Sunday, May 24, 2009

How Will Rationing Occur?

Dr JN sends this story, he is a board certified Neurologist, and had this experience recently with failure to get approval for an MRI from some flunky on the phone. This is already happening.

44 year old Rwandan woman, treated for 3 years with good control of HIV develops sudden onset of back pain with radiation down both legs Right >Left in March. No clear deficit, but interpreter services via her sister are only fair. AT&T phone interpreter worthless as usual. Bed rest and analgesics don't work. MRI ordered 4/8/09.

Rejected by Medicaid. "Not enough documentation, does not meet criteria" Call the MD line. Get a callback from Dr. X., who claims that he is a neurologist.

"You're just too lazy to prescribe Advil, is that it? Or maybe you're just a chickenshit who doesn't want to get sued. You know it's nothing". Refused. 33 years out of school, no one has ever talked to me like that, least of all another physician.

Resubmitted with extensive documentation of infection risk in African patient with compromised cellular immunity. Rejected again.

Called again. Now they say, if I send her to a "specialist" and the "specialist" orders the MRI they'll do it. The truth comes out - I AM a specialist.

Finally, 5 weeks later, it's done. BIG L3-4-5 epidural abscess, likely TB, cultures pending.


  1. I think I need an MRI...Cant...See...Post....


  2. I'm a neurologist, too, and I deal with this crap all the time.

    One of my patients is a physician who works for one of these companies as a reviewer, deciding who does (or doesn't) get an MRI. HIS OWN COMPANY refused to pay for his MRI, so he paid out of pocket himself.

    He had an aneurysm as it turned out.

  3. I didn't know that Dr. X calls people claiming he's a neurologist...just to deny an MRI and talk shit to another physician. I always thought Dr. X was a dentist(and spy)...but who knows.

  4. Dude...I thought DRX was a friend. A fellow comrade-in-arms

  5. Hey you have great blog here im definitely going to bookmark you!

  6. You got talked to like that ?!?!!!? Who do you go to, to report the M$#@^therf*%&@r?


  7. Used to run into that Catch-22 in the Navy... only the specialist can order the MRI... 8 Months to see the specialist unless you call em and get talked to like you did...
    For some reason Neurologists used to be the they were payin for the friggin MRI outta their own pocket... but they're the first to point fingers when the guy shows up in the ER with a tumor induced seizure...

  8. I work in the socialized medical sphere of Australia. Your problem is not rationing, it is Medicaid. It sounds like the perfectly functioning insurance company model is not so effective either.

    Not that our system is perfect, but it seems to me that your system is based on the ability to pay, so if you have more money then you get the "best" (or is it the most expensive?) treatment.

  9. I would send an official complaint letter about the verbal abuse you suffered from the "reviewer".

  10. dr boop, no, because of EMTALA you get the best regardless of your ability to pay, and this has made the efficient distribution of resources impossible. funny, for a minute there it seemed you were suggesting that one's ability to receive care should have nothing to do with one's ability to pay, but of course that would be enshrining health care as a right and require, well, a large centralized bureaucracy and administration, oh, and rationing.

  11. Hahahahahaha.

    It's not rationing, it's UI - no, no, the other one: utilization review. It's been going on for decades and it's not a sign/symptom of socialism or a democrat majority in congress, or because there is a black Marxist muslim in the White House.

    But I agree - this thing would never happen with private industry insurance companies.

    Wait a minute....

  12. Boop, I'm intrigued. I wasn't aware that Aussies had socialized medicine, so I will take your word for it.

    You say our problem isn't ratoning, but Medicare, as if there are far more perfect models of bureaucratized delivery of medicine. Please tell us how your more ideal system delivers all levels of all service to all patients at all times. Don't think we won't check up on any facts you cite to support your position.

    Don't run, please stay and play!

    (on a fun note, my first attempt to get past the comment verifier was "brisall"!

  13. nice try anonymous,
    the private insurance companies and the taxpayer are now footing the bill for some who are unable and or incapable of paying for insurance and a HUGE NUMBER (the caps help emphasize the sheer HUGENESS of the number) of freeloaders. yes, freeloaders. citizens and non citizens using the ER for everything from their stubbed toe to their end stage COPD knowing they will never pay a dime because we can not turn any single person away, ever.

    private insurance companies are in business to make money. shocker. and, again, forgive me for stating the obvious but there are some who may not understand how markets work, they can't make money if they can not turn people away. when they DO make money rates go down for their customers and the business can grow and insure more people who are higher risk. private insurers are now the safety net and it may make folks happy to stick it to them but to pretend that the government can run the system better than the private insurers is to betray blindness to reasoning and history.

