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So many lawyers, so little time...

"The prospect of hanging focuses the mind wonderfully"--Samuel Johnson

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Location: Louisville, KY, United States

Gastroenterologist, cyclist, cellist, Christian, husband, father, grandfather.

Thursday, October 20, 2005


Yesterday I had a great bike ride, except for a nasty spill leaving me just a little banged up. In a perverse way I've come to covet crashes; maybe it's because the injury kicks up endorphins that so generously flow afterwards.

The endorphins were flowing at full tilt until I returned to my office to do "admin work", known by some as "stoopid B.S. flung about by bean-counters to prevent patients from getting care and doctors from getting paid". I view it as performing penance to the Lord of the Free Market: it's necessary, but whether it's Evil or not is in the mind of the supplicant.

Recently I had made the diagnosis of celiac disease on a patient. Making the diagnosis gives us a warm and fuzzy feeling; with proper treatment, which consists of a very strict wheat-free diet, patients live full and healthy lives. The flip-side is also true: without proper treatment, the patient develops all sorts of bad things and can die a miserable death. Making the diagnosis and getting it treated is definitely a "win-win" situation.

Unless you're a bean-counter for the Beautiful Fields of Happiness health plan. A short while after scheduling the patient for a meeting with a dietician, we received this letter, which I am embellishing, but not a lot:

Dear Profit-loss center, AKA Healthcare Provider:

We will not cover your request for our client to receive Dietary counseling for his celiac disease. If you would have looked on page 127, paragraph 4 of the patient handbook and explanation of lack of benefits, you would have noted that dietary counseling is approved only for type II diabetes mellitus. Whatever celiac disease is, (we don't have time to look that crap up, we got a business to run here, you know) it does not appear to be type II diabetes mellitus. If you or your client don't like it, you can protest to our appeals board, or send a letter to the state insurance commissioner, or write your congressman, or camp out in front of the president's ranch. We know that if you're like most doctors, you'll lose patience (get it? har har) with it and just let the whole matter drop. We don't give a damn. Now go away.

Early in my career I would take this stuff personally, but know I realize that it's not personal. It's just business. Dutifully I write my appeals letter. I'm providing you a copy, with the translation provided in bold:

Dear BFH appeals person AKA contemptible bean-counter,

I have received you letter refusing to authorize nutritional counseling for my patient and your client. Celiac disease is a type of allergy to wheat to requires the patient to adhere to a strict and complex diet which you would have known if you would have picked up your stupid Merck manual . The standard of care known as things that cost a lot of money to you folks is for patients to receive proper dietary counseling. If they don't receive it and follow the proper diet, they will develop all sorts of gruesome complications and die a miserable death as listed on page 348 of the Merck manual, if you ever get three minutes to look at it.

It would be a shame for my patient and your customer to go through all of this just because of your refusal to authorize the nutritional counseling, not to mention that I don't give a rip if your CEO gets less than a $52 million bonus this year. Would you reconsider this ill-advised decision? You and I know that I'm bluffing here. If all those things bad things happen, you get blanket immunity from lawsuits from ERISA. On the other hand, I can get sued out of my pension.

cc: my patient and his lawyer. We can always hope.


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