I remember the Headlines

Anyone who stands to judge me needs to know and understand many things about the situation I was forced to deal with.

I saw the headlines:
“Annual Medicare award goes to Nevada Doctor” and “Medicare assists country doctors in helping rural homebound disabled”, and “Medicare lauds local physician at banquet for saving millions”.
Then I wake up from the dream. Of course, Medicare has no such assistance programs, awards and accolades; only punitive actions.


In my medical practice taking care of homebound disabled I did not recruit my patients; they were abandoned on my doorstep by social services, concerned citizens, relatives and caretakers of chronically ill people. I discovered an invisible and previously unknown world of suffering and hardship in these people. This apparently is not acknowledged by anyone in Medicare or Medicaid. I can only interpret the attacks from the government as part of this denial. Their actions have shown me that they consider my work to be on the same level of a carpet cleaner or dog groomer; unnecessary, unwanted and the subject of fraud,

It is impossible for me to imagine anyone participating in these government attacks having the slightest familiarity with the grave problems suffered by my patients. I can see no way that any of them have ever visited a homebound disabled person who has received scant and improper medical care for decades. The patients I accepted in my practice were mostly frail with multiple, interacting conditions requiring months or years with frequent visits to stabilize and hopefully improve. Suffering, anguish and hopelessness were almost always alleviated. These things apparently do not tit into the equations at Medicare. According to my “Discovery Documents” 97% of my visits were unnecessary. But they were not on the scene; In fact they were calling the shots for 3000 miles away. The stated attitude in Medicare is that monitoring a frail homebound person for worsening has no value. You may compare it to the local fire department. A citizen calls in alarm. Medicare asks for proven evidence of structural fire. The citizen answers that there is only the smell of smoke and the carpet is soaked in gasoline. Medicare answers “Wait for the flames to appear (you must send us documentation of this, which we will review and decide on a proper form of action) and we assign someone to look into the matter. Unfortunately, the only one in your area who does such work is being put behind bars, for your protection, of course. So good luck and tell us what happens!”

This way of handling such problems in our society is not only primitive and inhumane; I believe it to be the product of insane minds! I accepted only needful and neglected people into my practice. After stabilization, I assigned them to one of two groups: people that needed a minimum of at least one monthly visit, and those people that needed twice weekly visits. Of course, all my patients were on ALWAYS on the verge of destabilization, and ended up needing visits more frequently. So, who is a more appropriate person to decide what kind of care a person gets. A physician on the scene or a bureaucrat 3000 miles away? Some of these visits were, indeed, false alarms, Apparently Medicare thinks it more appropriate that a high school student perform the visit, Indeed, I would have trouble recruiting a high school student at the Medicare suggested payment for such services. According to Medicare, when a medical practitioner decides nothing needed to be done or changed, it is worth so little that you can’t even make financial ends meet doing so. Heroic measures, such as putting out the proverbial house fire, are rewarded much better. It’s much sexier that way. Preventive care and monitoring of the frail has little panache.




In illustration, primary care physicians have always objected to the heavier weight (in payment and importance, one must assume) given to heroic interventions, such as surgical operations. The practice of psychiatry, which requires considerable more time, effort and subtlety on a physician’s part, is automatically discounted 50% by Medicare.



I would like to describe in some detail the method I developed to keep both billing and treatment records in my practice. When I started this task I almost completely computer illiterate but was convinced that their use would streamline the process and allow me to not use ancillary staff for these purposed which were a standard expense of medical practice. I also could not afford to do otherwise. There was no guide or blueprint for doing this. Proprietary software was in the process of development but far too expensive for me to afford. I used what software I had: “Microsoft Word”.