  14. I know that I am throwing large rocks in the glasshouse, but I can't help myself:-

    Down here, in the backwaters of Australia, that patient would have got at least a CT scan very quickly, and if a neurologist had decreed it, then an MRI, too. Although, truth be known, I am sure that there is a waiting period for outpatient MRI's as a public patient(those orthopods would scan brains as well as every joint if they could identify them). Public patients get these things for free.

    Inpatient MRI is rationed by clinical need. Acute spinal lesions with neurological signs do not require as much begging by us junior staff to the radiologist consultants.

    You can get an MRI as an outpatient, much faster if you want to pay extra.

    And yes, we have freeloaders, too, as do all systems where there is no money exchange at point of contact involved. But those upstanding insurance paying patients don't give a co payment either, do they? it is not their own money, it is some insurance company's money they spend.

  15. " But those upstanding insurance paying patients don't give a co payment either, do they? it is not their own money, it is some insurance company's money they spend."

    Yes, I do. I pay 500.00 a week for a family of 4 (no health problems). An office visit co-pay for a physician is 40.00 and an ER visit is 175.00.

  16. "nice try anonymous,
    the private insurance companies and the taxpayer are now footing the bill for ...[SNIP!]"

    But I thought this post was about rationing health care? And that it had already begun? And to "prove" your point you describe a snotty and irritating utilization review encounter. You then pretend that the problem all hinges on the Federal system of medicaid as if this never happens with private insurers.

    That simply isn't reality.

  17. dear dr boop,
    please throw the stones. i am particularly interested in the Australian system as i have heard, and i am hoping you will clarify, that it is a 'two tiered system' in that everyone who is a citizen of Australia gets their basic health care as a government benefit but that one may supplement this basic care by buying private insurance. is this true?

    a few quibbles with your points. the health care provided by the government of Australia to its citizens is not 'free', it is payed for by taxation but i understand that this point is lost on many, especially those who are recipients of their neighbor's largesse.

    no doubt you are correct about orthopods but here we get into the sticky question of whether XRays are cost efficient when compared with scans. i don't know the answer but i do believe that in the ER we order too many scans as seen through the retrospectoscope, which is always 20/20.

    we have the same de facto arrangement with MRIs... it's hard for me to get one from the ER but i CAN get one for possible true medical emergencies (cauda equina syndrome and a few others). it is also true that you can get an MRI TODAY if you will pay for it or have good insurance. hell, people line up to pay $300 cash for the 'full body CT scan' to 'check and see if you have heart disease'. suckers.

    i think 'pink' has answered your questions about insurance and copays and there is another big difference between our two countries (again i stand to be corrected), EMTALA, the law that i rail against every other day has had the effect of mandating free care for all IN THE ER only and this includes illegal aliens and anyone who is breathing. this news is on the street and many who can well afford insurance have simply chosen to 'go naked' and use the ER for primary care. we collect about 30 cents on the dollar and this cost is simply shifted to private insurers and taxpayers. it's why our insurance is so expensive and why ERs are closing all over our country.

    finally, i have two friends who served as physicians in iraq and both said the Aussie docs were top notch. hope you continue to visit and comment.

    and anonymous,
    the whole reason that private insurers now HAVE 'snotty and irritating utilization reviewers' is because the government has declared ER care 'free' and they are helping foot the bill. the idea of course is to drive them out of business so the government can ride in and make our private hospital systems just as wonderful as the VA, where everyone except the physicians and nurses go home every day at five and don't work holidays or weekends. there is precious little difference between private insurance and government now and this has decreased quality of care for all. personally i look forward to the day that i work regular hours and have no incentive to go the extra mile, but this is for selfish reasons. it will be hell for patients. this is reality.

  18. Pink, you wrote:-
    "Yes, I do. I pay 500.00 a week for a family of 4 (no health problems). An office visit co-pay for a physician is 40.00 and an ER visit is 175.00."

    That is a frightening amount of money.

    Family physicians can charge $60 for a standard consultation in the better off areas; about 20 minute appointments. The government rebate is about $33 or maybe a bit more; (I haven't done that for a long time).

