Friday, March 17, 2006

Doctor at Work: Dr. Ketchum Puts Marty Griff Back in the Game

Marty Griff, 67, is a trim, conditioned tennis player who drives opponents to distraction by getting everything back. “It's like killing a snake,” a frustrated opponent says. “You hit a winner against him and move into position for the next point and the damn ball comes back. And it keeps coming back.”

But Marty is paying a price for his impossible gets in which he covers the court like a player twenty or thirty years younger. Running flat out on practically every point, he feels a sharp pain in both heels with each stride, push-off and landing. To keep going, he ices his heels before and after playing and does foot stretches between games as well as throughout the day.

On this particular day, however, Marty Griff, shown below, has reached the end of the road. He has gone just about as far as he can without doing something about his heel pain. A podiatrist, Dr. Jonathan Ketchum, has told him that he has an inflammatory condition in both heels called plantar fasciitis. It will require surgery.

He is to report the next morning to the hospital for surgery. So is Marty Griff at home resting up for surgery the next morning? No. He's out playing tennis and running around the court as usual, though grimacing in pain and limping between points. “You crazy?” his partner (me) says. “You're having surgery tomorrow morning.”


I shake my head.

As it happens, I also come off the court limping. I ask Marty for the name of his podiatric surgeon. Marty writes the name and number of Dr. Jonathan Ketchum on a piece of paper and hands it to me. He does so with a told-you-so look since I have been riding him about trying to be a hero at the risk of further injury.

“Go see him,” Marty says. “He's great.”

Marty has his surgery, in which Dr. Ketchum makes a small incision on the side of the heel and operates on the plantar ligament to release tension and promote healing of the inflammation. The procedure goes well. However, Marty mostly ignores the fact that he has had surgery on both feet and begins moving around almost immediately.

Meanwhile, with the help of sharp pain in the left heel that will not go away, I have acquired a sudden appreciation of Marty's heel problems. At Dr. Ketchum's office in Worcester, I luckily pounce on an opening within a week. (Even the most callous medical office gatekeeper can be moved by a pitiable figure saying he is racked with pain and needs help ASAP.)

Dr. Ketchum enters the examination with a warm smile and an outstretched hand. He carries a brand new manila file containing one item, the medications and permission-to- treat form that I, a new patient, had just just filled out. The medications part is all blank since I take no medications.

Dr. Ketchum looks like a high school senior. He is a ripe old 36, or younger than my two grown sons. He has a full head of straight light brown hair that falls boyishly over his forehead and that bounces as he moves. He swipes the hair out of his eyes and, adolescent-like, it springs right back. He is trim.

He is married with three little kids, the latest of whom is a two-month-old boy who keeps him up at night. He has a very busy podiatric practice. He has no time. Today, like every day, his waiting room is full and the office staff are bustling to keep the the line moving.

The smile is real and so is the warmth. Although this is the first time he has ever laid eyes on me, he seems glad to see me. More surprising, given all the people waiting to see him, he doesn't seem rushed. And he doesn't rush. He doesn't try to get me in and out as fast as possible – which is what everybody and everything around him is pushing him to do.

Almost defiantly, he gives a new and unknown patient plenty of time.

“Hi. Marty told me you were coming in. He's doing well, by the way.”

“Do you know that he was running around on the tennis court the day before you did the surgery on him.”

“I'm not surprised. There's no keeping Marty down. He's going to be fine. In four weeks he'll be playing again. So, you have pain in your left heel. Let's look at it.”

He slips the sock off and the problem foot is in his hand as if being weighed. He lifts the foot higher and studies the part that hits the pavement. He passes his hand over the bottom and then pushes his index finger into one spot at the heel.

“Ah,” I yelp. “That's it.”

“You got the same thing Marty has. You two guys are anatomical twins. It's called plantar fasciitis. It's an inflammation of a large ligament that extends along the bottom of the foot, from the front of the heel to the ball of your foot. The ligament is an extension of your achilles tendon.”

