Letters to the Editor

I just finished reading Dr. Donald Hause's article in the Jan/Feb 2001 issue of Sacramento Sierra Valley Medicine, entitled To Defraud or Not. As a second year student at UC Davis School of Medicine, I was intrigued by the scenario Dr. Hause described to obtain payment for a breast reduction for a patient who is covered by an insurance provider. What a runaround!

I liked his simple and seemingly obvious solution of making the insurance companies and government agencies pay for services up front. No need to inflate prices and try to trick the insurance company into paying fair compensation. I wonder if this solution is too simple.

Could it work? Could health care be run honestly and fairly? Would physicians come together and refuse to sign any more contracts that do not include adequate payment upfront? If I did business with someone who had a history of not paying for services, I would either not do business with that person, or I would require payment upfront.

Gina Tobalina
gtobalina@ucdavis.edu

The Professional Conduct & Ethics Committee is disturbed

We are writing regarding To Defraud or Not. This article was discussed in our committee and the opinions that follow represent the majority of the committee members present.

While we can understand Dr. Hause's frustration with the current state of the insurance industry, we found some of his observations and conclusions disturbing. First, the title of the article is unfortunate, as it implies that defrauding anyone is a course of action open to a physician. The practice he describes may or may not be fraudulent, but the implication that a physician may legitimately choose to commit fraud to receive adequate payment from an insurance company is inappropriate.

Dr. Hause's description of fee inflation is also concerning. There is no question that the insurance billing and payment system is unfair to physicians and patients. However, his goal of collecting a higher fee than the insurance company is willing to pay does not justify misrepresentation of the value of his service. Deliberately inflating one's fees in an attempt to collect "what it is worth" by deliberately inflating the level of service is unethical and fraudulent. Deliberately overcharging for a service, as Dr. Hause apparently did, is just ineffective.

Finally, we were most disturbed by Dr. Hause's apparent confusion between what is best for patients and what is best for him. He asserts that "our primary concern as physicians is our patients," then implies that this concern is the basis for his requirement that patients pay before their surgery. Paying up front benefits Dr. Hause, and he should not attempt to disguise this practice as a way to show concern for his patients. His analogy to car repair is not apt, as most physicians consider the service they provide to their patients to be of a different order. There is no Hippocratic oath for car mechanics, and treating medicine as a business like any other business has certainly not worked well for physicians and patients in the past. It is arguably one of the reasons for the very problems with the insurance system that are aggravating Dr. Hause in the first place.

Dr. Hause's patients want elective cosmetic surgery, and this allows him more latitude in requiring payment prior to service than most other physicians, who must often provide care in urgent or emergent situations where delaying or refusing care while awaiting payment could be dangerous. We do not take issue with Dr. Hause's right to run his practice as he sees fit, within the limits of professional ethics and the law. But he should not imply that fraudulent billing is an option, nor should he state that requiring the patient to pay before service benefits the patient. We welcome his comments, and the comments of other society members.

Joanne Berkowitz, MD, Chair
Professional Conduct & Ethics Committee

Optometrists are not like chiropractors

I found Dr. Ostrich's recent article [ Optometrists See an Opening - and Take it] irresponsible, misleading and unnecessarily vitriolic. I understand the CMA and ophthalmologists are upset that SB 929 has violated the territory heretofore considered to be exclusively that of the ophthalmologists. However, to move from a turf battle to compare optometrists to chiropractors is an unwarranted leap of faith.

Chiropractors are individuals trained in a discipline that is foreign to MD training and philosophy. Chiropractic is a non-science, teaching principals that make little sense to those of us trained in the allopathic tradition.

Optometrists, on the other hand, spend four years in post graduate school studying the complexities of the eye, from refraction to disease. During their four years they learn more pharmacology than many of us did in medical school. They certainly have learned more about the eye than most of us in primary care who are allowed to diagnose and treat eye disease.

In California, if they want to do therapeutics they need to take another set of boards. They are not charlatans masquerading as medical practitioners the way chiropractors are.

Unfortunately, they are also taught vision therapy, which the vast majority do not use in their practice. Yet this is a part of optometry that seems closest to chiropractic or iridology. It should not balance out the intense medically sophisticated and relevant training they receive. They are trained in the medical model. They are practitioners of eye health and are quite capable of diagnosing eye disease and should be allowed to treat it. Many think that they would not refer patients in a timely manner. This is no more reasonable than to think that a primary care doctor with less eye care training would do the same. I feel that our colleagues in optometry were done a disservice by your article and I, for one, would appreciate it if we would tone down the anti-optometry rhetoric.

Jeffery J. Rabinovitz, MD FAAP

The author replies

It truly is a pleasure to receive such an interesting and thoughtful response. I did not mean to suggest, nor did I suggest, that optometrists are comparable to chiropractors or iridologists. I have always received my own primary eye care from optometrists, and have complete faith in optometry as a legitimate profession. My concerns have to do with the erosion of our hard-earned professional reputation and autonomy and the general "dumbing down" of medical care.

It is more than a "turf battle." It is a battle over the right way to care for sick people. Probably 90 percent of people who consult chiropractors get better because they were going to get better anyway.

Is it simple viral conjunctivitis or is it iritis? A minor corneal abrasion or viral keratitis? Just an inflamed stye on a diabetic patient, or early periorbital cellulitis? Optometrists have convinced the people (or at least the legislators) that they are competent to make similar diagnoses and therapeutic decisions. I, for one, do not think so.

As a profession, we should continue to educate the people and politicians that we are the best folks to consult first if you have an inflamed painful eye, or a backache that radiates to your posterior thigh, or a vague malaise and a funny looking brown blotch that just appeared on your otherwise perfectly blue iris. To do less is to forsake our heritage and our patients.

John Ostrich, MD