My dad had a saying whenever we did something not to his liking. His quote has cemented itself in my head after all these years, and though I’ve never used it with my kids, there are times it flashes in my brain whenever I or someone else does something, really, really…for lack of a better word…stupid. So what did he say that left such an indelible mark on a young mind?:
“Are you really that
stupid or are you trying to piss me off?”
Yep, that was Dad. When
I was a kid, I understood this to be a rhetorical question, though rhetorical
was not yet in my vocabulary. This
was more of a statement rather than an inquiry.
I understood it required no response since its meaning was crystal clear,
until one day he looked straight at me for an answer.
“Well?”
What? Are you kidding
me? He actually wanted an answer! I stumbled with a bunch of “uhs” and still he
stood there, hands on hips, waiting for an answer. I was sweating it bad, going over all the
foreseeable consequences of a response. If
I said I was stupid it would seem I was mocking him—bad, very bad. And if I said I was pissing him off, well
that would be very, very bad. Nobody
wanted to piss-off ex-paratrooper-in-the-82nd-Airborne-Dad,
especially a 10-year-old kid. That would
be insane. That was the definition of stupid. And yet there I was in a Catch-22, another
word not yet in my vocabulary.
I hurriedly came up with the best answer I could: “Uh, uh, I think I’m stupid. Uh, I think I got that from Mom?”
Notice the last sentence was phrased as a question since I
wanted to convey an obvious sense of uncertainty with my response, hoping this
would mitigate the resulting carnage.
Surprisingly, Dad simply said, “O.K.”
Shocked, I walked then skipped away with a sense of
semi-joy. Sure, I insulted Mom, but if
it ever got back to her that I used her as a scapegoat, she’d know it was an
untruth. Mom was always much smarter
than my late dad, God rest his soul.
Fast forward years later.
I’m an ENT doctor and one of the many time-consuming annoyances is prior
authorizations, commonly referred to as “prior auths.” Prior auths are a bane to the practice of
medicine. A prior auth requires a
medical provider with years and years of education to ask the patient’s
insurance company to “approve” a certain diagnostic test (such as a CT or MRI)
or a surgical procedure. Mostly, it’s
one of the physician’s staff that must do this, but from time to time the
doctor must get on the phone to justify why a test or procedure is
necessary. Sometimes the test or
procedure is denied, and usually by someone with no medical training whatsoever. Many believe prior auths are a tactic insurance companies use to not only
delay treatment, but to frustrate the provider with the process such that
he/she will simply give up and not do the test or procedure. But most docs will suffer through a prior
auth for the sake of their patient. Prior
auths are a cost-saving measure that doesn’t save costs but shifts it to the
doctor’s practice. The time burden on
the doctor’s staff is enormous: in my practice, one staff member wastes the
equivalent of over one full day a week just on prior auths, when she could be
spending it more productively on meaningful endeavors that actually improve quality
of care. And I’m the only doctor in my
practice! Much larger group practices
and hospitals employ several fulltime people whose sole job is dealing with
prior auths. Multiply this by the gazillon
medical practices and hospitals throughout the country and you can imagine the
expense devoted nationwide just on prior auths.
Prior-auths do not improve the quality of care but lower it, by needlessly
wasting time that adds unnecessary expense. This is one reason healthcare is so expensive
in the U.S.
I recall years ago needing a prior auth for one of the most
common procedures done by ENT doctors: myringotomy and tube placement. You can refer to Ear
Tubes and Otitis Media for a more detailed discussion on this topic,
but the gist is a myringotomy is the incision into the ear drum through
which the tube in is inserted. You
must do the myringotomy first in order to place the tube. Plain and simple. Or so I thought.
One day after waiting for approval of a prior auth by a certain insurance
company, my office gets a call from that company saying, “We’ll approve the
tube placement but not the myringotomy.”
What?!
I was beckoned to the phone.
The average ENT doctor performs thousands of myringotomy and tubes during
the course of a career. It’s one of the
most common surgical procedures in children.
Yet there on the phone was someone telling me how to do my job. I tried to explain that I must do the
myringotomy, that without it I could not place a tube through the eardrum. I could not simply lie the tube on the drum
since that would be useless, nor could I push the tube through with brute
force, since that would damage the entire drum.
I explained the CPT book (a book that assigns a numeric code for every
surgical procedure known to mankind, and is the universal sourcebook used by every medical practice and hospital in the country) lists myringotomy alone or myringotomy with tube placement, but
there was no code for tube placement alone, and so “tube placement” as a sole
procedure does not exist. I also explained
the pathophysiology (in layman’s terms) of otitis media and the rational for the
surgical procedure.
I spent an inordinate amount of time, time that was taking
me away from patients waiting in the exam rooms, time I could never get
back. During this long spiel, in the
back of my mind I really had the urge to say:
“Are you really that
stupid or are you trying to piss me off?”
No doubt, that would’ve made matters worse so I held my
tongue. I use this example and Dad’s
quote on a Power Point slide and sometimes flash this during a lecture to
residents who likewise suffer the indignity of the prior auth process. They understand the sentiment and meaning
completely; they know full well this question speaks for itself. No answer required.
©Randall S. Fong, M.D.
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