Prior Authorization

It happened again today. It happens to frequently. I saw a patient in clinic, she needed an imaging study that costs more than a haircut, and based on her insurance we could foresee the prior authorization from a mile away. So we marched her off to the emergency department so that we could declare the situation critical, force the hand of insurance, and get the chest CTA to look for a pulmonary embolism. Fortunately, my patient does have a right lower calf thrombus, but no embolism in her lungs. (US is dirt cheap enough they never fight that.) Why do we have to do this dance though? I do have a vested interest in our radiology department, and full financial disclosure, when I order tests in my hospital, we charge insurance for them. There is monetary gain. However if I was truly going to violate all ethics for monetary gain I would have done an x-ray first, (her leg hurts!), then full panel of labs (could be a prothrombotic condition, we need a D-dimer to screen for thrombus, did she burn through all her platelets and clotting factors is this DIC!?). No, I just want to screen the warm area of her calf for a clot, she has left chest wall pain, can I look for a clot there? Would I could I, I certainly would use US for the chest, but alas it is not the gold standard. So I see a patient who acceptably comes to clinic, I know what tests to order, and someone in a building across the country says I cannot do that until some other individual, probably in some other building deems it necessary. Cost saving measure. Until I put her in the emergency department and bill for a visit there, rather than in clinic.

I initially wanted to write an article on how this terrible system came to be. Honestly I could not find any concrete facts to share with you. There is no smoking gun, no one bill passed in the senate that gave the insurers all the power. Which is too bad, we could possibly reverse that one statute, take the power back. Rather it appears to have been an insidious slowly advancing, cancerous process where the insurers slowly gained the control over our healthcare system. It is not slanderous to say they did so to turn larger profits, to make more money. This is not only apparent, but well documented. Problem being, they purchased lobbyists to fight for changes in our healthcare system that will allow for more and more profit, which purchases more lobbyists. We (under-reimbursed) healthcare provider entities will never reverse this system. They will always outspend us.

A recent discussion on this site asked us healthcare providers to weigh in on legislation that would force hospitals to disclose payer negotiated rates to the public. A vast majority of responses were in support of this. Likely because we all understand that if the behind the curtains shenanigans were exposed, people could find the health insurance that covers patients best, but also it would be exposed how little these entities actually pay the healthcare providers, providing the services rendered. Most appalled would be those who realize their co-pay is more than their insurance company paid, or even worse those who paid full price requested, who see how little the healthcare insurance companies are allowed to pay for the same service.

With any luck, full disclosure may very well be the first step toward righting the ship. I fear it will not change anything. Public opinion matters not, when every insurer is culpable. If everyone is doing it, and getting away with it, there is no onus to change.

I opened with a patient who certainly needed further work up to rule out/in a concerning diagnosis. I will close with one quite the opposite. It turns out we can be too skilled of clinicians in these situations. In clinic I had a 16 year old female with right lower quadrant pain all day. She presented to clinic. I examined her and it was textbook appendicitis. The pain had started in her umbilicus, moved to the LLQ, then the RLQ where she was still tender. Psoas sign+, Rovsings sign+, she had a fever, we ordered a CBC, she had an elevated WBC with left shift. So I ordered a CT scan of her abdomen and pelvis with contrast. The insurance company said they would get back to us in 72 hours, but added: the case appears to be classic appendicitis with diagnosis made CT is not recommended. Heaven forbid we A: confirm the diagnosis, but more importantly B: assess the status of the appendix, how enlarged is it, has it ruptured already, how much time do we have before she goes septic? I was in outreach so we sent her to the emergency room in the neighboring community, when I could have sent her straight to the surgeon. I thought it best to burden our community hospital ED with this nuisance rather than the trauma center with the surgeon. Right or wrong in that regard, the fact we had to jump through that hoop was ridiculous.

Sadly it is not just imaging studies as we all know, it is medications, medical equipment, sometimes even the right for the patient to see a specialist. My only hope is that in the near future, somehow, we can find a way to make practicing medicine make sense again. It is giving me a headache, and I know if I blow a vessel in my brain it will be days until insurance says I can have a head CT.

