ZANE POLLARD M.D.- THE BUREAUCRAT SITTING ON YOUR DOCTOR’S SHOULDER
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When I’m operating on a child, I shouldn’t have to wonder if Medicaid will OK a change in the surgical plan.
Dr. Pollard, a pediatric ophthalmologist with 40 years of experience, is director of the James Hall Fellowship in Pediatric Ophthalmology at Scottish Rite Children’s Medical Center in Atlanta.
The bond of trust between patient and physician has always been the essential ingredient in medicine, assuring that the patient receives individual attention and the best possible medical care. Yet often lost in the seemingly endless debate over the Affordable Care Act is how the health-care bureaucracy, with its rigid procedures and regulations, undermines trust and degrades care. In my pediatric ophthalmology practice, I have experienced firsthand how government limits a doctor’s options and threatens the traditional doctor-patient bond.
I recently operated on a child with strabismus (crossed eyes). This child was covered by Medicaid. I was required to obtain surgical pre-authorization using a Current Procedural Terminology, or CPT, 2475.TW +1.12% code for medical identification and billing purposes. The CPT code identified the particular procedure to be performed. Medicaid approved my surgical plan, and the surgery was scheduled.
During the surgery, I discovered the need to change my plan to accommodate findings resulting from a previous surgery by another physician. Armed with new information, I chose to operate on different muscles from the ones noted on the pre-approved plan. The revised surgery was successful, and the patient obtained straight eyes.
However, because I filed for payment using the different CPT code for the surgery I actually performed, Medicaid was not willing to adjust its protocol. The government denied all payment. Ironically, the code-listed payment for the procedure I ultimately performed was an amount 40% less than the amount approved for the initially authorized surgery. For over a year, I challenged Medicaid about its decision to deny payment. I wrote numerous letters and spoke to many Medicaid employees explaining the predicament. Eventually I gave up fighting what had obviously become a losing battle.
Every surgeon must have the option to modify and change a surgical plan according to actual anatomical findings that only become apparent during surgery. For example, if a general surgeon operates on a patient with a suspected acute appendicitis and finds that the patient is actually suffering from an ovarian cyst, that doctor must be free to change the plan and do what is best for the patient. The physician should not be denied payment simply because of a rigid government requirement to follow only the pre-approved plan.
We all expect that doctors will do what is best for us according to their best judgment. This is part of the oath that doctors take when they graduate from medical school. When the government interferes with the doctor’s right to select the treatment course and perform a necessary procedure, the integrity of the entire health-delivery system is compromised.
This same rigidity affects the dispensing of medications. I recently had to contend with a pharmacist’s unwillingness to go against Medicaid rules and dispense a prescription for an eye drop medication for my patient, a teenager with glaucoma. This disease, involving high intraocular pressure, threatens sight if it is not controlled by medication.
My patient’s glaucoma had been well controlled by a particular eye drop dispensed in a bottle available only in one size containing a dosage that would last for two months. Medicaid regulations only allowed the pharmacy to fill a prescription for a one-month supply. Medicaid did not want to approve my prescription.
The pharmacist asked me if I would change the prescription to order another Medicaid-approved medication that would satisfy the one-month-only supply policy. I refused because my patient’s ocular pressure was well controlled by the particular medicine I had requested. Her vision was preserved because of that drug’s effectiveness. Only after numerous contentious calls with the pharmacist and Medicaid was I able to obtain the prescription. Why should a physician have to struggle with the government for the most effective care for a patient?
Another example involved a life-threatening situation. I examined a 14-month-old child with the symptoms of Horner’s Syndrome, a condition that can be caused by a neuroblastoma (a malignant tumor). I ordered a CT scan of the neck and chest, as these are the two most common sites where this tumor appears. Medicaid approved a CT scan of the chest only. I spent several hours on the telephone pressuring my state’s Medicaid officials before I received permission to have both the chest and neck scanned. The scan of the chest was negative, but the scan of the neck revealed a malignant tumor. A pediatric surgeon removed the tumor and the child is doing well.
Had I accepted Medicaid’s protocol and only obtained a scan of the chest, that child might not be alive today. Is that battle with government bureaucracy one that you are comfortable having your doctor fight when your child’s life is at stake?
People of means, as well as those who need substantial financial assistance, must be able to trust their doctors. When government sets up rigid protocols that control the surgical procedures a doctor may perform, that limit the medicines approved for treatment, and that deny a critical diagnostic scan that may save a patient’s life, the bond of trust is broken.
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