Wednesday, February 18, 2009

Emergency Primary Care (Not)

I'm sorry, I can't be bothered to figure out why doctor's clinics are no longer allowed to have on-site lab and Xray. The "Stark" law comes to mind but I may be wrong. And today I witnessed the combination of poor primary care skills with the heavy hand of government which resulted in the near death of a patient. Here's what happened.

A little old man (LOM) went in to his physician's office yesterday for a routine checkup. Good enough. He 'wasn't felling well' and the doc took him off one of his anti-hypertensive meds. Today he feels worse and WOW! the labs that were drawn yesterday in the office were resulted today and showed renal failure and high potassium.

When the patient got to us he was 'almost dead' with a pulse of 30 and high, peaked T-waves on his EKG which made me convinced that the high potassium level was a real finding (it's often due to a lab error). So we did our stuff and brought him back from the precipice. I called his doc and asked why the labs took so long to be resulted and he said, "We have to send out all labs".

So this adds another pressure point to ER medicine. People know that when they go to their primary physician that they will not get answers that day. In this case it was almost a day late and a dollar short. Thanks Uncle Sam, you sure have prevented primary care physicians by overusing lab services and committing fraud by over-ordering tests. Good job. Bunch of freaking putzes.


  1. That patient's lucky, before too long the only treatment available's gonna be hyperventilation... Most of the offices I work at have X-ray...Labs restricted to Rapid Streps, Dip Stick Urines, and glucose...

  2. We have just decided to turn off the xray system in our practice. We were going to run it break even but then we considered the laibility of taking an xray to rule out one thing and not catching some other condition which we are not trained to find. The liability is too much to even run the xray system at no profit.

  3. I remember when I needed my blood drawn many years ago and was shocked when the doc handed me a form and told me to go to the lab. Lab? I asked. Don't you guys do this anymore? Nope, sez he. Insurance carriers wouldn't pay for him to run his own lab anymore.

    Same thing happened when I thought my daughter broke her arm. Went to the doc, and he gave me the dreaded form. WTF, doc? I've already blown an hour waiting for you. Can't you just x-ray it here? Nope, sez he. Insurance carriers won't pay for his x-rays.


  4. lynn... such language!!! and i consider you to be a fine lady in every sense of the word. do you talk to your mother with that mouth?

    and here writ small is the end result of liberal political policies and thought... folks who have never had to work under a system created by folks like them, or folks who thrive in such a system are calling the shots from long distance.

    the best way to succeed in america has always been to work hard and study and work harder and then succeed. but in the last 40 years or so it has become dangerous to be successful unless you are a celebrity or athlete. might as well paint a target on your back and run through the woods.

    the level of class envy and hate is high, and it comes from the left almost exclusively. in the present case physicians had figured out how to make money not just on seeing patients but also on lab and Xrays done on site. heaven forbid! i'm sure there was fraud comitted by some physicians in this regard but that's why we have laws against fraud.

    instead of enforcing current laws, the folks who wield power with clipboards and pens crushed it all to 'even it out'. and because of this patients die and this particular patient was lucky he didn't. stupid fucking fuckstick evil bastards and that's not ad hominem, it's just the truth.

  5. Disgruntled Internist6:52 AM, February 20, 2009

    I'm not the least surprised. Insurances won't pay for me to run anything but a UA and a rapid strep; some insurances won't even pay me to do even a UA. I have to send my labs out. I can't do them for free. I'm not a charity. I am in primary care and it's all I can do to put hamburger helper instead of macaroni and cheese on the table to feed my rag-clad and emaciated family.

    We have two labs here in town. Which one we send the blood to depends on the patient's insurance. One of the labs will send a partial report; the other lab won't send results until all the labs ordered have been completed, which can take a while.

    I saw a young woman in my office because of recurrent iritis. I sent off some rheumatologic tests--ANA profile and CH50--and they took a while. Of course, fate would give her the insurance not only wouldn't pay me to run a UA in my office, but also required using the slow lab.

    IT WAS 8 F'ING DAYS before I learned she had microscopic hematuria and a creatinine of 2.4. This was a jump from 0.8 from last summer. Of course, we call her up and have her come in for a stat creatinine (which can be ordered from even the slow lab if you are in a hurry). I didn't get the so-called stat result back until well after my office closed and because things were worse, off she went to the ER and was admitted, as you say, "a day late and a dollar short."

    We in primary care do our utmost to keep people out of the ER--honestly, we do. You think my patients like it when they have to pay a $100 co-pay and wait 5 hours to see you? But events like this are not uncommon.

    It's free-market medicine that got us into this mess, by the way: Insurance companies contracting to the lowest bidding labs so they can pay their CEO's millions in bonuses each year while paying their contracted physicians just-above-subsistance reimbursement rates after denying my claim twice over a six month period, requiring my billing folks to resubmit the claim over and over before they pay it.

