MD Whistleblower

Many patients are confused by the difference between a screening and a diagnostic colonoscopy.  While the actual procedure is the same, the distinction between the two depends on why the colonoscopy is being done.  While you might think that I am wading into a sea of nonsense and absurdity, I am offering you a glimpse of the rational and reasonable world of medical insurance!  Try to follow along. Here’s a primer. A screening exam means that you have no symptoms or relevant laboratory or x-ray abnormalities that justify a colonoscopy.   Consider this to be a simple check-up for your colon.   You are being screened to determine if you have a hidden abnormality or lesion.   Get it?   A diagnostic exam means that the doctor is investigating an existing or suspected abnormality. A medical condition is under consideration and a colonoscopy is advised to investigate.     For example, if you have bowel symptoms, weight loss, blood in t...

2022 is here!   2021 has been an annus horribilis for America and the world.   We have simply not been able to vaccinate and boost ourselves free of the suffocating tentacles of an evolving coronavirus. Here in Ohio and elsewhere COVID-19 tests are endangered species.  Folks spend hours trolling around town hoping that a local pharmacy or a public library will receive a supply at the very moment he or she walks in.  My own inquiries have all yielded the same result – no tests available and no idea if and when they may arrive. Did you watch the ball drop on New Year's Eve? The pandemic, which in any earlier time in our history would likely have drawn us together, is cleaving the nation.   The day before writing this, I saw 2 patients who had elected to shun the vaccine.   I’ll spare readers their explanations which originated in the huge ‘science-free zone’ that tens of millions of Americans inhabit.   And earlier in the week, a medical professio...

A week or so before writing this post, a patient came to my office requesting a colonoscopy.   Nothing newsworthy so far.   An individual wanted a service that our practice routinely provides.   Yet, I was reluctant to accede to her seemingly reasonable request.    She wanted a screening examination of her colon in search of a benefit that humans have pursued for as long as humans have existed – peace of mind.   I have found that ordinary folks are often confused by the meaning of the term screening.   Screening exams can be performed on various organs of the body.   When a physician uses the term screening, it means that the patient is not having any symptoms whatsoever.   For example, if I advise a colonoscopy on a patient who is having rectal bleeding or diarrhea, this is considered a diagnostic exam, not a screening test.     "You're paying the bill?  I'll have the steak!" Why does this matter?  ...

Opaque:   adjective, not able to be seen through; not transparent Medical pricing is beyond opaque.   It’s a riddle wrapped in a mystery inside an enigma.   Many readers will recognize that this clever phrase is not my own. Throughout my career, I have been unable to provide an accurate answer to the perennial inquiry, how much does a colonoscopy cost?   Patients, of course, find this to be baffling.   This ignorance is certainly not restricted to my specialty of gastroenterology.   Does it make sense, for example, that the same medication may have wildly different pricing at different pharmacies or in different cities?    In contrast, we would expect to find a similar price for a gallon of milk among supermarkets.   My strong suspicion is that seemingly irrational, inflated and complex medical pricing is all by design to serve those on the billing end – hospitals, pharmaceutical companies and pharmacy benefit managers. ...

I just read of a a jury award in excess of $25 million against an insurance company who denied a recommended cancer treatment to a patient who ultimately died.   I do not wish to review here the particulars of this case, and admit that my knowledge is limited by one news report that I read earlier today.   While I will not invoke the ubiquitous phrase FAKE NEWS, I always bring some measure of skepticism to various news sources, even those who enjoy excellent reputations.   The Olde Town Crier Always Told the Truth But this jury case raises an issue that physicians and patients wrestle with regularly. The physician prescribes a medication or recommends a treatment. The insurance company denies coverage for the recommendation. Sometimes, the reason for the denial is entirely reasonable.   For example, if an insurance policy restricts a patient to a network of physicians, the company will deny coverage if the patient wants to seek care o...