“What about tennis?”

“We'll get you back out there.”

“What's the cause? Too much tennis?”

“Not necessarily. Some people get it who aren't athletes. In your case, I would say it is anatomical, related to the shape of your foot and a rigid rear foot combined with a flexible forefoot.”

“Not an athletic injury I can brag about?”

“Unfortunately not.”

“Would an orthortic insert help?” (I have been reading up and fancy that I am in charge of my health care.)

“Yes. You have a lot of flexibility in the forefoot. People with this foot type typically respond well to an orthortic insert. If you like, we'll make an appointment to cast your foot and we'll order one for you. You'll have it in about three weeks.”

“Sounds good.”

Notice should be taken of a magic number that had recently assumed out-sized importance in my life, at least as far as the American health care system is concerned. I recently recently turned 65 and thus walked into Dr. Ketchum's office as an official senior citizen -- a dubious honor in our youth-crazed society.

This was my first visit to a doctor as a Medicare beneficiary. After a leisurely discussion of plantar fasciitis, I didn't want to take further advantage of a busy doctor's time. So I went to the bottom line.

“How do you get paid?” I asked. “ I have Medicare and Medex.”

“Medicare picks up eighty percent and Medex twenty percent.”

“What do I pay?”


“But I get reimbursed only thirty percent of my bill.”

“That's all?”

“What if you send me a bill for the difference?”

“Can't. Illegal.”

“What if I just give you a check?”

“Can't take it. Illegal.”

“So, in other words, my visit to you today is a great deal for me and a bad deal for you.”

“That's how the system works. The physician's bill and what's allowable under Medicare are two different things. I can take care of you, submit a claim, and be entitled to the full amount, but if Medicare only allows so much, that's what I get. Or I might not get paid at all if the claim is not submitted exactly right. Even though I provide the service and have a right to be paid like anybody else, the claim just comes back denied.”

“You can't question a denial?”

“Sure, I can have someone on the office staff redo and resubmit the claim and spend four hours fixing the problem. When you figure in all the extra work and paying her for four hours, it can cost me money to resubmit. They make it so hard for a physician to get reimbursed properly that I have to eat bills all the time. But while I'm working without getting paid, the overhead for this place keeps going.”

“The reimbursement burden is on you, not the patient?”

“When you think about it, paying the doctor is really the patient's responsibility. A patient walks in here of his own free will and asks me to take care of him. The agreement is I take care of him and he pays me for doing so. But in the world of Medicare and third-party payers, patients don't know how to navigate a very complicated reimbursement system. So we end up doing it. Somebody has to do it or we don't get paid.”

“In other words, you end up with the responsibility of doctor and patient.”

“Yes. And in dealing with Medicare, we go through the exact same frustrations that the patient would have to go through. Say I want to question a claim denial and want to talk to a human being. When I call, I have to press a whole series of options and then get put on hold. I don't have time to be on hold; I have patients waiting to see me.”

“Not what you signed up for?”

“No. I signed up to be a doctor and to take care of people. That's the part the system doesn't even recognize. I operate on Wednesdays and Fridays. On the night before, I lie in bed awake thinking about what I have to do and how to make sure I do it right. I run what-if scenarios over and over about everything from first incision to closing. Then I go into the office the next day and find out how Medicare is banging me on the head.”

The reimbursement problem is not just with Medicare, Dr. Ketchum says. He gives an example of a patient covered by Blue Cross. “I operated yesterday on a woman. I put screws on both sides of her ankle. But for all the time I spent with her, I'll be lucky to clear ten bucks an hour after I pay the overhead and all those people out front.”

Later, I talked to one of those people out front, the one responsible for billing and reimbursement, and asked about the example cited by Dr. Ketchum. She
retrieved the patient's file. She said that she could not give out her name or discuss her specific case, but could give the treatment for an injury such as hers, a fractured left foot.