Hospital Policy Trumps Reason, CNA Delivers Baby In Hospital Hallway

Manhattan KS: Certified Nursing Assistant Holly Schmidt earned her stork wings earlier this week as two physicians battled over patient acceptance while common reason flew out the window. The 27 year old female patient presented to the emergency department in what she feared was active labor. She stated she was 36 weeks pregnant and having contractions about 4 minutes apart. Staff clinician Dr. Edward Santos jumped into the air clicking his heels upon this news as hospital policy dictated all pregnant women over 36 weeks bypass the ED. “Straight to OB!” he giggled with delight. Upon arrival however, the attending obstetrician, using Naegle’s rule determined that the patient was actually 35 weeks 6 days, 10 hours, 54 minutes and 6 seconds pregnant. As such, hospital policy dictates, all possible labors under 36 weeks be evaluated in the ED to determine true labor. Thus the patience was returned to the ED.

Dr. Santos was dumbfounded. “I thought I had this gal off to OB to deliver her baby. I look up at the ED triage board though, and there she was again, I about fell over.” Dr. Santos called OB to discuss the situation and spoke to Dr. Gary Parry who calmly explained, “Hospital protocol is that if they are under 36 weeks they are seen in the ED first, I cannot be bothered with Braxton Hicks, I am a busy man, please evaluate her.”

Dr. Santos began a frantic search for a nurse to act as chaperone while he performed the intimate exam, but due to an acute MI, two strokes, a two vehicle MVA with an ejection, and a fever of 2 days duration all the nurses were otherwise occupied. After a five minute search Dr. Santos finally gave up and checked the patient found her to be at 8 cm and in active labor. Naturally, after exiting the exam room, he found a female coworker: Ms. Schmidt. “Holly Schmidt! We need to get this patient back to OB right stat now!”

A nurse was pulled from the lesser stroke to transport the patient with Holly in tow, back to obstetrics from which she had bounced. “As we were about to get into the elevator to go up to OB there was a code blue called back in the ED so the nurse sprinted back that way. “I didn’t really know if I should continue on my own, as the nurse is suppose to give report to the accepting floor, or if I should take her back to the ED, where her nurse was. After about 10 minutes I was getting pretty worried, as was the patient, she said she had just peed the bed. Of course it wasn’t pee, it was amniotic fluid. I prayed the nurse would come back soon but more and more passed, as did the baby’s head, then shoulders. Good thing I was there or he may have slid right off the end of the bed.” Holly reported smiling ear to ear by the bassinet, in OB. “It is fortunate that I always carry a cord clamp on my name badge. Also fortunate that about that time the nurse returned and we were able to continue up in the elevator to the OB floor.”

Dr. Parry did ultimately accept the patient, as well as her new roommate upon arrival, though he was rather proud to be found to be correct, “See that woman is not in active labor, why she is post postpartum at best!”

Book Signing Union College-Love Building

The next book signing has been scheduled, at the school featured in the book Through the Eyes of Young Physician Assistant; Union College in Lincoln Nebraska. The event will run from 9am-noon in the Don Love Building (#11 here🙂 September 9th, 2016

Come one, come all, bring your copy of the book, or purchase on site the day of; meet the author and get your book autographed.

Book Signing McCook NE

The next book signing will be at New Life Christian Books in McCook NE (212 Norris Ave McCook NE 69001) July 16  from 11am to 1 pm, coinciding with Crazy Days. Come meet the author, purchase Through The Eyes of a Young Physician Assistant and have it signed at no extra cost. Or bring your own copy and have it signed for free!

Book Signing Hays KS

The next book signing will be at Hastings Bookstore in Hays KS June 25, 2016 (3300 vine street Hays KS 67601) from noon until 3pm. Purchase Through The Eyes of a Young Physician Assistant and have it signed, or bring your own copy and have it signed for free!

Short story accepted for publication in anthology

So about two months ago 2LeafPress sent out a request for submissions for an anthology to be edited by Gabrielle David and Sean Frederick Forbes entitled What Does it Mean to Be White in America? I created a short story What Does Race Have to Do With It? specifically for this anthology. Last week I received an email that my story had been accepted for inclusion in what the editors hope will be a ground breaking publication. I am honored to be included. To read more about the project feel free to click here: 2Leafpress-Whiteamerica

First Book Signing

So as of today the contract has been signed, so it is time to start planning events. The current plan is to release to book (to great fanfare of course) at the AAPA National Convention in San Antonio TX May 14, 2016. Right now the AAPA is kind of being a stinker about only allowing keynote speakers to have book signings, so I am working on something at least close to the center with AAPA support. We have to stay within their guidelines, and I need their support. Regardless, there will be book signings all over the Midwest, so keep your eyes peeled to this page for signings hopefully in:

San Antonio (obviously)

Hays KS

Kansas City



Kearney NE

The teaming metropolis of McCook Nebraska