    In the less well off areas, those doctors who charge the $60 lose all their patients. You need to bulk bill to get any work; ie only charge the government rebate of $33, without any co-payment. This leads to problems with overservicing by the less ethical doctors to try to make money, and frustration by the good ones.

    Public hospital ER presentation is free if somewhat slow. Private hospital ED exists in some places but is not common.

    Dear dr911

    In Australia, we do indeed have a two tiered system. We have a government funded Medicare system which was designed as a universal health care system, and not as a safety net. The official levy is 1.5% of annual income, with an extra 1% for high income earners (more than $70 000 income per annum for singles, and $140 000 for couples). But really, the money just comes out of general revenue.

    Before Medicare arrived in 1984, most people only saw doctors if they had lots of money or were so sick that they would hope someone would take pity on them and treat them for reduced cost or for free. I think that most doctors just wrote off a lot of bad debt.

    So, historically, we had a private system. You can buy private health insurance with a large government funded incentive.

    Our family "hospital only" cover costs about $3500 per year. That will buy you choice of doctor when admitted to hospital, which is really only useful if you know the system. It also gets you a faster operation if you need a semi elective procedure such as hip replacement or cataract surgery, which can be life changing but is not medically urgent.

    With private insurance, you can go to a private hospital, but in reality, if you are really sick, then the public system with the drones of surgical and physician trainees is the best place to be.

    You can't be too unstable if you want to go to the private hospital. We used to try to explain to the patients, but ultimately, my cardiology boss would need to tell them.

    Private insurance will get you a pacemaker and a cardiac bypass faster, say tomorrow rather than next week. The food is much nicer in the private, and there are more single rooms, the surgeon is qualified and not a trainee, but the medical care is probably superior in the public. I should qualify this by referring only to the major teaching hospital I used to work at.

  19. dear dr boop,

    then it seems that what you have is what we had prior to 1986 and though it was not perfect, it was much better for all than what we have now. what we have now incentivizes people to abuse the system and to drop their insurance. i wonder, how are american ER docs received in australia? you guys seem to have maneuvered around the political correctness plague that has devastated our society. and besided that, i love aussie rules football and aussie beer (not the knock off Fosters they sell here). the only thing you guys don't have is mountains over 6000 ft but i could fly to NZ for that no?

  20. Disgruntled Internist5:59 AM, May 29, 2009

    You need to report Dr. X to the medical board. Seriously.

  21. Dear 911Doc,
    After reading many posts here, at WhiteCoatRants, Nurse K's, Happy Hospitalist, and other medblogs your point that the unfunded mandate and enormous entitlement that is EMTALA is at the root of many problems from cost inflation, to MD attrition, to overcrowding at EDs is very clear. Repealing EMTALA would obviously be politically difficult. I was wondering though, if you or others on this blog had specific suggestions on how to amend the statute (as in, specific fixes for the legislative language) so as to at least reduce ED abuse and focus it only on the original problem it was meant to solve, which is avoiding patient dumping. I ask not because I think that amending the statute would be a better approach than repealing it altogether, but rather bc it would be more politically achievable. Perhaps amending subpart (e)(1) which is the definition of emergency medical condition may be a way to get at this. If so then do you have thoughts on how to fix this definition? The current legislative language is accessible at the top link at
    I believe I also read either here or at Happy's another suggestion which was to eliminate liability for failure to diagnose. Any thoughts on legislative language that would achieve this?
    Thank you for your time and thoughts.

  22. Dear dr911,

    We love American ER docs. There is one who works at the district hospital where I am, as one of the bosses. He seems to like it, but doesn't seem to ever be on during my days.

    It is very quiet, here. We are on trauma bypass so there is rarely much exciting in an ER sense, just the usual ectopics and AAA's acute myocardial infarcts are about as exciting as it gets. Very, very rarely a knifing, more usually work related trauma or pissed, fell over. I have never seen gunshot wounds.

    In the less salubrious areas, knifings are more common.

    There was a funny story about an ER doctor who came from Washington DC. She started work in Adelaide, which is even quieter than Sydney. When it was time to go home, she asked security for an escort; they were a bit confused. "What for?" It took some convincing on their part that the car park was safe and that she could proceed unmolestsed and alone at night, to her car.

    Tertiary referral hospitals are more fun for ER guys. MVA's and sicker dialysis and transplant patients, but more politics, and patient turfing.

    If you are still unattached, working for the retrieval service and going in the helicopter is meant to be fun, or a rural stint doing Royal Flying Doctor stuff is also good.