    At least with Medicaid I can do a UA in my office, choose to use the fast lab and they pay me by automatic deposit within a week of me filing a claim. You can voice your opinions about "Obamacare" all you want, but for us primary care docs in cities with nearly 100% managed-care penetration, we wish we had a single-payer, universal health-care system. At least internists in England and Canada don't have to shop at the Goodwill on 1/2 price day for their kids' clothes. Thank God I have a 30-year fixed-rate mortgage on a modest home in a working class neighborhood and drive the cheapest car Saturn manufactures.

    You think I'm joking?

  6. dear disgruntled internist,

    no, i do not think you are joking. that's the whole point of the post. i am wondering as an aside how one becomes 'gruntled' if one is 'disgruntled' but that's just me.

    i do take exception to the statement you make that free market medicine is causing your problems. what free market? you are prohibited to have onsite lab and Xray lest you make too much money or 'self refer' too much and commit fraud. the losers are the patients like the one i describe above or the one you describe in your comment. dentists have a free market and they are doing fine. there are lots of folks with dental problems that 'can't afford a dentist' but i have yet to meet one who will surrender their cigarettes or cell phone and make payments on a scheduled basis for their dental care... they simply come to me for penicillin and lortab and an occasional trip to the OR for an abscess that has extended up into the facial fascia.

    i do not understand why you think the government bureaucracy, which has created your problem, is somehow the solution. why not take the cuffs off the docs and let the competition begin? the reason is that we are lurching towards socialism, so much so that VLADIMIR FUKCING PUTIN warned Obama yesterday to not go the socialist/communist route as it 'ruined his country'. the chicoms said the same. wake up people, the fox is in the henhouse and he knows what he's doing. mediocrity for all. misery for all. good job obama supporters!

  7. Okay...I am confused. The government isn't causing the labs and the x-rays to be was the insurance companies. And those damn managed care companies....created by the damn CONSERVATIVE Nixon. Hm......

    I understand your point....but please get your fucking politics straight

  8. Ladyk73, The private insurance companies will only do as medicare or medicaid does...
    So if those government agencies won't pay for certain tests, then the privates won't also.
    Also, I think this is an example of a very strict interpretation of the Stark law by the feds.

  9. dear 'lady k 73',

    you are right... it was nixon.

    for those of you who wonder if it may not have been nixon look at the widipedia, 'unbiased' summary of the stark law here. for a really befuddled (ie reasonable) summary from the American Academy of Family Practitioners see here, and see to what unbelievable lengths these physicians have to go to to be sure they aren't in contravention of said law.

    to translate, there is a law commonly referred to as 'the stark law' (named after representative fortney 'pete' stark, democrat, california) that is so complicated and intricate (not because of how brilliantly it was written, but because it was written by a dunderhead), that most primary care physicians can not be bothered to spend the time or money to hire the attorneys to interpret it for them to see if they can have a machine in their clinics to measure a complete blood count or renal panel or snap a quick Xray.

    here is a little legalese that 'explains' changes to the stark law. have fun reading it then tell me if i can do these labs in my office in town, or whether i have to send the labs to an outside facility to avoid a $50k penalty (whether or not my patient's life depends on it). to be sure, we HAVE cut down on kickbacks, you tell me at what cost.

  10. sorry, missed the link for the legal mumbo jumbo... enjoy...

  11. Just do what the PCPs in my city do. Call an ambulance. Headache after trauma? Stop touching the patient! Call an ambulance immediately? Chest wall tenderness? Cease all patient care! Call an ambulance!

    I guess common sense is out the fucking window.

  12. Are laws like this one ever reviewed to assess validity in the modern time? Not that Nixon is old. He's just what I would call a DLOM. D meaning dirty.

  13. I believe that CLIA a law regarding lab standards was passed in the early 1980s as a way of standardizing and 'improving' quality of lab results. The cost of certifying individual labs was very high, and physicians could not be paid unless they were CLIA certified. That led to the demise of the office 'lab'...It also increased the cost and inconvenience of having labs done on patients.

  14. in the world do you associate Nixon as a DLOM and the validity of old laws in modern times!??!!?!?
    Oh and by the way; Nixon died in April of 1994.
    As to the validity of old laws in modern times. How about the law that stated somebody carrying a red flag had to walk in front of those new fangled automobiles. Or in Arizona where you cannot tickle a women's nose with a feather. Or...well you get the idea.
    Some old laws are in dire need of review BUT; they will never get reviewed until somebody squacks enough.
    It seems to me that bloggers are usually on the point when it comes to starting a groundswell of change. They usually are the ones that point out the obvious and then people like you take the bull by the horns and talk to the lawmakers.
    Yes this Stark law needs to be changed, so start the ball rolling folks!!!!

  15. docs CAN'T legally do labs in their office? My pediatrician did a CBC in his office just three years ago when one of my kids was petechiating. Was that illegal?

  16. dear webhill,

    i don't think it's illegal per se, but many docs have chosen to forego the incredible amount of money and paper it takes to get an on site lab certified by CLIA. docs? 'cat?