That "Can't Do" Spirit

Why owning your own business is no loner a recipe for independence.

Susan Lee from the March 1996 issue

(Page 2 of 5)

But that's hardly Bacall's biggest headache. Of the migraine variety, there are two. The first is the Clinical Laboratory Improvements Amendments of 1988, which covers in-office testing. Now obviously, as both Bacall and Wilhelmy agree, in-office tests should be performed under certain standards and by qualified people. But, they argue, although CLIA standards may have started as a good idea, they quickly have become unnecessarily nit-picky.

For example, CLIA directs that only doctors may peer into a microscope--no matter that medical assistants have been trained to do so. About 90 percent of complaints can be diagnosed under a microscope, an inexpensive and quick procedure. But if doctors don't have the time, the microscope is either bypassed, resulting in a higher percentage of incorrect decisions, or the slides are sent out to a lab, which costs five to ten times more than in-office tests and takes several days.

Ditto for in-office blood testing. It's an easy procedure, and the machines that perform the tests are very accurate, but since CLIA requires two controls to be run once a day on each item--hemoglobin and cholesterol in this case--blood testing has become expensive and time-consuming. Bacall has compromised by limiting the days on which his office does blood tests.

CLIA also requires an enormous amount of paperwork. Everything must be logged. For instance, the temperature of the refrigerator and freezer must be monitored and recorded every day, as must a list of patients having tests performed, and a list of all control seras and their expiration dates. The office must also have a cleaning schedule for the lab, notes on how problems are taken care of, and a typed procedures manual stating how tests are to be performed--the manufacturers' manuals are not enough.

Bacall's office was checked by a CLIA agent last July, at the doctor's expense. The three-hour visit of one agent cost the office $1,000, payable to the federal government. If the agent had found anything out of line, they would have been fined in addition to the inspection fee.

The net result is that an increasing portion of Wilhelmy's salary and office budget is spent on satisfying the demands of government surveillance and a decreasing number of tests are performed in-office because they are no longer economically viable. Even after cutting back on in-office testing, Wilhelmy figures that following CLIA requirements takes a half hour of her day, every day.

A second migraine comes from regulations by the Occupational Safety and Health Administration. They are initially felt by Wilhelmy, who says it takes weeks of research to figure out just what OSHA wants when it issues guidelines. The last big issuance required, among other things, that the office purchase a bunch of signs to alert people that smoking, eating, or drinking were not allowed in the lab area; that it buy special cleaning substances to mop up spills; that it designate a separate space as an "eye wash station," in case anybody gets something in his or her eye during a procedure; and that it purchase separate refrigerators for certain items, clearly marked "BIOHAZARD: No food or drink in this refrigerator." Anything that might be touched by a doctor when examining a patient must be wrapped in plastic, including the examining light, which is sheathed in a sort of condom that must be changed after every patient.

Beyond the frustration and expense of having the government micromanage his office practices, Bacall resents having his treatment decisions second-guessed. "There is a layer, often a large bureaucracy--a government agency or some insurance company--interposed between me and my patient. I have to justify the treatment I know is right. I spend a lot of unreimbursed time on the phone calling and arguing with these gatekeepers."

The basic story is the same for Dr. Levit: government regulation constitutes a daily frustration and intrusion in the
way he practices medicine. Levit, 53, is an ophthalmologist specializing in retinal surgery. He got his degree at the University of Texas and began private practice in 1975 in El Paso, Texas. He works with two other doctors. The office employs 14 people; six devote all their time to the business side of things--an office manager, three clerks to handle insurance and collections, a receptionist, and a transcriber (because all chart notes are dictated). Levit spends, on average, an hour a day with the office manager.

Like Bacall, he's had to computerize his billing system--at a cost of $40,000 over the past five years--but he still waits, and waits, for reimbursement. "One of the reasons we computerized was to speed reimbursement, but now that the majority of physicians file electronically, the government has extended payment time to pre-computer levels by rejecting valid claims over and over again," says Levit.

Levit sees on average 30 patients a day. Five to seven of them are new, the rest are there for follow-up treatments. He sees both Medicare and Medicaid patients. He says that everybody is treated the same medically, but the demands imposed by government insurance mean patients are dealt with differently: "For example, Medicaid will only pay for one test per visit, so if we want to be reimbursed, we have to make the patients come in three or four times just to perform the minimum number of necessary tests," he says. That is, if the patient lives nearby; for those beyond 150 miles, Levit just does all the tests in one visit--and loses his reimbursement.

Levit's main regulatory nightmare is the Americans with Disabilities Act, especially since many syndromes involve both eye and ear impairment. (See "Unreasonable Accommodation," August/September 1995.) Before the ADA, he felt able to communicate with hearing-impaired people by gestures or through writing. Now he must pay $50 an hour for a professional signer to accompany them. In the case of Medicaid, which reimburses $8.00 for the entire office visit, he is out $42 right off the bat. He reckons that this requirement costs him $200 to $300 a month. (He lucked out on another ADA requirement, however. The arms on his six examining chairs can be removed, so he didn't have to replace them--at $5,000 a pop--to accommodate the grossly overweight.)

Now all these niggles, taken separately, don't sound like such a big deal. And maybe they're not. And maybe they aren't such a big deal when taken all together. Certainly both Bacall and Levit earn very good livings despite the regulatory overload and the reimbursement shortfalls. And certainly both know doctors who actually make the system work for them--a polite way of saying that some of their colleagues are making out like bandits.

But the effect of all the niggles goes well beyond time and cost and paperwork. A bigger burden hits job satisfaction. Although Bacall is responding rationally to increasing regulation --by cutting back on procedures, hiring two full-time office managers to handle the paperwork and regulatory requirements, and battling the gatekeepers--these responses limit the way he practices medicine. And leave him demoralized. "Part of me likes what I am doing," says Bacall. "It's hard to see myself doing anything different. But I am 45 years old and I feel like a dinosaur. I'm on the top of the list of being extinct."

Levit echoes this sentiment. He says that until six years ago, he never considered patients from a financial point of view and that it's hard to accept the new realities: "Younger doctors won't have as much difficulty adjusting to increased regulation and thinking about remuneration, but I feel outmoded in a way--abused may be a better term--it's hard to learn new habits."