    We have only hills here. There is lots of hiking, through wilderness, but no mountaineering. New Zealand is beautiful and cold enough for ice picks and hypothermia. They have a few mountains but they aren't very big.

    Come visit; you must have some friends here.

  23. dr boop,
    not only do i have friends down under, i have family. australia will take a lot of the professional talent from the US if we continue towards socialism. also, are you 'dr boop' because you are a pulmonologist?

    dear friendindc,

    any republican backed solution will be labelled as bigoted, racist, homophobe, xenophobe, germaphobe etc... so it's gotta come from the left, BUT, taking away the candy loses voters so i don't see any democrats wanting to do the dirty work either and if they do they will only take it away for 'the rich', who are soon to be those that make, combined, over sixty thousand a year.

    this has always been a political issue, not a medical issue. we are now MUCH LESS CAPABLE of taking care of the poor and underinsured that we were before EMTALA.

    but off my soapbox, here's how you fix it, so easy there's no way anyone will do it.

    1. cap liability for mandated free care. do not dispense with it entirely as the tort system as practiced by good attorneys and reasonable people helps us to stay on our toes, just cap the liability like it is for every single doctor that works in every single government run health care facility. also, throughout medical malpractice, institute 'loser pays' rules, or, loser pays court costs or 5% of their annual income as determined by their last three years tax returns (including ssi, and disability and any government aid), whichever is less. i know, i'm smoking pot, how unfair would that be?

    2. make care given under the auspices of EMTALA tax deductible for physicians and you will have us lining up with smiles to give away our services. i have more than two children, no deductions allowed for them, in fact, the only deduction i have is mortgage. so sad you say (rhetorical and not directed at you friend-in-dc)? it WILL be sad when the doctor shortage really hits (already started) because a lot of you who just LOVE that i pay through the nose in taxes will die one day for lack of someone like me... but i digress... i did not get out of debt from medical school till i was 37 and the 'rich doctor' myth is powerful but is easily debunked (search this site for 'medgeekonomics'). a tax break on free care would also motivate us to see more patients more quickly and would make medicine attractive again as a career from a financial standpoint.

    3. and most importantly and most politically unviable, MAKE EVERY SINGLE PERSON WHO CALLS 911 OR CHECKS INTO THE ER pay the equivalent of one hour's salary at the minimum wage. if they can not pay this then assign them five hours of volunteer service either in the hospital or with EMS (and this HAS to be enforced by the judiciary) or, failing that, spend 24 hours in home confinement with a tracking bracelet on the ankle and jail those who don't do it.

    problem solved, but what will happen instead is that the government will butt in, create about a million paper jobs, make getting health care like getting your driver's license, and then the rich will go to private hospitals with gold plated insurance or cash (unless the hospitals are declared 'illegal' by the government) and the situation will be twenty times as inequitable as it was in 1985. thus endeth the rant.

  24. Dear dr911,

    I am dr boop after the cartoon character betty boop.

    I started doing physician training and have had a few years off doing our babies. I just went back to the ED to familiarise myself with what I am supposed to do with patients. There is always someone to ask and the hours are fixed so I can pick the kids from school and day care.

    Hope to see you in Oz!

  25. My insurance is through Coventry. It's fucking awesome. I work in EMS and have given up a lot of take home cash so I can have great health coverage for me and my family.

    I know what kind of reputation the VA has. I know how little Medicaid pays for services. I see what happens when government gets into the business of health care -- "general hospitals" run by well-connected people who make good money while the front-line staff is beleagured by fucking rules about "Potty, poop, pain and positioning!! every hour! document!"

    I see people every day who hand me their medicaid care and say, "Look, I gots insurance!" No, taxpayers have insurance on you. There is no incentive for cheap care. Call an ambulance because you have belly pain for a week. Go to the ER because you can't get into the free clinic when you're drunk for a "buteral" refill.

    There is no incentive to control cost because these people pay nothing, and expect everything. Even with a low copay and great insurance, I still shop around for the best deal and avoid things like urgent care trips, third tier medications, or ER visits. We have 1,500 phyisicans to choose from in a 20 minute drive. I can get in today if I need with a few phone calls.

    Don't tell me how wonderful it is in Europe. Or Canada. Or Germany. The Germans I know all have private insurnace for a reason. With that "free" healthcare, you get what you pay for: something that looks a lot like the bowels of the VA or Indian Health Service.