A few weeks ago, I saw a patient with some gastro issues.  So far, nothing newsworthy here since I am a gastroenterologist.  I ordered a CAT scan colonography, a special CAT scan that is designed to view the colon in detail.  It’s the CAT scan version of a colonoscopy.  Why didn’t I simply perform a colonoscopy, which, unlike a CAT scan, would contribute to the Whistleblower Retirement Fund?  That’s an easy one.  Care to take a guess? The patient refused to undergo a colonoscopy. The patient had no insurance and I don’t work for free. The patient is a ‘cat lady’ and loves all things CAT. The CAT scan was a better tool than colonoscopy to explain her symptoms. Playing Cat & Mouse with Insurance Companies I expect that my discerning readers can identify the correct choice.  I ordered the CAT scan because it was the best option for the patient, which the insurance company summarily denied.  I called the insurance company (alway...

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 c...

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 th...

Most of us do not know the basics of economics, although we should.  It impacts every one of us every day that we are alive.  Yet, for most of us, once we get beyond the law of supply and demand, our knowledge of the subject starts to vaporize.  I can't explain fiscal or monetary policy.  While I regard economics as a science, it seems that experts routinely interpret data differently, which confuses beginners like me.  What are novices to think when one expert hails our continued job gains while another laments our anemic recovery? The Puppeteers I have a general feel for market forces.  If consumer demand for an item rises, then I will expect to pay more.  If I want to make a purchase at an independent appliance store, then I will expect to pay more in return for superior customer service.  If the item is manufactured in China, it will likely cost me less as this factory is not burdened with worker protections, environmental regulatio...

Most of us are skeptical that insurance companies are devoted to our health.  Answer the following question.  Do you think your insurance company is more interested in your health or in controlling costs?  Pretty tough question, huh? There is a tension between medical quality and medical costs.  If we had a system that offered perfect quality, it would be unaffordable.  If we imposed rigid cost controls, then medical quality would be compromised.  Where do we draw the line?  It is clear to most of us that the medical industrial complex is riddled with waste.  Keep in mind that one man’s medical waste is another man’s income.  For example, physicians define waste as excessive charges by hospitals.  Government officials define waste as excessively high drug prices.  Patients define waste as high co-pays and deductibles.  Drug companies define waste as outrageous legal expenses to get drugs to market and to defend against...

Cleveland took a major economic hit a few years back when United Airlines cut most of its flights from our city.  An airport is the heart of a metropolis.  Lack of their direct flights means that business meetings, leisure travel, conventions and trade shows will likely opt for more convenient locales. This was a business decision for United which I am sure was rational.  Nevertheless, their gain was our loss. As a result, we have had several low cost carriers who have swooped in to gain market share.  We have Frontier, Spirit, JetBlue and now Allegiant.  Not a day goes by that I don’t receive an e-mail blast from one of them announcing fares so low that it seems simply not possible.  Many of the flights’ stated fares are less than it would cost me to drive to the destinations.  How do they do it? Of course, the fare price that is stated is not what you will pay.  The total cost of your flight has been fractionated resulting in an a la carte p...

Physicians are expected to be hostile to insurance companies.  Indeed, a prior Whistleblower post directed arrows in their direction.  They are an easy target, often vilified for their greed and perceived indifference toward those they insure.  Ask most of us if we think insurance companies favor profits over patients, and most of us will respond that profits prevail. Insurance companies are businesses, not charitable undertakings.  Sure, we all like free stuff.  Or, if it’s not free, we prefer that someone else pays for it.  We are outraged at the costs of chemotherapy, hepatitis C treatment and biologic treatments such as Humira and Remicade, leaving aside the zillions of dollars it takes to research, develop, manufacture, market and monitor innovative new drugs.  We want to drive a Cadillac, but only pay for a Chevy. We want to pay for this... ...and drive this. No person, business or organization is wrong all of the time....

May I whine for a few sentences please?  My staff and I have a high-deductible medical insurance plan.  As the costs of coverage increased each year, we had to find a product that we could afford for our small private practice.  As any small business owner knows, margins are tight, revenue is declining and expenses inexorably rise.  And physicians, unlike other retailers, cannot raise our fees.  Would you want to invest in a company with this business model?  If so, then contact me directly. High-deductibles health plans are painful for consumers.  The first several thousand dollars are borne by the individual.  While we have an HSA (Health Savings Account), which confers a tax advantage, it is still painful to fork over wads of one's wages to cover medical expenses.  Isn’t that what medical insurance is supposed to do? Would we expect fire insurance to cover only part of our house if it burned down? Will fire insurance cover a...

