MD Whistleblower

“Does my insurance cover this?” I cannot calculate how often a patient poses this inquiry to me assuming wrongly that I have expertise in the insurance and reimbursement aspects of medicine.   If I – a gastroenterologist –  do not even know how much a colonoscopy costs, it is unlikely that I can speak with authority to a patient’s general insurance coverage issues. Of course, patients assume that we physicians have an expansive expertise of the medical universe, both in the business and the practice of medicine.   Often, friends and acquaintances will informally present a medical issue for my consideration that is wildly beyond my limited specialty knowledge, and yet they expect an informed opinion.   “Hey, aren’t you a doctor?”    Yes I am, but if you think a gastroenterologist – a Colonoscopy crusader – can advise you on your upcoming hip surgery, psoriasis treatment retinal detachment, or cardiac rehab, think again.   And, I likely know m...

Our practice will no longer see nursing home patients in our office.  If a nursing home patient is already established with us, then we will see him; but, we have decided not to accept new patients. Of course, we believe that these individuals – like the rest of us – deserve medical care.  This demographic not only deserves care, but has the greatest need for medical services.  Our practice will see every person who wants to see us, including the uninsured.  Why, then, would a welcoming practice like ours close our door to new nursing home patients?  We just couldn’t take it anymore. These patients, who often have serious physical and mental challenges, would typically arrive to our office accompanied by a driver, who naturally has no medical knowledge.  The patient often had no awareness of the reason for the visit.  The ‘medical record’ consisted of a nearly indecipherable list of medications of uncertain accuracy.  Typically, no reaso...

One thing that gastroenterologists know about is stool.   But, I’m not referring to that kind of stool in this post.   Follow along . When we do a colonoscopy, for example, we are relying upon stool, or more accurately a stool, as in a three-legged stool.    This metaphor illustrates that the three legs must be equally strong or the stool will not stand.   The three pillars of support that a colonoscopist needs include: Knowledge Skill Judgment All 3 Legs Needed As the gastroenterologist guides the colonoscope along your long and winding colon, he may discover a lesion.    He needs knowledge to identify the intruder.   Is it a cancer or a benign polyp?   Could it be Crohn’s disease or some other form of colitis?   Is it a normal structure that simply appears atypical? Obviously, the more experienced the gastroenterologist is, the more likely he will be able to identify the abnormality. But, every gastroenterolo...

We do most of our colonoscopies in our ambulatory surgery center (ASC), which is attached to our office.  We are proud of the work that we and our staff do every day and are grateful for the outstanding feedback that we consistently receive from our patients.  Some insurance companies will not cover procedures in our ASC so these patients must get ‘scoped’ at the hospital instead.  For many of them, this means required blood tests a few days in advance of the procedure, which we would not have required for an ASC procedure.   On the procedure day, the patient and the driver will enjoy spending hours in the hospital for parking, checking in, interviews with various medical personnel, the procedure and the recovery period.  And, since it is a hospital, delays are inevitable.  Not only does this experience take hours longer than it should, but we are mystified that an insurance company would take on the expense for a hospital test that we could do more e...

Last week, I related a vignette where a routine medication refill was denied by a patient's new insurance company.  The patient had developed symptoms 2 weeks after he ran out of the medication. I surmise that 100% of gastroenterologists surveyed would have agreed that refilling the medication was the next step. So, even though the best medical option was to refill the medicine that we know has worked, the new insurance company won’t cover it and the patient cannot afford to pay retail for the drug.  (As a separate point, I challenge anyone including those with PhD's in economics to explain retail drug pricing.)   The patient did his best to navigate the insurance company’s website and found a colitis medicine that is covered, but it is medically inferior.   Should we just cave and prescribe it to save money and a hassle?  Is this an issue that we want on our sick patients' agendas?  How would you like to face surgery and be told that the newer cla...

A patient came to see me recently with a suspicion that his colitis was recurring.     In general terms, colitis describes a condition when the large intestine is inflamed or irritated.   Typical symptoms are diarrhea, abdominal cramping and rectal bleeding.   This patient was concerned as his last 3 bowel movements were diarrhea.   He had been on a medicine called mesalamine, a safe and effective treatment for colitis, but he ran out of it 2 weeks ago.   While he was taking the medicine, he felt perfectly well.   So, his bowel change developed 2 weeks after he ran out of his medicine.   For readers who like to play doctor, choose among the following options: Schedule an urgent colonoscopy to verify that nothing has changed since his colonoscopy 6 months ago. Observe the patient without any treatment to give him time to heal himself. Recommend probiotics to restore his digestive health. Refill the mesalamine at his usual dosage. Reque...

First there was Bitcoin, a cryptocurrency that utilizes blockchain, a decentralized system of data collection and transactions that we are told will defy hacking.   (Wasn’t the Titanic said to be unsinkable?)    We read that cryptocurrency and other blockchain functions will be a societal gamechanger, much like the internet was when Al Gore invented it some years ago. My own state of Ohio will now accept Bitcoin as payment for commercial taxes.   And, of course, there are many other cryptocurrencies mushrooming around us.   In my life, many innovations seem to be solutions in search of problems.   I don’t find my current methods of transacting business – cash and credit cards – to be so onerous that I am screaming for a new way to conduct commerce.   But, I will admit that I have security concerns about my credit card number and other highly personal data being ‘safely stored’ all over the internet.   Some years ago, I enjoyed the thril...