Wednesday, August 22, 2012

Fairness in the Pediatric Office

There is the theory of ethics, and then there is everyday fact.  We try to be fair in our practice and to do what's right, but sometimes you really have to think through what is right, what is fair, and what is practical.  So, here are a couple of instances.

I belong to SOAPM, the Section On Administration and Practice Management, of the American Academy of Pediatrics.  As a major benefit, we have Listserve.  Boy, so we have a listserve.  Don’t look at it for one day and you pile up 50 postings!  And, even though everyone on the Listserve isn’t Jewish, about 100 opinions.

A recent topic was this: what do you do when patients no-show?  This is a big problem with running an office, so we have a no-show fee that we charge our private patients.   Pretty common, and understandable why we would do this.  But here's the rub: a huge percentage of no-shows are on Medicaid (Medi-cal in California.)  And for Medi-cal patients, we are forbidden to charge them for no-shows.

Why do Medi-cal patients no show?  One thing I tell our staff is, this is why they are on Medi-cal!  This is the way they run their lives, in a disorganized and, in this case, disrespectful way.  And self-defeating.  But no matter - the very group that most needs the prodding to keep their appointments are insulated from consequences.  Some practices kick them out of the practice if they no-show a couple of times.  We try not to do this.  For one thing, as I tell our staff, imagine being a kid in such a family.  Our medical practice might be one of the few stable pillars of their lives.  These kids are subjected to what’s now being called toxic stress.  We can be at least one place where they are treated well, with caring and respect.  Just doing what we can.

Not that is doesn’t piss me off, because it does, a little.  It would piss me off more if we were on fee for service payment, but our Medi-cal patients are largely capitated, which means we get paid a monthly fee regardless of the visits.  But still, the no-shows can wreck havoc with our schedules.

So, here's the ethics part.  A poster on the Listserve (a nurse, actually; 95% of the Listserve participants are doctors) opined that if we charge our private patients for no-shows, but don't charge our Medicaid patients because we are forbidden from doing so, we are being unfair to the private patients. 

To me and to most of my colleagues on the Listserve, this was shockingly bad reasoning.    In this case, the fact that we can’t charge no-show fees to Medi-cal patients is a real deficiency, not so much for the lost income we would get from the fees, but for the effect it would have on the patients.  In fact, we are being unfairly treated by Medicaid with this prohibition, and for us to then go and amend our reasonable policy with private patients would only compound the unfairness of it all.

Another Medi-cal case:  We have instituted a new procedure in our practice for patients with asthma called spirometry.  This is a procedure where we sit the patient down with a mouthpiece and a tube connected to a computer.  A specially trained medical assistant has the patient blow very hard into the mouthpiece – it’s hard to get them to do this properly.  We then get a report from the computer for the clinician to interpret – again, this requires special training.  The result gives us great information on the state of the lungs and airways, and helps us in diagnosing and managing asthma.

For this procedure we get paid about $30 to $40 per test by commercial insurance, which covers our costs plus a little margin.  But can we do this for Medi-cal?  Sorry, no.  If it is a Medi-cal patient, we either have to do it for free, or we can refer them to our local Children's Hospital, which will not only do the spirometry for quadruple what we would accept for payment, but will tack on a full pulmonology consult as well.  And most commonly our Medicaid patients won't complete that referral anyway. 

So, if we do the spirometry in our office for private patients but not for Medicaid, are we being unfair to our Medicaid patients?  Should we do the spirometry in our office for Medicaid patients for free?  (Some of our docs want to do this.  They are not paying that particular bill.  I told them they could do it on occasion, just don't tell me.)  Or, should we stop doing it for our private patients, thus decreasing the quality of their care, putting "equality" or "fairness" above quality?

My answer has always been to say, we don't make the rules, we just try to do the best we can under the rules that someone else makes, and we go ahead doing private spirometries and referring out the Medicaid, and try to point out to Medicaid the error of their ways.  (Fat chance.)  We would rather have one common level of care, but we sometimes can’t help it if we don’t.

Another instance: this is what happened with flu shots a couple of weeks ago.  We got some private flu vaccine delivered; we are still awaiting our Vaccines For Children allotment of flu vaccine for our Medi-cal patients.  One of our doctors wondered if, to be “fair,” we should delay giving our private patients flu shots until we got our VFC flu vaccine shipment so everyone would get an "equal" chance.  So, should we decrease the protection of one group, (maybe kill a kid, who knows?) for the sake of equality?  My view is to go ahead and immunize the private patients and add the Medi-cal kids when the VFC comes in, just playing the hand we are dealt.

A non-Medi-cal case: Years ago a new vaccine for Hepatitis A was introduced, at I think about $125 a pop, with two doses recommended.  Hepatitis A only rarely kills, but it gives months and months of yellow skinned and vomiting misery.  Yet it wasn't generally recommended because it would have cost public budgets a lot of money, and private insurance companies as well.  It was all out of pocket to the patient.

What to do?  I offered it and recommended it to all our private patients and let them make their own decisions.  It was inherently "unfair," since the wealthier patients would be favored.  But what could I do?  Let the vaccine go unmentioned in the interest of "equality" and "fairness."  Let some patients who could afford the vaccine get the disease?  Would this "fairness" really have helped anyone?  I just played the hand I was dealt and tried to help who I could.  

We need to be a little humble.  We just play the cards we are dealt the best we can, and try to treat our patients fairly and equally when we can, but above all, to give the highest quality care to each individual patient we see.  But the latter is conditioned by circumstances beyond our control.

Seems to me, anyway.

Budd Shenkin