When I accepted a new patient I made an MS WORD file with the pertinent patient information. This information would be duplicated on any document or correspondence associated with the patient. This save much time in having to duplicate information. It looked like this:

Blow, Joseph/ DOB: 01-01-1901/Gender: male/
Address: Phone:
Special directions to home:
Caretaker
Home Health Service:
Pharmacy:
Medical Supply Company:
SS#
Medicare #:
Medicaid #
2nd Insurance ID:
Date of Visit: CPT Code:

Diagnosis 1
Diagnosis 2
Diagnosis 3
Diagnosis 4
Diagnosis 5
Diagnosis 6
Diagnosis 7
Diagnosis 8


For billing purposes I made a separate, permanent MS WORD file with new pages for each patient. Since I generally knew what patients were to be seen on a weekly basis, this list would grow and shrink slowly, but be generally the same. At the end of the week, all I had to do was open the file, Change the date and submit the file electronically to my billing agent. The level of service was usually the same, so if a field worker thought the level was different, I could easily overlook it. I will discuss substantiation for level of service elsewhere. This technique I developed on my own, and as I have noted, was prone to errors, but it worked efficiently and was the best I could do. IT definitely allowed me to pursue more valuable patient care issues.

I really could have done without a billing agent. When I first stated the practice, I was completely ignorant of billing practices and had to rely on contract services of so called professionals, who, it turned out, were just as incompetent as I was. On my third agent I contracted with Gordon Clarke, who admitted he was new to the business of insurance billing and had had little idea how to proceed. He was trying to work at home in order to care for his father. As the years passed Gordon became almost completely incapacitated with arthritis, requiring around the clock powerful narcotics for pain relief. After his father died, I continued using his services in order to keep him off the street.

At no time during my medical practice did anyone, including State or Federal government agencies offer help or advice. I had to do it all alone. I thought I was doing a good job with the paperwork. I knew that I was helping my patients attain a better state of health, comfort and dignity. And regardless of what the Government’s rules and regulations were, I was going to continue doing the same thing until the patient’s death or they found alternative health care services.

That’s all for now…………

A little about me

Please ignore this post if you don't want to understand the author of ten thousand felonies.

All facts in this statement are a matter of public record.

Biography
I am a 56 year old white man born in California. My father was a photo journalist, my mother a housewife. I was raised with 2 brothers, a sister and two cousins. Our family was not financially privileged. My mother supplemented my father’s income with washing, ironing and babysitting.
When I was age 12, my father joined a union dispute against his employer, the Hearst Corporation. This strike was to last over seven years and resulted in the financial ruin and fragmentation of our family. I left home at age 18 and have been self supporting since that time, financing my own 15 years of higher education. At age 18, I became a Buddhist, and thus a pacifist. This caused many problems when I was drafted at age 19. I refused military induction and after much effort and emotional trauma I was assigned to a civilian program for conscientious objectors to war where I worked in a hospital for two years. During this time I also attended college, participated in peace promotion and developed a strict Buddhist practice which I have maintained for 37 years.
After release from service, I worked, attended college with the goal of becoming a physician and contributed to peace promotion, including counseling other men with conscientious objection to war and representing my religion at national and international peace conferences. Due to financial and logistic constraints it took me eight years to complete a bachelor’s degree and another two years to be admitted to medical school. During the first few years of college I suffered from a lack of preparation for completive academics and did not fair well. I was advised to abandon my goal of becoming a physician. I persevered and eventually graduated with honors from the University of California. After graduation I attended California Polytechnic University, studying subsistence agriculture and nutrition. My life before attending medical school could be characterized by hardship and struggle. This experience shaped my world view and allowed me to devote my future to helping society’s socially and economically disenfranchised.
I attended medical school at the University of California in San Francisco from 1978 to 1983. I then completed a three year post graduate training program in family medicine at the University of North Dakota in Bismarck. After graduating, I worked with the Indian Health Service in North Dakota and Nevada for 3.5 years. I attained the rank of Lieutenant Commander in the Public Heath Service. I would have preferred to continue on in the Indian Health Service as a career but was treated abominably by the Federal Government. Their regard for my physical safety and mental health was so poor and appreciation for my work and innovation so scant that I resigned my commission in 1990. After leaving government service I worked as a physician in various positions in rural areas in the West between then and 1997. In my free time I developed a not-for-profit Native American TV/Radio production studio in Reno, Nevada. We produced public service announcements and advertisements for tribal functions. I invested over $100,000 and most my free time in this project from 1990 to 1994.
In my pre-graduate college years I had a special interest in the economics of poverty, international public health dilemmas and the ecological destabilization caused by deforestation. I allied myself with a company called Sun Ovens International that had just perfected solar ovens for household and commercial use. Since the majority of the world’s population use wood fuel for baking and cooking food, deforestation has ruined ecologies in many areas. The inhalation of smoke from wood cooking fires is directly responsible for the deaths of over two million children a year. Also, preventable water born illness is the most common form of death in the world. Since solar ovens successfully address all of these issues I spent much of my free time from 1995 to present and spent over $50,000 of my personal money in solar oven education and promotion. I have traveled extensively in the USA, Mexico, Haiti and Barbados in the service of this project. I have served a consultant in this regard to international aid organizations. War has prevented planned trips to Ethiopia and Ghana. I promote solar ovens and educate in their use on an ongoing basis.
I'm going to take my nap now
Kirk