She said: “The surgery took two hours. He put in five whole plates and five screws. He saw her for a 30-minute post-op appointment. After the surgery, there is a 90-day global period. During that time he saw her eight times for about thirty minutes each time. Altogether, it came to about six hours of face time. There was also about three hours of paperwork. We billed $1,000 and were paid $480.”

“What did you charge for the surgery?”

“Everything Dr. Ketchum did during the 90-day global period, the surgery, the post-up, all those appointments, are included.”

“He was reimbursed for less than half of what he billed.”

“Yes. Basically, Dr. Ketchum didn't get paid for all that follow-up care.”

Dr. Ketchum gave another example, the patient's new orthortic. “A cast technician will come in here for twenty minutes working under my direction and probably make more per hour than I do. I went to school for 13 years at a cost of $500,000 that I'll be paying for after I'm dead. He took a few week's training and is working under my medical license and my supervision.”

“Being a doctor isn't what it used to be, is it?”

“It sucks.”

“But would you want to do anything else?”

“No. I want to do exactly what I'm doing. I want to do what I'm doing with you, getting you back up and running so you can enjoy life. The system knows that's how we feel and takes advantage of us. It grinds us into the ground and then it grinds us some more.”

“I hear many doctors are leaving the profession.”

“It's true. Plus the best students are no longer going to medical school. When I got accepted to medical school, it was super-competitive. Only top students got in. Now applications are down 37% at my medical school and, frankly, the quality of the students accepted is down. You can see this reflected up and down the ranks of the profession today.”

I mention that I am writing about health and the health care care system.

“Couldn't pick a more important topic. If you want, I'll sit down with you some time, maybe have something to eat, and I'll tell you stories that'll blister your ears.”

“Let's do it.”

“You're on.”

We meet and I do get an earful.

The next week I come in to have Dr. Ketchum make a cast of my foot so the orthortic can be made. I give a lift to my now fellow patient and tennis partner, Marty Griff, who is coming in for his first follow-up after his surgery. However, being a rookie podiatric patient, I have the time for my appointment wrong.

“No problem,” Dr. Ketchum says, not missing a beat. “If it's okay with you guys, I'll take you both together.” He ushers the two of us into the same examination room.

“I'll do Marty first. He's in more discomfort.”

It has been a week since Marty's surgery and he is walking, though haltingly and grabbing on. Though his pain has gone, it's not easy to walk on two bandaged feet with little attached drain bags bobbing from them like balloons. Both drain bags are nearly full. Dr. Ketchum helps Marty onto the examination table and begins carefully unwinding and cutting bandages, while I sit in the corner and watch.

“This will take a while,” Dr. Ketchum says. “I have to be careful so I don't hurt Marty.”

Turning toward me, he says, “You're not squeamish about
blood, are you?”

“No,” I lie.

It takes probably twenty minutes to get the bandages off both of Marty's feet, revealing the small incision on one side of the heel and the attached drain bag on the other side. Dr. Ketchum studies the surgical wounds and drain bag sites.

“All we have are two little incisions on the sides of the heel, one for drainage and the other for the camera and instruments to make the incision of the plantar. Three years ago, the procedure involved slicing the whole bottom of the heel and lifting up the fat pad flap to get to the plantar fascial ligament.”

He asks Marty to take a deep breath and yanks one drain bag out. Marty grimaces. After a repeat of the same drill, the drain bags are out. The second yank squirts droplets of Marty's blood at my feet.

“Did I get you?” Dr. Ketchum asked.

“No, just the floor. This procedure takes time. Doesn't it?”

“Yes, if you don't want to torture the patient.”

“How does Medicare pay you for this?”

Dr. Ketchum laughs. “They don't. Post-op care over what they call a global period of 90 days is covered within the surgical fee. And because I'm doing both feet at the same time, I get the full price for one but only half price for the other. If I did them both separately, I'd get paid for both. In other words, if I do something that makes no sense either for Marty or for me, I make more money.”

