From the President:Medical Practice: Gone to the Dogs
Tamzin A. Rosenwasser, M.D.
The operative note is brief, to the point; there is no ludicrous
E&M code, or “procedure code” that must be satisfied. There are no
mandates that certain specific things be mentioned, on pain of
One day toward the end of November, Koochi seemed lethargic,
down-coding, with the result that the veterinarian will not be paid
with a stiff neck, so I called—the health plan’s utilization review
for the real, valuable work he did—for me and my dog, not for some
nurse? No, no, this is a dog; there’s none of that.
government or insurance bureaucrat. In fact, regardless of the
We were out of town, so I looked in my dog club directory and
actual work a physician does under Medicare or Medicaid, if
found a nearby member, who gave me the name of a veterinarian.
certain “bullet points” are not mentioned, a “Recovery Audit
I called and got an appointment for that day. Koochi was
Contractor” can snoop it out and claim the physician committed
examined, had a lateral neck X-ray, was treated with muscle
fraud, and should not have been paid for the work done because it
relaxants, and seemed normal until Dec 2, 2003, when she awoke
isn’t documented exactly the way it should be.
Koochi crashed again; the methyl methacrylate plug that had
I called the vet, and said I needed a referral to a neurologist.
been inserted to keep the vertebral bodies apart fell out; so she went
They gave me a referral—but it was out of your network? No, no
back to surgery Feb 13, and another plug was inserted. This work is
not easy. The veterinarian knew I was worried, and that I love my
I called the Veterinary Specialist Hospital, and they fit us in that
dog. He has to work with small bones that surround the spinal cord.
day, through their emergency room. The patient was examined and
A Newfoundland has a heavy head. Doing surgery is not like
the neurologist recommended a magnetic resonance imaging study
running in to get an oil change. It’s not like running a company, or
(MRI). The study, done that afternoon at a center for veterinary
drawing up a will. There is no work like it on earth, but in 21st
patients, showed a big disc herniation between C6 and C7. We
century America, the people who do it for human beings are as
decided to try medical treatment with prednisone, but she could not
disposable as used tissues as far as the people who pay for others to
be weaned from it. Long-term prednisone in a 124-pound
get their medical care are concerned.
Newfoundland would have bad consequences. There were
By the next afternoon Koochi was walking, but by Sunday
discussions with her various veterinarians—and the pre-
morning she crashed again. A CT scan showed the plug was in
authorization committee? No, no insurance company involved; it
place, but the weakened bones had collapsed around it, and once
was just between me and her vets. They know me and this dog; we
again, she had lost the space between the two vertebrae. Her mind
do not have any insurance “plan” that has switched us from one
was clear, but she could not bear her weight or move.
veterinarian to another. We trust each other. They know I will pay
I was in agony, and I imagine the veterinary neurosurgeon was
them, and I know they will do their best to save this dog’s life and
also. I had to leave her there alone in Boston, and go to begin my
return her to good health. They know she will not bite them.
job. The vet called me the next day; she was deteriorating. Did I
She had an anterior cervical slot procedure, got much better, and
could walk normally within 12 hours. But her neck had not been
There was one other option; he had never done it on a dog down
stabilized, and she relapsed to almost total paralysis within 24
for so long, or this old, or on prednisone for so long—a dorsal
hours. She had a myelogram, showing instability.
laminectomy, more painful, with a longer time needed to
Her veterinarian was paid more for this than a physician doing
recuperate. I said to do it. It was done the next day, Tuesday, but she
the same work; the money went directly to the veterinarian; it was
did not get better. I went to Boston on Saturday with my sister to
not routed through a huge bureaucracy, leading to a reduced
pick her up. She remained flat on her side, immobile except for her
payment, months later, to the person who actually did the work.
face. Through all of this, the vet attended her every day, and fed her
Since I had to be in New Hampshire, I asked for a referral to
Boston, almost 1500 miles away, and with a friend, I drove Koochi
We took her out as she came in, strapped flat to a stretcher. I put
there, strapped to a stretcher. She was examined Feb 9, 2004, and
her on an air bed, and on Feb 21 hired a veterinary technician to
had a second anterior slot on Feb 11, because a dorsal laminectomy
assist me daily with physical therapy, using a sling suspended on
was thought to be too risky without stabilization of the slot. She
two poles. Within a week she could roll onto her sternum. By the
improved immediately to ambulatory status.
end of April, she could walk 150 yards or so on her own. Journal of American Physicians and Surgeons Volume 12 Summer 2007
up “Resource Based Relative Value Units.”
The value of their services is determined
stranger for permission to get medical care
very simply: if you are willing to pay for it,
that is the value. Human medical care in the
useless information, “Clinical Laboratory
charges, and they were the same for her as
for a younger dog, a wealthier owner’s dog,
hospitals, “Health Insurance Portability
and Accountability Acts,”—accountability
paid for the valuable work they did; that is,
their work is valuable to me. I delivered this
sion, free of the dead weight of all these
diktats, is more private, more efficient,
the moment of her birth. If her veterinary
being, “covered” under some “plan,”
ment-sponsored bounty hunters) are prying
into my dog’s records, to make sure that the
some employer’s “plan,” no government
hapless taxpayers haven’t mispaid her bills
became restive or angry about the effects of
would anybody be the least bit concerned.
that’s pretty old for a Newfoundland dog.
Free and the Home of the Brave, a surgeon
services that are more reasonably priced,
directed medicine, is required to trivialize
myself, and the veterinarian is often paid
profession, than physicians taking care of
coding initiative” must be included for him
conducive to being directed by people who
did, rather than another, lower code, or he
do not actually take care of the patient. My
simply will not be paid for the work he does
for your child. He may be paid some lower
veterinarians who took care of my dog andme She is now almost 13 years old, still
“waste, fraud, and abuse,” though it is
Tamzin A. Rosenwasser, M.D., is a board-
riddled with spendthrifts of other people’s
certified internist and dermatologist, who
practices dermatology, and is president of AAPS. Journal of American Physicians and Surgeons Volume 12 Summer 2007
The 59th annual Montagna Symposium on the Biology of Skin presents POSTERS Ewout M. Baerveldt1,2 , Armanda J. Onderdijk1,2, Chris Wohn2, Marius Kant1,2, Eddy F. Florencia1,2, Jon D. Laman2, H. Bing Thio1, Johann E. Gudjonsson2, Errol P. Prens1,2 1Departments of Dermatology and 2Immunology, Erasmus MC, Rotterdam, The Netherlands 3Department of Dermatology, University of Michigan, Ann
up “Resource Based Relative Value Units.”
The value of their services is determined
stranger for permission to get medical care
very simply: if you are willing to pay for it,
that is the value. Human medical care in the
useless information, “Clinical Laboratory
charges, and they were the same for her as
for a younger dog, a wealthier owner’s dog,
hospitals, “Health Insurance Portability
and Accountability Acts,”—accountability
paid for the valuable work they did; that is,
their work is valuable to me. I delivered this
sion, free of the dead weight of all these
diktats, is more private, more efficient,
the moment of her birth. If her veterinary
being, “covered” under some “plan,”
ment-sponsored bounty hunters) are prying
into my dog’s records, to make sure that the
some employer’s “plan,” no government
hapless taxpayers haven’t mispaid her bills
became restive or angry about the effects of
would anybody be the least bit concerned.