Personal Statement
November 2006
By Kirkland White
Date of Birth: September 3, 1950
Case #CR06-0172-BES-RAM

When the people fear the government: that is tyranny. When the government fears the people: that is liberty- Thomas Jefferson

They can’t jail all of us! Or can they? -Kirkland White

CITIZENS!
I am a family physician, who was arrested and charged with 98 counts of Medicare Fraud on Nov, 7 2006. They think a 480 year prison sentence is appropriate. I do not. Here is my story.

All facts in this statement are a matter of public record.

I knew from the beginning of my training that there was something very wrong with health care delivery in the USA. For this reason I found little satisfaction in any job venue. Demands were always placed to see more patients and spend less time with them. I concluded that judicious time spent with people could actually solve their problems, but that this was immaterial and even counterproductive to the economics of medical practice in the USA. In 1997 I started developing a unique practice plan: that of delivering medical care to the homebound disabled. I soon came to realize that I had absolutely no preparation for what I was to encounter in this endeavor. I discovered that the days of the county doctor visiting the sick and infirm in the comfort of their homes is not accommodated not by our existing system. The doctor now needs the accompaniment of lawyers, accountants, experts in insurance billing, business, computing and communications consultants, banks and money lenders, skilled interpreters of cryptic government documents and, unfortunately, finely honed political talents. Since I am none of these things and cannot afford to buy the services of such, I embarked on a monumental self education path that continues to this day. This will be a recurring theme in my story.
To my utter amazement, I was exposed to a patient population I had never encountered in my twenty years of medical practice; the homebound disabled. They were of all ages and had unique personal and medical histories. Most had slowly deteriorating, agonizing and untreated conditions. Most could leave their home only with heroic and dangerous effort by them or their caretakers. Most had fallen into despair. All were impoverished. Many of these patients refused to leave their homes due to pain, discomfort, embarrassment, fear of the loss of what remained of their dignity and their previous rough and impersonal handling by the medical establishment. Physicians did not visit them in their homes for various reasons, including loss of revenue, the extensive time expenditures and massive paperwork involved in their care, and fear that their clinical judgment and decisions made with traditional physician skills (listening, touching, using the stethoscope, etc.) were not up to the task, exposing them to excessive liability. Most of my patients were referred to me because NO OTHER PHYSICIAN WOULD HELP THEM. I accepted these challenges and the risks involved. I was able to spend three to four hours on an initial visit with another equal amount of time spent in formulating treatment plans, arranging in-home services and documentation. Not including travel time, a physician in conventional practice could see thirty to forty patients and receive twenty times the revenue for the same amount of work. I persevered in this practice out of financial naiveté and the fact that, for the first time, I could see dramatic improvement in my patient’s physical, mental and spiritual lives. The patients were the sickest, most decrepit and deprived I have ever encountered. They and their caretakers waited silently for death in extreme suffering. Most had over 10 severe, interacting and untreated medical problems.
By the sixth month of practice, I had over 100 patients, mostly referred from state social services. I was working without assistance, seven days a week, 10 hours a day. Although I was making dramatic progress with my patients, I quickly became chronically fatigued and depressed. There seemed to be no end to the homebound disabled. According to the year 2000 US Statistical Abstracts, there were an estimated 30.000 people in Western Nevada who had difficulty leaving their homes to receive medical care, enough to require 60 physicians in their care. I offered my services to any needful person in Nevada and east of the Sierra front in California. I have traveled up to 500 miles round trip to visit a patient in rural Nevada. The paper work required in my patient’s care was massive, requiring over half my time, and increasing on a daily basis. Adding to my growing