Katrina Story, Chapter 8: Our House

(Dr. Scott's inner demons persuade him to return to Katrina Story at long last! My apologies if I repeat any details from prior chapters; I'm going to put pen to paper...er, fingers to keyboard...and write while I have the time and inspiration.)

After assessing the office and hospital, we turned from the professional sphere to the personal, and drove towards our house in Waveland. As we turned onto Jeff Davis Avenue (hey, this is Mississippi!) we saw a now-familiar sight: house after house with destruction, devastation, and the ubiquitous orange spray-painted "X." Immediately after Katrina, search-and-rescue teams went to each and every building across the Gulf Coast. The teams would tag each building (both residential and commercial) with an "X," and each quadrant of the X had a different piece of information: the date searched, the team that was there, the number of human bodies inside, and the number of dead animals (pets) inside. Fortunately, almost all of these orange Xs had zeroes or empty space in the last two fields.

The street was much narrower than it had been two weeks ago, due to the fallen trees and debris already starting to be pushed to the road. Power crews were also out in force, with their trucks in the road making the street just barely passable. Downed power lines crisscrossed the street and hung from tangled branches. At long last, we reached our house.

A massive tree had fallen across the front yard, completely blocking the driveway. A branch of the tree had punctured the side of the house, emerging in the master bedroom. The yard fencing on the other side was squashed under more fallen trees. Two beautiful magnolia trees in front had been stripped of leaves and now looked half-naked. A few towels and quilts were draped on the fallen trees, already bleached from the hot Mississippi sun.

We climbed the stairs to the screened front porch and tried to unlock the front doors. The doors were massive and made from solid wood, which meant they had warped stuck and refused to budge. I hopped the fallen fence and walked around the side to the back, climbing over a few more trees.

The back deck had been completely flipped over, concrete anchors up in the air. A huge tree that had been in the middle of the deck became uprooted during the storm; presumably the water loosened the roots while the wind pushed the tree down. When the tree fell, the roots came up, and the deck went with them. The whole process must have been terrific to watch: the charcoal grill landed neatly under the deck, only now upside-down.

With the deck out of the way, the back door was now four feet off the ground. I climbed up and unlocked the door and stepped into the mudroom, never more aptly named. The carpet was still sopping wet, squishing with every step.

I continued around the corner into the play room and then the living room. The wooden floors were horribly buckled. The glass screen of the television (bought only a few months ago) was marked with a horizontal line of dried debris, the water line, at about 3 1/2 feet off the floor--which translated to about 6-7 feet off the ground. We were about 1 mile north of the beach.

The boys' bedrooms were strewn with books and toys, while the beds had been neatly submerged, now giant wet sponges. In the master bedroom, our wooden dresser had tipped on its side and refused to be moved.

We opened some windows for ventilation, and to half-heartedly drive off some of the pervasive odor of mold. Back in the kitchen, flies buzzed around half-emptied juice bottles. I tried to take stock of what might be salvaged, especially before any looters thought the same. The wedding china was above the floodline in the cabinets, all intact. I wrapped it up in some of the boys' clothing, also preserved. A desk in the hall still held a book of blank checks, some photos, and personal trinkets. The jewelry chest from the bedroom fell apart like cardboard, but its contents were still present, if covered in muck. Most of our photo albums and my wife's wedding dress had been stored up high and untouched. Also saved were my collection of my father's cuff links, an audio tape of my wife when she was a toddler, and a few paintings done by my wife's grandmother. Lastly, I returned to the kitchen and grabbed a still-unopened bottle of Canadian whiskey, given to me by a medical student I had preceptored, and I tossed the remaining bottles of booze out of the window (lest they serve to attract vagrants into the house). We locked up the house, loaded the car as much as we could, and I walked two doors down, where our neighbor had Oscar the dog.

Nearing her house I heard a frantic barking. Oscar and two new canine friends were having a run of the place, cavorting and having a grand old time. The house's human resident came to the door, apologizing for the mess, at which I had to laugh. Oscar had been a fine houseguest and she had been happy to oblige. I offered my profuse thanks and asked if I could get her anything on my next trip down, perhaps in a week. "Fresh fruit," she said. "What I wouldn't give for a nice orange, or a banana." Her Jeep had been flooded, ruined, and she wouldn't be going anywhere, anytime soon.

We wrangled Oscar into the car, with much jumping and licking, and started to drive out. It was now about 4:30 in the afternoon. But we had one last place to go before returning to Birmingham.

The HIPAA in the room

With all the talk about HIPAA and its hassles and headaches, I had to share this little incident:

A few days ago I received a call from an irate mother. She wanted to know why we were blabbing her daughter's medical information all over town.

Excuse me?

"Well, I got a call from my baby's daddy's wife, and she heard from y'all that my baby had been to the doctor nine times, and she wanted to know what was wrong that a 3-month old had been to the doctor nine times."

Ma'am, first of all, why do you care what your baby's daddy's wife is telling you? Second, what is your current relationship with the baby's daddy?

"He's not involved, he's never been involved from day one and he's got no intention of being involved."

