PSRO, PCA, UPRO?  Why Not Some TLC?



 Gautier grinned.  If there is such a thing as a malevolent grin, Gautier owned one.  His waxed moustache pointed down while the corners of his mouth creased an upward arc.


“You medicos will finally be put up against the wall, now that HR 1 has been enacted to monitor the finances of the medicare and medicaid laws.  Are you going to join the PSRO, Lapius?”


“You throw initials around like any pretentious bureaurocrat, Gautier.  Why PSRO?  Why not a PCA, or a UPRO, or maybe OSCHUR.”


“What are they?  I’ve never heard of them,” Gautier said, his moustache wiggling a bit to denote bewilderment.


“Well, then, Gautier, let’s not toss initials around so pedantically.  PSRO, of course stands for the Professional Standards Review Organization.  The other acronyms stand for similar organizations.


These all flow from the Bennett Amendment to the Social Security Act which says, in effect, that a physician has to justify continuing a mode of treatment that extends beyond standards established for the illness according to the patient’s age and diagnosis.


“Frankly, I don’t think it concerns me one bit,” Lapius pushed his chair from the table, leaned back, and lit one of the large black Havana cigars he imported from Nicaragua.


“Aha, typical doctor’s comment.  Ready to flout the law,” Gautier said gleefully.  “Don’t come crying to me, Lapius, when the government tries to put you in jail.”


Lapius snorted and blew a cloud of smoke that enshrouded Gautier and started him sneezing.


“I’m not flouting the law.  I’m not interested in Peer Reviews, not in hospital bed utilization.  My job is to take care of my patients.


When they are hospitalized, I will keep them there until I think that medically they are ready to go home.  If the government chooses to cease payments, that’s between it and the patient.


I inform all patients who have been hospitalized for a protracted period that insurance might not cover extended stay and they may have to meet the bill.  They are free to sign out of the hospital if they choose to.  But then they leave on their own responsibility.


I certainly won’t take the medical responsibility for aborting their hospital stay if I think it’s risky.”


“But, Lapius,” Gautier became serious.  He wasn’t needling now.  “You have a responsibility to the community.  You can’t usurp beds unnecessarily—” The word unnecessarily was a mistake.  It galvanized Lapius into attempting to stand up quickly, which involved a frenzy of activity.


First his chair was too tight, then he was still too close to the table.  He shoved mightily and the table slid away.  When he struggled to his feet the chair spun off his backside to land upside down.  Lapius ignored it and turned to Gautier

“UNNECESSARILY?” he thundered.  “Is it you, Gautier, who will determine how long my patient stays in the hospital?  He’s not your PATIENT, or the GOVERNMENT’S PATIENT.  As long as I’m the doctor he’s MY patient, and I’ll brook no interference.


He can go home anytime he wants to; all he has to do is sign himself out.  I’ll inform him of the risks.  Don’t talk to me about community responsibility taking precedent over the responsibility of a doctor to his patient.


NOTHING takes precedent over a doctor’s responsibility to his patient.”


“You’re too excited, Lapius,” Gautier cautioned.  “But let me understand.  Are you saying that doctors shouldn’t be involved in the utilization review.”


“Precisely.  This isn’t oriented towards patient care.  No one is checking on the care given the patient by the doctors, the hospital, the nurses.  It’s strictly a watchdog operation to govern finances. Who will patients sue if doctors become so skittish by having someone look over their shoulders that they discharge patients prematurely?  The Government?  The PSRO?  Not on your life.  They’ll sue the doctor.  And they’ll be right.”


“But Lapius, you know that hospital beds are over utilized.”


“Listen, Gautier, you are a lawyer.  What background in medicine, other than what you’ve learned in your close association with ambulances, gives you the expertise to judge complex medical problems?”


“But other doctors can judge.”


“No one can judge.  No one unless they know the patient, his disease, his family, the accommodations at home, the temperament of the people he’ll be going home to, the distance of the home from the hospital, the availability of outpatient nursing service…


What gall to believe that an outsider can come in, whatever his qualifications, and intrude on a doctor-patient relationship in such a manner, merely to decide the merits of the case in relation to the costs the government is willing to expend!


No, Gautier, doctors should not be concerned with anything but that patient’s illness.  Anything else is a community problem.


Maybe the community needs more hospitals, more extended care units.  Maybe hospital costs are too high.  But none of these considerations should be brought to bear on an individual illness.”


Lapius paused for breath, and then said sweetly, “But we are old friends, Gautier.  We shouldn’t argue.  Let’s change the subject.  What’s the current status of no-fault insurance?”


Gautier turned pale.  The tips of his moustache trembled and twitched.  He slammed his hand on the table.  “What right has a government to decide that there is no fault in an auto accident, or that a client isn’t entitled to proper legal representation?”


“I’m not sure I agree with you, Felix.”


Gautier stood up, more gracefully than had Lapius several moments before, walked up to the still-standing S.Q. Lapius and waggled a finger under his nose.  “You’re a doctor, not a lawyer.  What do you know about legal matters?  Stick to your own profession.”


“I intend to,” said Lapius, “I intend to.”