Spotlight: Lester Karotkin, M.D.

Socialized medicine is not merely a vague, distant threat. For the past decade, since the enactment of Medicare, American doctors have been sliding slowly into socialized medicine, largely without realizing it. Under the guise of making Medicare work, preventing overcharging, setting quality standards, etc., the Federal government has intruded deeper and deeper into the practice of medicine in this country. Today many doctors and their staffs spend huge numbers of hours filling out government forms in order to be reimbursed for treating Federally-subsidized patients. In many cases they now find themselves being reimbursed according to government-devised fee schedules, regardless of their actual charges. The saddest aspect of this situation is that most doctors are voluntarily taking part in this process, when there is no legal requirement that they do so.

One man who tirelessly points this out is Lester Karotkin of Houston, TX. Dr. Karotkin notes that "Nowhere in the various Federal laws and regulations are physicians required to accept third-party intervention. But the bureaucrats are clever. The key words are always request or if—if a physician certifies, never a physician must certify.…" In other words, the HEW bureaucrats have devised a constitutional way of persuading legally ignorant doctors to give up their right to be free of government interference.

Even before Medicare began, Karotkin had figured out how to avoid third-party intervention in his practice. "We doctors are good citizens and we tend to do what we're told," he relates. "I know that I always did, until one day when I was filling out insurance forms I suddenly said to myself, 'My God, I've become a clerk for insurance companies.'…I stopped filling out their forms and sent them my own, which requires from me only a simple statement of diagnosis, treatment, charges, and my signature."

Karotkin's plan worked, and when Medicare was enacted, fellow physician Ben White generalized the idea into what they called the Individual Responsibility Program (IRP). The basic principle of IRP is that the doctor-patient relationship is one of mutual responsibility. "The physician undertakes to provide the patient with the best medical services he can," notes Karotkin, while "the patient, in turn, assumes the responsibility of compensating the physician for his effort." Thus, any relationships with third parties are extraneous. If the patient wants reimbursement, whether from Blue Shield, Medicare, or a private insurer, it is his responsibility, not the physician's, to obtain it. In this way the physician remains free of government attempts to control his practice.

The Harris County Medical Society adopted IRP in 1965, and it was endorsed by the Texas Medical Association in 1966 (and later by the AMA). Unfortunately, after an initial burst of enthusiasm, interest faded. Many physicians could not resist the lure of easy money from Medicare and Medicaid. Fearing that many patients might not pay if billed directly, they opted for the "sure thing" of obtaining reimbursement from the government. But when Medicare budgets soared out of sight in the 1970's, HEW began being stricter about how it reimbursed; paperwork requirements increased, fee schedules were adopted and tightened, to the point where many doctors today receive only partial reimbursement for their services.

The result is a new interest in IRP, and new attention focused on Lester Karotkin. After articles on IRP and Karotkin appeared in Private Practice last year, his office began receiving numerous requests for information, from doctors all across the country. In response, he provides all inquirers with basic information on how to set up such a program, including sample reporting forms and explanatory letters to patients. In a nutshell, Karotkin recommends the following principles:

1. Address any medical reports about a patient only to the patient himself.

2. Submit statements of charges for professional services only to the patient or his guardian.

3. Accept payment only from the patient or his guardian.

4. If payment is received from a third party, send it back with an explanation (and send a copy to the patient).

5. Explain the program to patients, pointing out the mutual trust involved in the relationship.

Karotkin reports excellent results with IRP. His practice has increased in volume each year and his collection rate has remained at over 90 percent. He reports few problems with insurance companies. "At first they balked at the idea…but after adequate explanation, virtually all insurers acknowledged the propriety of the method and silenced their objections." As far as the government is concerned, Karotkin himself has had no problems, since he is a non-participant in Federal subsidy programs. But some of his patients have recently been refused reimbursement of hospital care service by the local intermediary for Medicare, Group Medical and Surgical Service. Karotkin is working on preparing a lawsuit against them, in cooperation with the Private Medical Care Foundation. He contends that the intermediary (which demands that Karotkin supply additional information on its forms, as a condition of reimbursing the patients) is violating Section 1801 of the Medicare Act, which explicitly prohibits interference with a physician's practice of medicine by agents of the Federal government.

With the government now trying to introduce PSROs, and with the threat of National Health Insurance in the air, Karotkin is more than ever convinced that IRP is the only way out. "Ten years ago we tried to tell American physicians that in IRP we had developed a first refuge from third-party interference in medicine. Now I believe it's a last refuge." (Those interested in details on setting up an Individual Responsibility Program can contact Dr. Karotkin at 6720 Bellaire Blvd., Suite C, Houston, TX 77036.)