have correctly requested a Return in 5 Year recall.  While this may sound egregious, ask your doctor how many screw ups he has committed on electronic medical record (EMR) systems.   Indeed, EMR has created a new niche for medical malpractice attorneys to sue physicians and hospitals.

So, I have a patient before me who endured a night of purging, who has missed work and has a driver with him.  But, he is 2 years early.  What should I do?

Sunday, February 11, 2018

Why Did CMS Contact My Office? Medicare Fraud?

In our society, there are absurdities that simply defy reason.  In the past week or so, I have read about an individual who was denied the ‘right’ to bring a peacock on board a plane for comfort.  Just this morning, I read of a women who was cruelly denied to fly with her comfort animal – a hamster.  Readers are invited, if they dare, to use their preferred search engine to discover the tragic denouement regarding this hapless hamster.

'Let me comfort you.' *

If a person needs a peacock, a snake, a pig, a kangaroo or a pterodactyl for airborne support and comfort, then perhaps flying is not for you.  The rest of us have some rights also.  Rent a car.
The medical world has its own exhibits in the Theater of the Absurd.  Here’s our latest performance.
Our medical practice received notice last week from The Centers for Medicare & Medicaid (CMS) that we owed the federal government money.  Apparently, according to federal brain trusts, we had billed a patient under Medicare when we were not entitled to do so.   I’ll let readers choose from the following explanations for the government’s accusation.
  • A random audit demonstrated that we had never seen the patient.
  • The patient was dead at the time we claimed we had treated him.
  • A whistleblower (love that term!) had contacted CMS regarding our fraudulent billing practices.
  • CMS routinely sends out letters like this knowing that some medical practices will simply pay on demand rather than take on the Mother of All Bureaucracies and risk an audit of their billings over the past century.
  • There was an unconscionable error in our electronic claims submission to CMS.   We used the abbreviation Ave. in the patient’s street address in direct violation of CMS policy that dictates that acceptable abbreviations for streets include Dr., Blvd., and Rd, but that Avenue must be spelled out.
Have you made your choice?  I’ll be you are incorrect.  Sure, you may have accumulated a decent measure of knowledge and wisdom in your life, but this is no match against the brainiac feds.  They asserted that we were wrongly paid for medical services because when we claimed to have seen the patient he was already stone cold dead. 

While actual facts support that the patient was quite alive on the encounter date, try explaining that to a federal bureaucrat who believes otherwise.  The patient did, in fact, pass away a couple of weeks ago, months after we saw him.   However, when his death certificate was prepared, the incorrect year of 2017 was inserted instead of the correct year.  The scientific term for this event is call a typographical error.  The government now believed that this patient entered the hereafter a year ago.  Therefore, all social security and Medicare payments made on his behalf last year must be returned to the government.  We should support such fiscal responsibility by our government knowing how wisely they spend our money.

Of course, this will all get straightened out by his poor family, who are still mourning his loss.  They will have fun with lots of phone calls, long wait times, maddening phone menus, letters, forms and maybe even an attorney.  The whole affair has stressed me out.  Where’s my hamster?

Sunday, February 4, 2018

Top CEOs Aim to Disrupt Health Care Market.

Since the infamous memo released this week by the chairman of the House Intelligence Committee has taken up so much oxygen, other newsworthy events were relegated to a lower priority by the media.  In my view, many of these second tier issues deserve Page 1 coverage, but our media in general has decided that potential or actual scandal must lead their coverage. 

Can anyone defend, for example, the prominent and repeated coverage that Stormy Daniels has received?   If CNN received a lurid videotape of Stormy and the president on the same day that North Korea declared that it wanted to denuclearize their country, which would be the lead story?  The editors would be agonizing!

Tell the truth, would your rather be reading about Stormy?*

A bombshell announcement in health care came this week when when 3 titanic corporations stated they aimed to reform health care coverage from within.  Amazon, JPMorgan Chase and Berkshire Hathaway will combine their resources, ingenuity and mammoth leverage to bend the cost and quality curves in opposite directions.  While this will undoubtedly be good news for their million or so employees, will it be good news for the rest of us?  Hard to say.

Amazon inspires a range of emotions in businesses and individuals across the nation.  Their economic triumph is iconic, but this success has had great costs for businesses and individuals across the country.  Have you seen many small hardware stores, book shops, music shops, clothing retailers or any of the small businesses that used to be dotted across the land?   If you want a closer glimpse of the culture of working at Amazon, I suggest that readers view the 2014 documentary Amazon Rising, or peruse a 2017 book called Nomadland, by Jessica Bruder, which chronicles what life is like inside Amazon’s walls.
Just today, I read about an Amazon patent that can track workers' location and even what they are doing with their hands, unwelcome technology for workers who have nasty habits.

I have no doubt that these companies can fashion a health care system that would correct many of the health care system’s deficiencies at large.  Here’s why.
  • They have unlimited cash
  • They are aiming to provide coverage to employed people, and do not need to address the uninsured or unemployed.
  • They have stratospheric expertise in finance and technology.
  • They can exert enormous leverage over insurance companies, hospitals and the pharmaceutical companies. 
  • If they can track where an employee’s hands are, imagine how they can track health care expenditures and outcomes and have incentives in place.
  • They are large and rich enough that they could self-insure their employees, which would whittle away administrative costs. 
What is less clear, is what the effects of this disruption would be to the health care system at large.   Would hospitals and insurance companies and drug companies who are excluded survive?  Would medical costs on the rest of us be raised in order to offset the Trio’s discounts?   Is their true intent, despite their denials, to become a profit center for medical care in the United States?  

I thank readers who have made it this far.  Those who didn’t likely clicked off in search of a morsel on Stormy.  I'm sure that Amazon is tracking them.

*Photo credit:  Glenn Francis
Attribution :  © Glenn Francis,

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