One of the basic tenets of American jurisprudence is that an individual is innocent until proven guilty. Lately I have come to realize this no longer applies to physicians.
In cleaning off my desk I came upon two publications from professional organizations (i.e., AMA and College of American Pathologists) urging me to create a "compliance plan" for my practice. The purpose of such a document would be to provide evidence any mistakes in coding for medical services were inadvertant and thus not fraud and to show the practice has made a reasonable effort to avoid such misbehavior. In other words unless I can prove I have a plan I will be suspect of fraud.
One would think being a professional with a sense of ethics and common sense to know one does not bill for services one doesn't perform would be enough, but no, the federal government doesn't have to prove intentional fraud, the physician has to prove innocence. Thus the vast majority of physicians who have in the past behaved in an ethical manner have to adopt these compliance plans because a rather small number of us have not coded correctly.
Arthur H. Mensch, MD
Beware of a Career in Medicine
Dear Dr. Weaver,
Thank you for your article in the September/October 1999 issue of the Medical Sentinel. I fully agree with you. I am 41 years old and have completed two residencies. I don't know if I would do it again.
We are in an Orwellian System where 1 + 1 = 3. Party A (3rd party controllers/payers) is in charge of processes 1, 2 and 3, but Party B (physicians) is held accountable for Party A's management of processes 1, 2 and 3. This arrangement is insane. The only situation that I can think of where it is acceptable is that of sadistic despotism.
It would be far more rational if the government stopped forcing employers to provide health care to employees. A more logical approach would be to allow individuals (not just those who are self-employed) to fully deduct their health insurance premiums and have Medical Savings Accounts (MSAs). Additionally, the floor for medical deductions (now at 2 percent of adjusted gross income) should be lowered if not eliminated.
Unfortunately, I have learned common sense is not so common. However, I am still hopeful reason will win the day.
Roy Blackburn, MD
The Personal Touch of Medical Care
As a physician my main concern is the health of my patients, and they are the ones who make the medical decisions for their care, treatment, drugs and consultations.
I came to this country because I wanted freedom of choice and the freedom to practice medicine in the best way possible. The first ten years I was able to work in my profession as I believed it should be done, but now I am very disappointed because of my inability to practice medicine the way it needs to be practiced, in the tradition of Hippocrates.
The "bureaucratic" doctors who work for insurance companies, HMOs (mismanaged care) and the government do not have the personal touch of patient care. They only read the physician's notes, the computerized information which is not the same as face-to-face encounters with the patient and sharing the patients' concerns which comes from the personal knowledge of their backgrounds and knowing their medical problems.
I have been reading articles from newspapers, periodicals, medical bulletins and journals, and I am convinced medicine has become so bureaucratized it is no longer what it once was. That is the reason I will not contribute any money to the Republicans who voted to protect the HMO objectives with the so-called Patient Bill of Rights which the Medical Association of Georgia called, "A sweetheart deal for HMOs that will hurt patients." Although I am disappointed with Republicans, I do not want to join the socialist Democrats who only want to tax us more and more. (As a doctor, I charge my patients fairly for the time I spend with them and I do not want someone dictating what I can charge.)
Chief Justice John Marshall once said, "The power to tax is also the power to destroy." In a sense, the amount a physician can charge a patient is dictated by the government, HMO, or insurance companies and I do not like it.
Fernando Campos, MD
Report From the State --- Missouri
Dear Mr. Meier,
I enjoyed your article regarding the state legislative activity in Missouri regarding health care reform. In my opinion, without having the benefit of knowing State Rep. Harlan personally, it appears that he is following a pattern that seems to be very common at the state level.
Liberals do not need enlightenment --- i.e., they don't need someone to "show them how to reform health care." They believe that their way of reforming health care is the only way that is acceptable, but if they are unable to get their legislation passed, their secondary objective is to insure that no conservative method gets a chance to demonstrate effectiveness.
