Medical practice: gone to the dogs.
Subject: Veterinarians (Practice)
Veterinarians (Finance)
Physicians (Practice)
Physicians (Finance)
Health care reform
Author: Rosenwasser, Tamzin A.
Pub Date: 06/22/2007
Publication: Name: Journal of American Physicians and Surgeons Publisher: Association of American Physicians and Surgeons, Inc. Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2007 Association of American Physicians and Surgeons, Inc. ISSN: 1543-4826
Issue: Date: Summer, 2007 Source Volume: 12 Source Issue: 2
Topic: Event Code: 200 Management dynamics; 250 Financial management Computer Subject: Company financing
Product: Product Code: 8044000 Veterinarians; 8011000 Physicians & Surgeons NAICS Code: 54194 Veterinary Services; 621111 Offices of Physicians (except Mental Health Specialists) SIC Code: 0740 Veterinary Services; 8011 Offices & clinics of medical doctors
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 164872236
Full Text: One day toward the end of November, Koochi seemed lethargic, with a stiff neck, so I called--the health plan's utilization review nurse? No, no, this is a dog; there's none of that.

We were out of town, so I looked in my dog club directory and found a nearby member, who gave me the name of a veterinarian. I called and got an appointment for that day. Koochi was examined, had a lateral neck X-ray, was treated with muscle relaxants, and seemed normal until Dec 2, 2003, when she awoke with four-limb incoordination.

I called the vet, and said I needed a referral to a neurologist. They gave me a referral--but it was out of your network? No, no such thing.

I called the Veterinary Specialist Hospital, and they fit us in that day, through their emergency room. The patient was examined and the neurologist recommended a magnetic resonance imaging study (MRI). The study, done that afternoon at a center for veterinary patients, showed a big disc herniation between C6 and C7. We decided to try medical treatment with prednisone, but she could not be weaned from it. Long-term prednisone in a 124-pound Newfoundland would have bad consequences. There were discussions with her various veterinarians--and the preauthorization committee? No, no insurance company involved; it was just between me and her vets. They know me and this dog; we do not have any insurance "plan" that has switched us from one veterinarian to another. We trust each other. They know I will pay them, and I know they will do their best to save this dog's life and return her to good health. They know she will not bite them.

She had an anterior cervical slot procedure, got much better, and could walk normally within 12 hours. But her neck had not been stabilized, and she relapsed to almost total paralysis within 24 hours. She had a myelogram, showing instability.

Her veterinarian was paid more for this than a physician doing the same work; the money went directly to the veterinarian; it was not routed through a huge bureaucracy, leading to a reduced payment, months later, to the person who actually did the work.

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 there, strapped to a stretcher. She was examined Feb 9, 2004, and had a second anterior slot on Feb 11, because a dorsal laminectomy was thought to be too risky without stabilization of the slot. She improved immediately to ambulatory status.

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 down-coding, with the result that the veterinarian will not be paid for the real, valuable work he did--for me and my dog, not for some government or insurance bureaucrat. In fact, regardless of the actual work a physician does under Medicare or Medicaid, if certain "bullet points" are not mentioned, a "Recovery Audit Contractor" can snoop it out and claim the physician committed fraud, and should not have been paid for the work done because it isn't exactly the way it should be.

Koochi crashed again; the methyl methacrylate plug that had been inserted to keep the vertebral bodies apart fell out; so she went 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 dog. He has to work with small bones that surround the spinal cord. A Newfoundland has a heavy head. Doing surgery is not like running in to get an oil change. It's not like running a company, or drawing up a will. There is no work like it on earth, but in 21st century America, the people who do it for human beings are as disposable as used tissues as far as the people who pay for others to get documented their medical care are concerned.

By the next afternoon Koochi was walking, but by Sunday morning she crashed again. A CT scan showed the plug was in place, but the weakened bones had collapsed around it, and once again, she had lost the space between the two vertebrae. Her mind was clear, but she could not bear her weight or move.