distress was that Medicare had not paid me for services until almost a year after I started my practice. This was for reasons I have yet to ascertain. The California Medicare intermediary delayed over 3 years in payment. (Claims over two years old are not paid.) I tried to recruit physician colleagues to help me, but they universally thought the work far too difficult. After a year had passed I was deeply in debt and barely making enough to meet expenses. Then came a brief time when Medicare increased their reimbursement to the point that I could operate my practice with minimal losses. From my recollection, my taxable income during these years peaked at $43,000. This represents an hourly wage of $11.268. More typically my income ranged between $6,000 and $20,000 a year. Then Nevada Medicaid lowered their payments to 1/30th the level of previous. This is when they paid anything at all. In my 25 years of medical practice, I have yet to see a single dollar for services rendered from California Medicaid. My medical liability prememiums skyrocketed (representing a 30 fold increase from the time I started practice in 1984). Then the insurance companies refused coverage. Fortunately, the Nevada State legislature mandated insurance companies to provide coverage, which they did at double the rates. I have not carried insurance since 2003. The company demanded payment of $50,000 to cover “past claims”. Of course I did not pay this. All these things exposed me to extreme risk of litigation. Medicare payment cutbacks continued at about %5 a year. Any state programs providing the homebound disabled with help in home repair, maintenance and safety issues were terminated. Those of my patients who were not eligible for state pharmacy benefits went without. During this time I spent thousands of dollars buying them pharmaceuticals, durable medical equipment, making home repairs, etc. Those with State pharmacy benefits added to my paperwork burdon by at least %25.
On a bright note, I finally was able to recruit 2 physician assistants and a nurse who were among the finest people and most gifted practitioners I have ever known. I was able to regain my lost energy and my depression lifted. I realized that we were fighting a losing battle and decided to form a non-profit corporation, achieve 501(c)3 status and apply for grants for continued operations. I had to do this without any professional advice because I could not afford it. Patient referrals were increasing steadily. I made two presentations regarding the deficiencies in health care delivery for the homebound disabled to the Nevada State Legislature during this time and was met with absolute indifference. I could summarize their response to me as :
“This is all very interesting, Dr White, but what does it have to do with us?”
I contacted every Nevada State official regarding my plight, about forty in number, including the Governor, Senators and Congress folk. I had two replies: one from a assemblyperson who stated he understood my problem but had just been elected and had not the slightest idea what to do about it. The other was a seasoned assemblyperson who generally misdirected me or gave me information that was totally erroneous. Even though I had little experience in grant writing, I applied for a $200,000 grant to the Nevada State fund that was created from the tobacco industry lawsuit settlement. I was not awarded this grant even though %95 of my patients had major medical diagnosis related to tobacco use. I was told by the grant committee that my grant was “…just another grant to supply elder medical care.” I found this quite puzzling.
Everyone, including my patients, staff, and State Social Services wanted me to persevere and continue to apply for grants. I determined that the nearest grant I could achieve was at least two years away, and then there was no guarantee of an award. I was already over $200,000 in debt, had mortgaged my home and did not desire a debt increase of over $100,000 a year. I stopped accepting new patients and discharged my employees. During the ensuing months many of my patients mercifully died. There were several suicides and a murder/suicide. I achieved transfer of care for some but was left with twenty-five people who came to me because NO OTHER PHYSICIAN WOULD HELP THEM. Since I have never been a wealthy man, and it costs me $100 a day to practice medicine even at the most simplified level, I was faced with a severe ethical an moral decision. I made a decision and this is where my history will end.
Feel free to ask for elaboration or verification of any of these statements.