“Sounds crazy.”

“It's just one little example that's repeated over and over. Okay, your turn.”

“What now?” Marty asked.

“The ligament is separated.” Dr. Ketchum brought his hands together, interlocking his fingers, then pulled his hands apart. “Like this. What we don't want now is for the ligament to come back together.” To demonstrate, he brought his hands back together. “So this doesn't happen, I want you start moving right away. Walk, go about your regular activities, do the exercises I gave you, ice regularly. Using your feet will make your recovery go faster and keep the ligament from reattaching. You're going to bounce right back.”

Marty slides off and assumes his place in the corner as spectator while his doubles partner gets up on the table. With his usual all deliberate speed, Dr. Ketchum fits soaked plaster-like material to the left foot. It will harden into a mold for the orthortic insert. While it is firming up, he goes off to see other patients. Like most doctors, he does not have a minute to waste. He comes back in about ten minutes, takes off the mold and the doubleheader is done.

“We should have the orthortic in about three weeks. We'll see you then. Marty, you know what you have to do.”

Marty follows Dr. Ketchum's orders to the letter about icing and stretching exercises. However, he makes a slight adjustment in the amount of healing time that would be needed before returning to tennis. Dr. Ketchum said that he could be out on the court in four weeks. Marty cuts that to days.

After eight days, he goes out and hits for twenty-five minutes. Exactly nine and a half days after surgery, Marty shows up for tennis with his regular group, to the utter astonishment of all present.

“You are crazy,” I tell him. I'm wearing the orthortic.

“Don't worry about me. Did you ice?”


“And don't forget. You have to stretch that foot between games, fifteen seconds each stretch. These guys can just wait.”

Marty and I are partners in a doubles match. Before we start playing, Marty whispers to me. “Wait till you see all the drop-shots, the bastards.”

Play begins – and the first return from the opponents is an attempted drop-shot, which plops into the net. “What did I tell you?” Marty says. “The bastards.”

“They're all heart, aren't they?”

With competitive juices flowing and the air thick with concentration, the battle rages. During the change of court sides at odd-numbered games, Marty makes sure I stretch against the net posts. While it's okay for him to make his own rules, he wants his partner's stretch done exactly as Dr. Ketchum has instructed.

That afternoon Marty Griff is the speediest, most competitive player on the court, chasing down one heartless drop-shot after another. By the time the opponents catch on that he is not the crippled player they expected, it is too late. Marty, covering extra court to make up for a partner moaning about pain in his left heel, carries his team to victory.

The unseen player on the court for that victory was Dr. Jonathan Ketchum. Without his diagnostic and surgical skills, Marty Griff could not have made such a remarkable recovery. Yet, for the most part, Dr. Ketchum's invisible but essential role is unsung.

To be sure, a couple of aging tennis players are grateful to him for keeping them in the game. But powerful health care forces – from insurance companies to HMO's to state and federal reimbursement rules -- press down on him every day from all sides.

For 2007, the federal government has proposed a 4.6% decrease in the reimbursement rate he gets for treating Medicare patients like Marty Griff. This decrease is from reimbursement rates so low that Dr. Ketchum feels he is practically donating his services, not to mention spending time and resources negotiating complex government regulations.

Many doctors have started to cut back on taking new Medicare patients because they feel they have no other choice. Dr. Ketchum has not yet done so -- he took me as a new Medicare patient.

But he does not know how long he can continue treating new Medicare patients. To those making the rules he must work by, his part is never good enough. Surely, they tell him over and over, he can do it faster and cheaper.

Postscript: Over the several months since this was written, Marty Griff returned to top tennis form but began having problems with his right ankle. Last week, Dr. Ketchum performed surgery on the ankle, removing bone and repositioning a tendon. He is walking and expected back on the court soon, running like the wind and making opponents pay for every mistake.


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