The Last Straw

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alt“That’s it! I’ve had it!” I shouted to the air, throwing the envelope on the floor.
“What is it now?” my less-than-sympathetic wife said, dramatically emphasizing now.
“They’re already hiking our taxes, that’s what,” I said, rising from the breakfast table and starting to pace.

“That’s it! I’ve had it!” I shouted to the air, throwing the envelope on the floor.


“What is it now?” my less-than-sympathetic wife said, dramatically emphasizing now.

“They’re already hiking our taxes, that’s what,” I said, rising from the breakfast table and starting to pace.

“Tax hikes? What are you talking about? Did we get a letter from the IRS?” Now I had her attention.


“No, the DEA!”


“My DEA renewal just went up again – to $731! That’s a 33% increase. I thought the $551 fee was already outrageous. They might as well call it a tax on being a doctor. They say it is to pay for expanding the ‘tactical diversion squads’, increased registrant investigations, responding to new synthetic drugs, and establish a new information system. Aren’t these problems everyone’s problems, not just doctors?”

“I’m just thankful it’s not a letter from the IRS,” she said with a sigh, acting if it was all a false alarm.


“Hey, it’s the DEA today but the IRS tomorrow, baby. I’m not kidding you.” She walked away with an I’ve-heard-it-all-before wave of the hand. “I know you think I’m exaggerating. You’ve told me that a million times. But this is for real. Everybody is gunning for us. We’re part of the 25% of the country who are paying 85% of the taxes. And they think we’re still not paying our ‘fair share.’

“Hey,” I continued to pace after her, “I got a notice the other day to think about not documenting so much because it makes us look like we’re trying to up-code. It’ll get us in trouble with the feds.”

“What are you talking about?” she said, finally turning around to face me. “I thought the billing department was always trying to get you to document every little thing you did. Correct me if I’m wrong, but isn’t that one of the things you’ve complained about so much, having to write so much you don’t have time to see the patients anymore?”

“OK, so I complained about it. But I finally saw the reason for it and after a zillion kicked-backed charts I got the hang of it. And now they tell me to be careful that I don’t document too much.”

“How can you document too much?”

“Well, if you finally get as compulsive as they want you to be, you actually ask all the history and review of systems, and you document every thing that you did.”

“I fail to see the problem.”

“Well, apparently, if the outcome turns out to be minor, Medicare only wants to pay the lesser charge. So they are now claiming that we are billing for excessive care. But the billing office charges for the actual time you spent with the patient getting information that it turns out you didn’t need.”

“So you wasted your time…like you are wasting mine now,” she said with a peevish squint.

“Oh no, that’s too simple. Medicare sees that as fraud. Even if it’s the billing people who do the charge, it’s my name on the chart. The government can fine the group up to $5,000 for each ‘offense’ and they can go back in time to really run up the tab. They can even put me in jail. I know a guy that it happened to.”

“Really? How long would they lock you away for?” she said with a smirk.

“Very funny. I’m being serious here. There’s more. The hospital let us know that Medicare patients can’t be re-admitted within 30 days of their last admission or they will be fined. One percent of the total Medicare bill.”

“Only 1 percent?”

“One percent of the total reimbursement from Medicare for the year. That could be hundreds of thousands. And the next year that will increased to 2%, and 3% the following year. I’m telling you, old people are not going to be admitted to the hospital like they use to.”

“Is that really so bad? I thought you told me there were a lot of abuses of the system.”

“Yeah, some attendings will admit every old lady for a hang nail. But they really are the exception. Often, we really need to admit someone for ‘social reasons’. And now we can’t or we’ll get hammered.”

“Social reasons?”

“The other night I had a little old widow who fell and broke her ankle on the ice. She lives alone. She had no way to get to the toilet or feed herself. It was Friday night and her family lives across the country. So I called her attending and asked if we could admit her, tune her up, and send her to ortho rehab in the morning. He said, “This conversation never happened” and then hung up on me. We ended up sending her home by ambulance, plunking her in her bed, and walking out. I guess I could have kept her all night and dumped her on the next shift. She might have ended up staying in the ED all weekend. Either way, I think it’s unconscionable. Everyone’s afraid to do the right thing. Or what happens if they just get sick again within 30 days? It doesn’t even have to be for the same problem.”

“But don’t you think they have a point? You keep saying we have to get needless admissions, overdiagnosis, and overtreatment under control.”

“Yes, but you can’t legislate those kind of things from Washington. Those of us at the bedside are the only ones who can make those decisions. There has to be room for tailoring to the individual circumstances.”

“How will you hold each other accountable?”

“You know I love it when you ask these kinds of questions,” I said professorially, seeing my chance to hold forth.

“Is too late to take it back?”

“We can hold each other accountable to practice evidence based medicine,” I responded, ignoring her.

“But that takes dialog and consensus. We need to have honest dialog about what works and what doesn’t, what testing is necessary and what isn’t.”

“Like the pregnancy test they do on me ever time I get an X-ray.”

“Hey, the X-ray may be unnecessary, but the pregnancy test? You are still married to me,” I said with lecherous wink.

“You obviously haven’t taken your Haldol today.”

“Speaking of crazy,” I continued, ignoring her barb, “I think some specialties are going to have to get real about what they charge. I heard the other day that the charge for a trauma CT can be over $15,000. Now that’s crazy.”

“You don’t really think that’s going to happen do you?” she said shaking her head dismissively.

“Hey, all I know is what I read, and the Justice Department recovered over $3 billion last year from healthcare fraud. And most of the recoveries were from whistle-blowers in what they call qui tam cases.

It turns out Billy Mallon was right. When we see our colleagues committing fraud we need to call it like we see it. It could get really ugly before it gets better. But doctors are the only ones who can tell the difference between bending the rules to help patients and outright greed. We’re going to have to you-know-what or get off the can.”

“So let me see how many people you are going to have gunning for you; the government, the hospital, the other specialists. Can you think of anyone else you’d like to annoy today? Never mind, don’t answer that.”

Mark Plaster, MD Founder and Executive Editor of Emergency Physicians Monthly


1 Comment

  1. Right on Mark! This is scary stuff and we live in scary times and this will only keep getting worse. When will people wake up?

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