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I read with exasperation that Dr. David Axelrod has dismissed the criticism that the Joint Commission on Accreditation of Health Care Organizations had for certain aspects of the New York State Health Code as the result of a vendetta against his department. As I recall, Gov. Cuomo also dismissed the New York State Medical Society's negative evaluation of Dr. Axelrod's work as being purely the consequence of doctors' antipathy for regulation. I think it is high time someone replied.

It seems to me that there are two main areas in which New York State's health-care bureaucracy actively impedes health-care delivery. The areas are the Department of Health regulations and the Medicaid system.

I personally believe that federal and state regulation in general contribute immensely to the quality of health care. However, this does not make all regulations good. The new policy regarding physicians' orders not to resuscitate terminally ill patients (DNR orders), for example, may have originally had a humane purpose -- to encourage communication between physician and patient about whether the patient wants extraordinary measures taken to prolong his life. In practice, now the doctor must have a long and rather complicated DNR form filled out properly before the nursing staff can comply with such an order. Relatively few physicians can manage to get all the right signatures in all the right places on these forms. What actually happens is that the right signature is on the wrong line, so the dying patient is resuscitated against his wishes.

Some of our physicians have seriously stated that they will no longer discuss DNR orders with their patients because of the difficulty in actually getting the order carried out. The implementation of this regulation is resulting in patient abuse -- the resuscitation of dying patients against their will -- not better health care.

The Medicaid system is at least as aggravating. In the quest to root out fraud, physicians have their records reviewed to determine whether all lab and X-ray requests were warranted.

Again, this sounds like a good idea, but in practice it is a mess. Whether or not a given lab test is indicated or whether or not a given case is complicated is to a certain extent subjective. A physician and a state examiner may disagree with each other without the physician actually being wrong in his treatment of a patient or in his billing practice. Nevertheless, such a physician might face a large fine as a result of accepting Medicaid patients.

Situations like this are extremely frustrating to physicians. Allegany County is a relatively poor, rural area and many of our physicians are here at least in part because they believe there is a moral imperative to serve such communities. These doctors rank among those who should be most receptive to Medicaid patients, but even here it is difficult for Medicaid patients to find a physician. The problem is not greed -- it is the bureaucratic harassment to which Medicaid officials subject doctors that drives them out of the program.

I am not a primary-care physician, but I sit on a number of hospital medical committees. This morning I listened to an emergency room physician beg the hospital staff to accept new pediatric Medicaid patients. The overwhelming response was that Medicaid has become such an administrative nightmare that many cannot.

The alternative is either for these children to receive their primary care in the emergency room (at a cost to the state of $90 per visit vs. $11 for an office visit) or for the child to go to Buffalo, which is two hours away. To have to try to deal with problems like this and like our DNR ordering problems and then to find our state officials saying that the whole problem is just a matter of doctors' attitudes is maddening.

Doctors are just plain human. We are the people who have to work with these laws and codes and when we cannot work with them, they do not have their intended effect. It is time that our lawmakers recognized that fact.


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