If my memory serves me right, I think that Oklahoma received a Robert Wood Johnson Foundation grant in the early 1990s, as did 11 other states, which provided money to promote a plan at the state level for increasing the level of managed care run by the state government in preparation for the Clinton plan which never materialized. Many of the states were not able to get plans off the ground, but even if that aspect of the grant effort was unsuccessful, the entire process allowed the Robert Wood Johnson Foundation an opportunity to "educate" state legislators about the "correct" way to reform health care and the "incorrect way."
Oklahoma actually passed and implemented a Medicaid managed care plan, and the results have been similar to TennCare, but on a much smaller scale, because thankfully, conservatives were able to limit the scope to just Medicaid, and just AFDC until this summer when the ABD were added.
The only Medicaid groups involved have been in three metropolitan areas, because the state agency's attempt to implement the rural phase was a disaster. In spite of this track record, when SCHIP [State Children Health Insurance Program] passed Congress, liberal state legislators refused to consider any of the conservative methods (benchmark plan) for increasing coverage for uninsured children. They only would consider expanding the Medicaid managed care program, despite all the difficulties it had been having. At the national level, Vice President Gore's plan to expand coverage for children up to 250 percent of the poverty level is a result of that same mentality and motive. Someone needs to take a good look at the Medicaid managed care programs that have been implemented in various states with the help of the Robert Wood Johnson Foundation, and see if they can find one that is working. The only Medicaid managed care program that is working well is the one in Wisconsin, and they did not follow the Robert Wood Johnson Foundation outline. With that information, someone then needs to ask Mr. Gore how he thinks passing his plan will help if the basic Medicaid managed care strategy is not working except in isolated areas.
Some examples of some problems: the government is unable to locate all of these kids needing health coverage; they can't even locate kids that are eligible for Medicaid and HMOs by the droves are bailing out of state contracts, so if they do finally expand to 250 percent and beyond, and they can find these people that they say need their help, what HMOs will be left to provide the care? Finally, the welfare rolls are at all time lows, and so what happens to all of their cost estimates when the welfare ranks begin to swell again?
Conservative strategies for health care reform make the most sense, and are most flexible and resilient. Rep. Dick Armey (R-TX), House Majority Leader, is right when he sees changing the tax code as a key element in this process, but Stuart Altman of The Heritage Foundation told The Wall Street Journal conference in May that tax code changes will never be a part of health care reform. In my opinion, liberals do not need to be enlightened to open the door for real health care reform, they need to be defeated.
Glenn P. Dewberry, Jr, MD
The U.S. Constitution says all federal taxes must be either uniform or apportioned. In Brushaber, 1916, the U.S. Supreme Court ruled that this remained true after the Sixteenth Amendment: the Court ruled that although the Sixteenth Amendment allowed "income tax" to be unapportioned, unapportioned income tax had to be uniform.
Since 1980, three federal courts of appeals have erred about what the Brushaber court said. In its U.S. v. Francisco opinion, the 8th Circuit misquoted Brushaber by striking the negative from the sentence, so it would read that income tax did not have to be uniform. The Supreme Court refused to hear the appeal.
Federal estate tax is held to be uniform in a minimal way called "geographic uniformity," but the Medicare "limiting charge" explicitly violates even geographic uniformity. The "limiting charge" is a tax: indeed, the physician must "refund any overcollection" or incur "civil money penalties and/or exclusion" ("Fact Sheet --- Changes for 1995")...
Joseph C. Keller, MD
This past summer the Advisory Commission on Electronic Commerce met to figure out a way to tax "electronic commerce." Rep. Dick Armey (R-TX) urged his colleagues to make permanent a three-year tax moratorium included in the Internet Tax Freedom Act passed last year.
On the Senate side, Sen. Bob Smith (R-NH) has introduced a bill that
would make the Internet tax moratorium permanent, but there has been no
congressional action. (http://www.newsbytes.com)
Correspondence originally published in the Medical Sentinel 2000;5(1);1-3. Copyright©2000 Association of American Physicians and Surgeons (AAPS).