Despite our professed values, everything has a price. We value life, but our society is unwilling to lower the highway speed limit to 40 mph, which would surely save lives.  The price of our collective inconvenience and economic impact is too high. Lower Speed Limit and Save Lives? We leave no soldier on the battlefield, but this military value cannot be viewed in isolation.  We are told this week by our commander-in-chief and his acolytes that rescuing a captured soldier is worthy regardless of the price.  We are told that negotiating with terrorists, breaking the law by not notifying congress and the release of 5 hardened Taliban detainees is a reasonable price for the return of a captured sergeant.    I feel that the price exacted was too high, although admittedly my view would be different if the sergeant were in my family.  For those who argue that no price is too high to rescue one of our own, should we have surrendered to the Nazi...

I’m a physician and I’m against wellness.  Let me explain. Wellness is the new health mantra that has much more to do with marketing than with evidence-based medicine.  Wellness institutions and practitioners are omnipresent promising benefits that are often untested or rejected scientifically.   Hospitals that years ago would have shunned new age healing arts, now offer yoga, meditation, Reiki and massotherapy.  Do they do so because they have had a Damascus Road experience and now believe that these techniques are effective?  Guess again. Paul's Conversion on the Damascus Road Wellness is no longer restricted to medical campuses, costly weekend retreats for emotional and physical catharses and ubiquitous yoga storefronts.  Wellness is now championed by corporate America.   Business leaders argue that keeping employees well is not only a demonstration of good corporate citizenship, but is also good business.   Heal...

I’m a physician and I’m against wellness.  Let me explain. Wellness is the new health mantra that has much more to do with marketing than with evidence-based medicine.  Wellness institutions and practitioners are omnipresent promising benefits that are often untested or rejected scientifically.   Hospitals that years ago would have shunned new age healing arts, now offer yoga, meditation, Reiki and massotherapy.  Do they do so because they have had a Damascus Road experience and now believe that these techniques are effective?  Guess again. Ahead of His Wellness Time? 100 Years Ago Metchnikoff Suggests Probiotics  Wellness is no longer restricted to medical campuses, costly weekend retreats for emotional and physical catharses and ubiquitous yoga storefronts.  Wellness is now championed by corporate America.   Business leaders argue that keeping employees well is not only a demonstration of good corporate citizenship, bu...

Though I have been accused by various commenters as protecting my own specialty when I point out excesses, flaws and conflicts of interest in the medical profession, this accusation would be handily dismantled after a fair reading of prior posts.  Indeed, my own specialty of gastroenterology and my own medical practice has felt the effects of the honed Whistleblower scalpel.   If an individual or an institution will not willingly engage in self-criticism, then it creates a credibility gap that may be impossible to bridge.  If you want a seat at the table, then arrive exposed and humble. My Preferred Instruments A study was published in the prestigious medical journal JAMA, the Journal of the American Medical Association in April 2013 publishing what we have known for decades: hospitals make more money when medical errors are committed.   As an aside, I have much more respect for JAMA than I do for the AMA , but I’ll resist the strong temptation ...

Truth is more absurd than fiction.  Mayor Michael Bloomberg’s wacky ban on certain sizes of sugary beverages, a scheme which was riddled with inconsistencies and exceptions, was properly squashed by a New York judge.  The mayor’s next play was to order all establishments that sell cigarettes to hide them from patrons.  I hope that this policy is examined in the same courtroom that ruled that the leaky soda ban was illegal.  Is this guy a mayor or an emperor?  Who can legitimately defend the government dictating to private businesses how they can display legal products to its customers?  Where would candy, potato chips and other poisonous snack foods be sequestered?  Speaking of sequestration, which the president warned would crush the country, the earth still rotates, the sun rises in the morning and congress has a 15% approval rating.  In other words, not much has changed.  We learned that there was not enough cash to fund White Hou...