Okay, ma'am, but do you have a court order granting you sole custody, or another legal document excluding him from care?

"No, I haven't gone through that yet, but I don't want you sharing information with no one else."

I understand, ma'am, but he is still the father and he still has the right to information. We don't have to share information with his wife if you choose, but do have to release information to him, unless you have a legal document saying otherwise.

"You're saying that anyone can call up and say they're my baby's daddy, and you'll give them the information?"

Yes, if someone claims to be the baby's father we will take him at his word; we have no way to prove they aren't, and no reason to either.

"Well that's not right."

And, then, a few days later:
"I want a copy of your HIPAA policy."

Now, for all that HIPAA does and does not cover, it doesn't give you the right to keep the baby's daddy out of your baby's medical record, as long as he still retains legal status. Get down to the courthouse, sort it all out between the two of you, then come back with an official piece of paper, and my wish is your command. Nevertheless, I can just imagine a call from the feds:
"Is it true you gave out Protected Health Information against the mother's wishes?"
"Isn't it true that you don't verify the identity of parties requesting Protected Health Information?"
"Did you make a notation in the chart as to who has received information?"

For the record, my staff (both of them) denies ever giving any information to anyone about this baby. This is a small town. It's just as likely that someone was in the waiting room one day, overheard a couple things about "past appointment" and "next appointment", and then told baby daddy's wife. But it's all irrelevant, because this has nothing to do with HIPAA. This has to do with dysfunctional family arrangements. And yet, I can see HIPAA becoming the blunt club, the shotgun, the tool used to cause retribution.

Three more things:
(1) I'm not sure HIPAA ever solved any problem. Was there a serious epidemic of doctors releasing information to unauthorized parties? I am much more aware of privacy issues now, which is a good thing, but could someone show me that there ever was a problem before? If we want to discuss privacy, let's talk about corporations and federal agencies losing laptops with thousands of social security numbers...
(2) I realize the terrible meta-irony in discussing HIPAA issues by using the example of a patient who is already concerned about HIPAA. What if she comes across this blog and feels that her privacy has been violated yet again? Nevertheless, I haven't touched on medical issues (so it's doubtful that HIPAA truly applies here), and she would have a hard time proving that this little incident described here has now compromised her privacy and identified her to the world--unless she herself has been spreading the story...
(3) So, when will I be getting a call to appear on the Jerry Springer Show?

Another iteration of tragedy

My thoughts and prayers go out to those at Virginia Tech having to deal with unspeakable tragedy.

I cannot pretend to imagine what it must be like for a university to lose so many of its community in one day.

And yet...

I remember going out to dinner with my wife on a spring evening eight years ago. We were in an Irish pub in East Boston. The television in the bar was showing footage of a horrible massacre in Littleton, Colorado, at the local Columbine High School.

I was in my last year of residency, and I was working on a free-form elective rotation, looking at firearm injuries, where and how they were occurring, and different ways to address the problem: office counseling, community education, product design, legislative efforts, and such.

I remember saying to my wife that this country has a choice. We can sharply reduce the probability of another such event happening, but it would require a political turnaround, implementation and enforcement of strict gun regulations, and a massive grassroots clamor saying "enough is enough." Or we can continue to hold high our right to bear arms, our right to armed self-defense and recreation, realizing that events like this may be the price that we periodically pay for that freedom.

This is the choice we have made, and we must reluctantly acknowledge its occasional and tragic consequences. Let us express our sympathy, our condolences, our anger at this event. But let us not be so naive as to be shocked or indignant, both now and when it inevitably happens again.

The Last Generalist

Are pediatricians an endangered species?

This is the question that was recently posed on a listserv I read, as well as here and here and here. Stagnating or declining reimbursement for primary care and escalating financial pressures (particularly for vaccines) make it harder and harder for pediatric practices to survive. Meanwhile, nurse practitioners and retail-based clinics are claiming they can do the same thing we can, only with more convenience and less cost. The future doesn't look good.

A CEO of a Boston hospital believes insurers will eventually start realizing the value of preventive medicine, and start reimbursing, or shifting funding, accordingly.

But insurers--not to mention the government, via Medicare and Medicaid--have long known how good a deal preventive medicine is. There's even been data to back it all up, for years and years. Just look at vaccines. Yet insurers continue to pay ridiculously low amounts for vaccines (sometimes even under our purchase cost!), or similarly pathetic rates for infant check-ups. Because they can. They know (as I alluded to in my last post) that doctors--especially primary care doctors--are not businesspeople. We are here to help others, and if we have to shoulder some of that burden to care for our youngest and most vulnerable, we do it. The surgeons raise a proper stink if they don't get "fair" reimbursement for that gall bladder removal or tonsillectomy; we just suck it up and see another few patients per day.

There has been talk about creating value. Fight the retail-based clinics by offering evening hours, or open-access appointments (a type of scheduling that basically insures everyone who wants to be seen, is seen, that day). Show the insurers the data that our great care can keep the kids out of the expensive ER, and is therefore worth something to them. Or create programs that offer convenience and value to both patients and insurers--such as weight-loss classes, new parent discussion groups, or asthma education sessions.

