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Rules and Regulations

December 17, 2013

Last weekend I flew on an airplane.  I’ve done this before, of course, and the experience has morphed over 40 years from totally cool and exciting to mind numbing and infuriating.  What?  Sounds like medicine you say?  Indeed.  So I have only 45 hours on a beautiful tropical island in December, where I am escaping from a snow storm.  Between one thing and another it takes 11.5 hours to get from Boston to this wonderful place. The flight is only 3.5 hours.  Same thing going back, except of course that going back it sucks because you’re, well, GOING BACK.  Here’s my rant, and it does relate to health care.

On the flight onto this island the flight attendant kindly advises us that we must arrive back at the airport when going home 2.5 – 3 hours prior to flight time.  The flight time, according to the boarding pass, is a “scheduled time” as opposed to an “estimated time” which is sometime later than the scheduled time.  Island time I guess.  Why you need to get to the airport so early is unclear.  Most people obey.  Like we did.  Remember, 45 hours.  Now we’re down to 42. As you check in, they ask to see your passport.  When you go through security they ask to see your passport.  When you go through the gate to get on the plane they ask for your passport.  As though the three hours in the (one room) waiting area, which you can’t get into without going through security (in which your passport is checked), were for the purpose of giving you time to criminally alter your passport and/or your appearance.  I wonder how many people’s passports have altered in the 250 feet between security and the gate?  Oh, but the attendant at the gate is the only one who asks me to take my hat off.  Because the airline staff is highly trained and experienced in passport and identity fraud.  Then you get on the plane and the flight attendant on the plane asks to see your boarding pass.  Which someone just saw (along with your passport and your bad hair day) 50 feet ago.  Then when you get back to the good old cold USA, there are signs saying you can’t use your cell phone while waiting in line at immigration.  Too bad because the wait is long enough to watch a couple of episodes of How I Met Your Mother.  Actually, in a flight from the Philippines I actually had my bag sent through the scanner on the way OUT of the airplane as well as on the way IN, I guess to prevent people from taking advantage of the large and low-cost weapons superstore that is floating around at 35,000 feet.

Different example, same insanity:  Tiredoc, MD wrote a post on KevinMD about medicaid.  Here are the rules for prescriptions for medicaid patients in his state:

1. If you are not a child, an AIDS patient or insane you can only have 5 prescriptions per month.

2. If you take more than 5 different medications, the state recommends that you stagger them, filling only 5 each month.  So you can choose to control your blood pressure, your diabetes, or your asthma on alternating months.  So it balances out, you know.

3. If you take narcotics, you have to get a new prescription every month.  So you stagger the other 4.  Or something…

4. PA duration (I don’t know what that is but it sounds serious) has a maximum of 2 months duration.  So every 2 months you have to fill out all the forms again.

5. You can only get one brand name prescription per month.  So you stagger the other 3.  Or something…

6. Prescriptions to medicaid patients will only be paid for if the prescription is written by a medicaid physician.  Given numbers 1-5, those physicians are a dying breed.

Look, what I’m talking about here is rules without merit.  Regulations that exist without any reason, without any evidence, without any clear purpose other than obstruction.  Requirements that provide no explanation, but whose strictures require that you comply or you cannot move on in life.  If two checks of the passport are good for security, three must be better.  If requiring PAs for every medication is good, requiring them every 2 months instead of 6 must be better. If one time out in the OR is good, two must be better.  If getting to the airport an hour before your flight is good, getting there 3 hours before must be better.  You can fight these rules but the result is only that you don’t get on the plane, you don’t get the medication, you don’t do the case, you can’t accomplish things that really matter.  So we all do them.  We keep following the rules as they get more and more unreasonable and burdensome, in order to do what matters.  Evidence from my reading of what really good doctors are saying is that the tipping point is coming.  Doctors who love their work and are committed to their patients and feel genuinely called to the work are talking seriously about leaving the field.  Read KevinMD, or TheHealthCareBlog, or any of the other venues in which doctors write what they really think.  Good people will stop doing medicine.  Although I’ll still show my passport 50 times if it will get me out  of Boston in December.

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2 Comments
  1. thetinfoilhatsociety permalink

    PA: prior authorization.

    I think what may end up happening is a two tiered system in which people with ANY cash to spare will go to a physician in a cash only practice and the rest will see whoever they can in the state sponsored system (ACA for instance).

    • Thanks! I did figure out what PA meant, eventually. A small blessing that anesthesiologists don’t have to deal with them! About the future, I’m afraid you might be right. It certainly already occurs in specialty practices in affluent areas, like dermatology in manhattan. Sort of seems backward doesn’t it?

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