My family practice solo clinic opened in May 2010. I chose to contract with medicare only, because I want a single payer system, medicare for all, I'm a Mad as Hell doctor, etc, etc. I'm happy to see anyone, but the non-medicare people pay cash, and can then try to get money from their insurance company if they have one.

My business plan is built on medicare payments, which suck, though they don't suck as badly as medicaid. The real issue with medicaid is that I would have to have someone hired to call them and ask permission for every referral, x-ray, MRI, CT scan, treadmill, etc, etc. I would have to have at least one more employee to get "Prior authorization" all the time. I don't have a nurse, too expensive. Just me and a receptionist. I do have an electronic medical record.

Right now, medicare is bribing us to demonstrate "Meaningful Use" of an electronic medical record (EMR), and if I do this before December 31, 2011, they will pay me $18,000. Since I'm still seeing an average of 5-6 people a day, the "Meaningful use" bonus would be quite helpful. I have to demonstrate 15 core uses of the EMR and 5 of ten menu items. Unfortunately one of the core ones involved writing about 50 policies and procedures for HIPAA and the new HiTECH law, but we have that done.

One of the requirements is that over a three month period we have to have "complete" demographic and "vitals" information on all patients seen. Not just medicare ones, mind you. All. I think it's 80%. (Correction: 50%) They have included race, ethnicity and preferred language in the demographics. Height, weight and blood pressure in the vitals. Do I measure height at every visit? "Oh my god, you've lost 1 mm since last visit, or are your socks thicker? Strip down, right now."

For race they are using the United States Census categories. Here are the choices:

American Indian or Alaska Native (no, really. Not Inuit and not Native American)
Black
Black Hispanic
White
White Hispanic
Asian
Native Hawaiian or Pacific Islander
Refused

I'm finding this ludicrous and embarrassing to bring up with my patients in clinic. First, my receptionist and I discussed where the line is between the Pacific Islanders and Asians. Malasia and Thailand? Do I really care? And there's no "mixed" or "other".

One man replied "human". That is one of my favorites.

An 80 plus year old replied "Scots, German, English and Cherokee." She picked American Indian over White or Refused.

Two of my 80 plus year old white ladies asked, "What if I say Black?" I replied, "Well, ma'am, that's what I'll put. I'm not here to make decisions or judgments about that."

My Native American patients are going with Native American, though most say "Half white, half Native American." So which half did you want me to put down?

A group of docs was meeting to discuss "Meaningful Use" and one said that he was just going to put "Refused" for everyone. But then the threat of the Dreaded Medicare Audit looms.

Why, you say, is the United States government doing this? There have been studies about "racial inequalities in screening tests", that is, if you are black or hispanic, you are less likely to have gotten a pap smear or a flu shot or a colonoscopy. This is part of some attempt to deal with that. But.....it's completely crappy nonsensical data. We are going to have data and reports and Congress will wave things around and it will be based on completely crappy data collection and ANYHOW -- race isn't scientific. The whole thing is more insane stupidity. I still want a single payer system but it's sort of depressing that I can't stitch up someone's arm without documenting their race.

I've decided that when the census rolls around, I'm going to change my race like my shirts. It's too cliche for a White woman to be a wanna-be Native American, so next time I fill out my census forms or go to my doctor: I'm a Pacific Islander. But only for that visit -- I'm going to change it every time.

Medicare "Meaningful Use" Program
http://www.cms.gov/PQRS/
https://www.cms.gov/EHRIncentivePrograms/Downloads/EP-MU-TOC.pdf
http://www.cms.gov/EHRIncentivePrograms/Downloads/7_Record_Demographics.pdf

Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity
http://www.whitehouse.gov/omb/fedreg_1997standards/

Racial inequalities in screening
http://www.nejm.org/doi/full/10.1056/NEJM199609123351106
http://www.opas.org.br/observatorio/arquivos/Sala237.pdf
http://www.mcgilldaily.com/2009/01/study_finds_racial_inequalities_in_cancer_screening/

Ok, now I've read part of the standards and you can't have "multiracial" but technically you are supposed to offer checking more than one box. My EMR doesn't. But it has already passed it's CCHIT testing, so am I going to argue?

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