These suggestions are great, but they can't be done by a solo pediatrician, or even a small group. Only a large group can do it. And many are doing it, or at least starting.

The days of the solo pediatrician are indeed numbered. The pressures are too great, and the innovations can't be reached, at least not without burning yourself out.

This doesn't spell the end of pediatricians, however. A good friend and colleague of mine likes to say that pediatricians are the last generalists. I don't mean your country doc, cradle-to-grave caregiver, delivering babies in the middle of the night at the Smiths' farm and being paid with a hog and a bundt cake. (There may be a few of those family practitioners still around, but they're not even endangered, they're basically extinct, outside of film or TV.) I mean the I'll-treat-anything-that's-bothering-you doc, the absolute-expert-about-the-whole-person physician. The Save-The-Day kind of doctor who, in this case, is the ultimate authority on kids. The doc who can resuscitate and stabilize a premature infant, start an umbilical line, calculate a drip, bag and intubate, and perform the spinal tap, all at 3 a.m. The doc who can differentiate ADHD from a learning disorder from a simple acting out, and start correcting any of the above. The doc who, even if he can't insert the ear tubes, can still keep straight a chronic serous otitis from a Eustachian tube dysfunction from an acute suppurative otitis media, figure out the right medicine, and--most importantly--explain it all to the mother who never made it past seventh grade. And the doc who might talk to the local PTA about newly licensed vaccines one night, and to the district attorney about a case of child abuse the next.

We may not do all of those things everyday, but we've been trained well enough that we can. If it concerns kids, we can handle it. Period.

And--I know this is going to get me some of my first hate mail--that Medical Degree means something. I'll say this with sincere respect: NP's can do great things, and bring wonderful perspective to the craft of medicine. Both NPs and MDs can follow protocols, develop judgment from a wealth of experience, and communicate well. But the MD has the base and the background to be the Authority. Only the MD has the training in biochemistry, psychology, pathology, pharmacology, epidemiology, research, the whole toolkit, and the mindset to be able to deal with the unexpected. A pediatrician's scope of practice is limited only by what he or she wants to tackle.

As long as that remains true, there will be a need for pediatricians. We are the generalists who specialize in children. We may be practicing in large mega-groups, or employed in government clinics, but we will be around as long as there are kids.

And maybe that's what I like best about being a pediatrician.

AAUGH!

Just like Lucy pulling the football away from Charlie Brown, Medicaid loves to play games with the pediatrician.

For the uninformed, a primer: Medicaid is the government's "safety net" insurance program for the poor. Many children are covered by Medicaid (in fact, here in Mississippi, about 3 out of 4 are). The federal government provides much of the funding, with the rest coming from each state, and each state also administers the program. Each state provides benefits as it sees fit--within certain broad federal guidelines--and can also set provider reimbursement in a similar way.

Medicaid represents government at its best and worst. The concept is wonderful, and enables patients to receive care at any willing provider. But the bureaucracy can be inscrutable, bizarre, and sometimes downright moronic, bordering on abusive and arrogant.

At the end of last week my billing manager was reviewing our past few statements from Medicaid, and she found that most of our newborn nursery visits were denied without payment. Late last year Medicaid started requiring prior authorization on many inpatient hospital stays. But babies born eligible for Medicaid don't receive their official Medicaid numbers until 4-8 weeks old.

You can't give a patient a "prior authorization" before they are born, and you also can't give them a P.A. before they have an ID number! The customer service rep agreed, and brought in her supervisor, who told us the grim news: a computer glitch was unexpectedly and incorrectly kicking out these newborn visits. Payment would be forthcoming when the problem was fixed--but that could take weeks to months.

I don't have a problem with providing charity care, as long as I determine the when and how. But I draw the line at systemically providing care for free, particularly when a payor tries to make it so. I can't pay my overhead on goodwill.

And so I am boycotting Medicaid babies until the problem is fixed. No more nursery coverage, unless I absolutely must (e.g., hospital call). I'll see them as soon as they are discharged, for an office follow-up visit. No payment, no care. Or, as others have said, "no margin, no mission."

This is not ideal care. In fact, some might even call it dumping on my colleagues, who will now see "my" babies on "their" nursery rounds. Of course, they have the option to do the same as me, in which case we all dump on each other, and it all evens out. They also have the option to suck it up and continue to provide free care, in which case you may call them "patsy," "sucker," or "loser."

Perhaps I'm deluding myself, but I like to think my profession entails doing some good in this world. I make sure kids stay healthy, or get healthy. This is not about "playing games" or pushing paper, this is about real-world results and making a difference. Compare and contrast with those who seem to erect barriers to said goals.

I'm not accusing Medicaid's bureaucracy of purposefully creating these computerized denials. But I think their response will be most telling, as to how quickly they fix the problem. And trying to deny proper due payment to providers for services rendered--especially contracted services delivered to poor babies--is most certainly "playing games."