…today the term, “byzantine”, is used as an adjective for things that are complex and dazzlingly confusing.
The Byzantine Empire
The Byzantine Empire which existed from the Fourth Century A.D. until its fall to the Ottoman Turks in the Fifteenth Century was noted, among other things, for intrigue, complexity, and corruption. So deep was this empire’s reputation for labyrinthine and secretive political machinations that today the term, “byzantine”, is used as an adjective for things that are complex and dazzlingly confusing. Such is the Byzantine Kingdom of today’s healthcare system. What follows is an edited excerpt from an unpublished book that I wrote over twenty years ago:
The Lab Inspector
One of the first evidences that the Kingdom of Byzantium was gaining influence in a large way in the world of medicine was the appearance of diagnosis and procedure codes and fee schedules in the Medicare program during the Eighties. It was easy to see from the start that having Family Practice or General Internal Medicine as your calling was a distinct financial disadvantage. If you didn’t have a “procedure” you got paid a whole lot less. The guys who figured out the payment schedules must have liked gadgets and all that fancy stuff. You sure got paid a lot more for using a knife, a needle, or a machine to help a patient than your ears, eyes, hands, and brain.
This, of course, was a significant inequity, resulting in a relative devaluation of primary care doctors’ services compared to their specialist colleagues. This also had the effect of making specialty practice more attractive. (This is a primary reason for the continued overabundance of specialists today. ) However, believing as he did in the importance of the “generalist” in the overall scope of medicine, our young doctor thought this inequity, by itself, was one with which he could live.
…the “Clinical Laboratory Improvement Act” of 1988, or, CLIA.
But the Byzantine onslaught continued to wash in upon him, wave after wave. One memorable surge of the Byzantine invasion, was a benevolent-sounding legislative attempt to improve the quality and standards of medical laboratories. It was called, euphemistically, the “Clinical Laboratory Improvement Act” of 1988, or, CLIA. After a mandatory registration fee of one hundred dollars or so, most independent doctors in primary care laid low, working quietly, minding their own business , hoping that nothing would come of it.
Fat chance.
Once set into motion, the result was a done deal. Laboratory reforms inundated the country, subjecting every medical lab, from the mega-labs of Smith-Kline (now Quest Labs) to “one-holer” dipstick labs (such as was found at the young doctor’s office) to inspections, regulations, and restrictions. One may remember (or not) that these well-intended but misapplied reforms arose from a legitimate and well-publicized outcry about mis-read Pap smears. This made “Sixty Minutes” or some other media scandal-of-the-month Club.
So what began as a well-intentioned campaign to correct a widespread (but certainly not universal) problem of laboratory quality control (and in some cases medical integrity) became a legalistic, mindless, and costly invasion of small offices from coast to coast. The cure (which was never designed with the small, private, clinical office lab in mind) has certainly wrought more damage than the problem.
Those with military experience will understand this characteristic…
Those with military experience will understand this characteristic of Byzantine world conquest, herewith illustrated: Suppose a visiting general to a Texas army post trips over a three-legged armadillo as he enters the base, fracturing his arm. (You see, the poor hobbled creature, only recently arrived from South-of -the-Border, had not yet gotten access to the resources available to him through the Armadillos With Disabilities Act. Therefore, with his mobility still hampered, he was unable to get out of the way.) You can bet before taps sounds that evening that a “three-legged-armadillo-surveillance-and-avoidance-for-general-staff-officers” policy will have been enacted on military bases from Guam to Antarctica. Such are the ways of Byzantium.
So the inspection of the doctor’s office went something like this:
“You need to correct these deficiencies,” commanded the CLIA inspector imperiously, “prior to the re-inspection of your facility.” The doctor’s “facility” was, in fact, smaller than most people’s closets. So small that the lavatory had one of those little signs like those you see at “Six Flags” at the entrance to certain scary rides… “You must be this tall to ride the ‘GUT BUSTER’”. Only his sign was horizontally oriented… “You can’t be over this wide to use the lab bathroom.” Actually, it was rather cozy to be able to catch a cat nap while resting your chin on the sink as you answered nature’s call.
One particular item on the list of “deficiencies” in his lab was the lack of a written protocol for “panic” lab values. Strict reporting protocols for getting drastically abnormal lab reports back to the ordering physician in a timely manner are indeed important for giant lab companies like “Labs-R-Us”. When a lab processes tens-of-thousands of specimens from hundreds of nameless and faceless doctors across an entire region each day there must be well-documented procedures for getting potential life-and -death results back to the doctor.
“Doctor, would you come here and look at this!”
But in this lab, the doctor and the patient, both, were no more than twenty feet away from the lab at the moment that the results appeared. A simple, “Doctor, would you come here and look at this!” was more than adequate.
Another particularly obnoxious requirement imposed by the inspector was that the doctor had to remove the urine bacterial culture incubator from the premises. The doctor had already determined early on in the inspection process (when he saw how things were going) that he would not be performing nor billing for urine cultures in the future (The requirements for quality control on microbiological testing in laboratories could only be practical in a lab with the capacity and staff hundreds of times the size of his and necessitated a budget that would float the entire US Navy for a month.) He only did four or five urine cultures per month, anyway.
Nevertheless the implacable inspector unequivocally stated that if the incubator remained on the premises it would be subject to inspection and the requisite controls daily.
“The incubator must go!” She said.
Oh, but there’s more…. He wasn’t even allowed to keep the incubator on the premises on the off chance that he might elect to do an occasional culture at his own expense, for academic curiosity, or for an extra measure of diagnostic certainty, or just for grins. “The incubator must go!” She said.
It was at this juncture in the inquisition that he sneaked a peek at the inspector’s briefcase while she wasn’t looking just to see if there were a “Hammer and Sickle” stamped on the side and he’d awakened in the wrong country that morning.
This isn’t even the best part! There’s even more. Every other year he still gets to pay around a thousand dollars or so for the privilege of subjecting himself to this abuse. (For the same price he could have an annual proctoscopy… a better deal and probably a more tolerable inspection.)
The doctor did manage to salvage some small measure of satisfaction in all this, thanks to the presence of a modicum of good humor (and good sense) on the part of his inspector. He dutifully created a written “panic value” protocol which consisted of a 3×5 index card taped over the sink. It read: “IN THE EVENT OF PANIC LAB VALUE, SHOUT, ‘HELP!'”
He passed the reinspection.
Did CLIA improve laboratory services for this doctor’s Medicare patients? Get real.
Accessibility? Now patients had to drive miles down the road for many tests he used to perform on site.
Quality? The only labs he had ever performed were those for which he could do in-house standardization and controls. He would never have been satisfied with inaccurate data and information when diagnosing and treating people about whom he cared. He was, after all, a professional.
Besides, he had the ultimate measure of quality control right there at the lab… the patient.
Cost?
Does anything the government touches actually ever end up costing less? What did result was delay in diagnosis and treatment which, at best, disrupted the continuity of patient care and, at worst, could have resulted in actual harm to the patient.
So you tell me: Does government regulation and control really help healthcare?