I was in agony, and I imagine the veterinary neurosurgeon was also. I had to leave her there alone in Boston, and go to begin my job. The vet called me the next day; she was deteriorating. Did I want them to "put her to sleep"?

There was one other option; he had never done it on a dog down for so long, or this old, or on prednisone for so long--a dorsal laminectomy, more painful, with a longer time needed to recuperate. I said to do it. It was done the next day, Tuesday, but she did not get better. I went to Boston on Saturday with my sister to pick her up. She remained flat on her side, immobile except for her face. Through all of this, the vet attended her every day, and fed her personally, by hand.

We took her out as she came in, strapped flat to a stretcher. I put her on an air bed, and on Feb 21 hired a veterinary technician to assist me daily with physical therapy, using a sling suspended on two poles. Within a week she could roll onto her sternum. By the end of April, she could walk 150 yards or so on her own.

There were no insurance cards to show, no bureaucratic gobbledygook, no preauthorization forms, no begging some stranger for permission to get medical care for my dog. Just dedicated veterinarians solving a problem that had befallen my beloved dog.

I received an estimate of the expected charges, and they were the same for her as for a younger dog, a wealthier owner's dog, an older dog. They were set by a free market, not by an ignorant government bureaucrat, as directed by a clueless congressperson. The veterinarians were paid for the valuable work they did; that is, their work is valuable to me. I delivered this dog, and have known and loved her since the moment of her birth. If her veterinary neurosurgeon were operating on a human being, "covered" under some "plan," whether as part of a taxpayer-funded government "entitlement program" or some employer's "plan," no government bureaucrats, taxpayers, or insurance company would have cared whether she lived or died. Only if enough people became restive or angry about the effects of bureaucratization on their medical care would anybody be the least bit concerned.

In 21st century America, the Land of the Free and the Home of the Brave, a surgeon who is operating on your child, under government and insurance company-directed medicine, is required to trivialize his thinking about the actual medical problem the child has, in order to make certain that he is including the exact number and kinds of details in his notes about what he did. Whatever the government has decreed in the "correct coding initiative" must be included for him to receive the payment allowed for some specific code number, reflecting what he did, rather than another, lower code, or he simply will not be paid for the work he does for your child. He may be paid some lower amount. Or, he may even be charged with "waste, fraud, and abuse," though it is absurd to contemplate a government riddled with spendthrifts of other people's money charging anybody else with waste, fraud, and abuse.

For veterinarians, nobody is counting up "Resource Based Relative Value Units." The value of their services is determined very simply: if you are willing to pay for it, that is the value. Human medical care in the United States has become burdened with initialing, coding, notes stuffed with useless information, "Clinical Laboratory Improvement Acts" that serve only as uncompensated make-work and hidden taxes extracted from physicians and hospitals, "Health Insurance Portability and Accountability Acts,"--accountability to the government, not to the actual patient--whereas the veterinary profession, free of the dead weight of all these diktats, is more private, more efficient, more humane, and has more freedom, than the human medical profession has.

No recovery audit contractors (government-sponsored bounty hunters) are prying into my dog's records, to make sure that the hapless taxpayers haven't mispaid her bills (of course, the snoops get paid, for producing nothing of actual value). No medical technologist or nurse is second-guessing her veterinarian's judgment; nobody is saying her life should not be saved because she is nine years old, and that's pretty old for a Newfoundland dog.

I can get the equivalent medical services that are more reasonably priced, with less trouble, for my dog than for myself, and the veterinarian is often paid better, while living a working life with fewer hassles and more pleasure in his profession, than physicians taking care of human patients, who are constantly harassed by government and insurance bureaucrats.

Nothing is more personal than medical and veterinary care. Nothing is less conducive to being directed by people who do not actually take care of the patient. My deepest appreciation goes to the veterinarians who took care of my dog and of me. She is now almost 13 years old, still walking, still a joy.

Tamzin A. Rosenwasser, M.D., is a board-certified internist and dermatologist, who practices dermatology, and is president of AAPS. Contact:

Tamzin A. Rosenwasser, M.D.
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