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.”