With a single code entered into the Medicare billing module, the friendship that had developed over two decades with my G.P was almost fractured. How it was described on the code of his billing form that he filled out, Dr. S. could not recall, but he knew it was not the words that appeared on my Medicare Billing Statement, "Impaired thinking and developing a treatment plan"
I remember on my first visit to him, I noticed his award from the Republican Physicians Association on his wall, which turned out to be an opening for some candid discussions, and evolved into mutual respect, He greeted me with a title that I never earned to show our equality, "Doctor Rodbell." At one point after many years, he commented, “You and are now pretty close on the political issues we’ve discussed.”
In our conversation, when he was toying with the idea of transforming his practice to “concierge” meaning stretching the Medicare rules to charge an annual fee of a couple grand for expedited appointments and such, he echoed the tone of the Times article. Associated with ACA, but hardly known outside of physicians is something called MACRA which over several years would provide incentives to pressure private practitioners to join medical groups, and as Dr.S said, “my income won’t be based on my medical skill, but how talented is the person who does my computer billing.”
One point that we did share was our opposition to the inclusion in ACA of "The annual wellness visit" This was passed with no publicity, or discussion of how this would be a sea change in breaching the confidentiality that is essential in the doctor -patient relationship. In the name of helping the Medicare patient, reports on his/her memory and sense of well being were to be monitored, which means sharing with bureaucracies without permission from the patient.
If the doctor doesn’t want to spend the time anticipated in getting to know a patient, he/she could farm out out the administration of the cognitive and depression questionnaires. The ideal of fostering a supportive relationship is too easily evaded. We treated it with the contempt it deserved, the danger of a return to a paternalism that had in recent years has been replaced by the norm of candor between both parties. Knowing my psychology background, on our last visit he simply asked how I would do on the standard cognition test. But, he spent time with me, on an aray of issues that concerned me, that warranted payment for an extended consult, which he entered with no awareness of the offensive description.
When I went to his office, and with a bit of an edge asked him how he determined that I had “impaired thinking” and told me he never said that, and read exactly what his notes were, and provided a copy of it when I left. In the official notes he even described how he asked me how I would do on the cognitive test, rather than administer, and even said that my memory loss was not severe, and “In my opinion he is overly concerned with this.”
The Medicare Administration sends out several million of these forms every month, for the beneficiaries to check out that the claims were correct. I would guess that it’s some fraction of one percent who actually read them, as the attitude is “I’m not paying anything for it.” And they may realize that if they question a code the doctor could be offended, and as Dr. S. was before our discussion felt that I was accusing him of Medicare fraud, which I denied.
But Medicare fraud does exist, one estimate being to the tune of fifty billion dollars annually. This was not an example of this crime, as the dedication and humanity of my doctor is something I value, and that he wants to get paid for it is only reasonable. My comment didn’t get much applause from the Time’s readership, as it was a bit off topic. But, it does show another aspect of the de-personalization that is another side of what the article described. It is not only the “doctor’s well-being that is being affected, but also the patient’s