“Dr. Brown, the new computer order system won't accept your history of 'fever' for a pulmonary CTA on Mrs. Stern. You now have to have a reimbursable indication, like SOB, or chest pain.”
“So enter 'chest pain.'”
“I'm not going to lie. That's why Dr. White is now doing prison physicals.”
“Fine. I'll take care of it.”
“Take the medical student with you.”
“Kid, I am going to show you about real medicine, the stuff they don't teach you in medical school.”
“Mrs. Stern, you've been having chest pain, haven't you?”
“No.”
“It must hurt when you cough?”
“No.”
“You gotta have a little twinge, a slight sense of chest pressure?
“No.”
“What about when I push on your chest like this?”
“No.”
“What if I take my knuckle and grind it into your sternum….”
“OUCH!!! That hurts!”
“See, kid? Chest pain. Son, don't let any pinhead bureaucrat tell you how to practice medicine. Now I'll show you how to get an annoying patient out of the ER without getting sued. Put on that elbow-length rubber glove……”
A probing study in the February 2008 issue of Annals of Emergency Medicine, “The Law of Unintended Consequences: The Joint Commission Regulations and the Digital Rectal Examination,” reported how the commission had set up new regulations concerning digital rectal exams to improve patient care and the detection of cancer. Unfortunately, the unintended consequence was a decrease in testing for occult malignancy. It seems that doctors came to view the test as having a “cost” to perform, which was not adequately compensated.
Such has been the complicated relationship of fee-for-service and Medicare as documented in study after study. When Medicare effectively reduces fees, doctors look to compensate for the lost income by increasing utilization elsewhere. For every dollar in fee reduction, doctors recoup 40¢ through increased ordering of other tests. Doctors are smart enough to know how to game the system; so much for cost savings.
