Jennifer Novak's WRIT 1133 Foucauldian Analysis of an Everyday Text

For this assignment, students were asked to make an argument through critical analysis of a text. They were to use an argument from either Judy Segal’s “A Kairology of Biomedicine” or Michel Foucualt’s “Enunciative Modalities” as a framework for interpreting an object or text: an article from any magazine (ranging from the New York Times to JAMA), a journal article, a blog, an ad, an image, a commercial, or a medical object (ranging from a stethoscope to the packaging for a Powerbar). The audience for the paper was located within the humanities academic research tradition. The essay needed to: 1) forward an argument, 2) address potential counterarguments, 3) offer a style and tone appropriate for an academic audience, and 4) select the best possible evidence for the chosen audience.

The PCS and its Uses:
The Discourse of Aid, Physicians and Corporations Exist in Documentation
Mike Engler

The idea of taking care of the sick and disabled has a utopian stigma gating the reach of its effectiveness — we are willing to help but perhaps only under certain conditions. The certain conditions which govern the United States' disbursement of aid are mitigated through government health programs like Medicare and Medicaid, where qualifications for government help are decided by a combination of private and public departments. In subsidizing public aid through Medicare and Medicaid departments that have authority to contract with private healthcare, the government is making healthcare profitable, and thus subject to pressures of maintaining profits and not that of improving standards of healthcare. While it is difficult to determine, microscopically, the shortcomings of contracting healthcare through private companies, it is less difficult when done on a smaller scale (e.g. the documentation that legitimizes the public-private transaction). The reasons for this interaction of private and public institutions through their documentation can be analyzed through Foucaltian considerations from Michel Foucault's The Archaeology of Knowledge. Foucault's dissenting consideration for the role of the patient questions whether public aid is truly for the patients' benefit, and how that patient's role is fragmented between different institutions of power (the physician, the skilled nursing facility the Colorado Medical Services department (CMS)). The discourse inherent to the PCS form can be separated into different modalities: the parties contributing to the PCS forms use, the institutions that use the PCS form and legitimize it, and the context in which the PCS form is used. Through analyzing the PCS in terms of these modalities, we can appreciate the meticulous construction of disability and worth of medical treatment; it can also be speculated what effects this power has on the patient and those providing treatment. Careful analysis of the PCS form through these modalities suggests that the main consideration in designing the PCS form is to influence the physician's decision to certify the transport, and in some cases, to shape the rejection of authorization for transport for questionable patients. Thus this authorization process supports the existing discourse of power of the physician caring for the patient, of capitalism through the pursuits of corporations, and finally of the ultimate authority to the government, which oversees and approves the former.

There are many members interacting through a PCS form: the government department paying for the transport, the physician who is medically responsible for the patients treatment under the guidelines of the aforementioned department, the ambulance company that takes temporary responsibility and receives compensation for treatment, and finally the patient, as a subject in need that must justify his or her need through this piece of paper. The CMS has general guidelines for Medicare and Medicaid that appear in several categories on the PCS form. For example, on the PCS form found on the Tri-med Ambulance website, the PCS defined Medical Necessity using Medicare guidelines, "The Medicare definition of Medical Necessity for non-emergency ambulance transportation is: The inability to get from bed without assistance and the inability to ambulate and the inability to sit in a chair or wheelchair" (Tri-Med). Not only does this PCS from Tri-Med show that Medicare and Medicaid have the power to define the guidelines of a private company's transport, but it also shows the discourse of the Medicare department is being imposed upon the patient, who is only in Medical Necessity of medical transport at the approval of Medicare. Also working under an agreement with CMS, and therefore with Medicare or Medicaid, the physician delegates CMS's requirements by signing the form: this signature requirement validates and reinforces the status of the physician and that of the Medicare Department by making the physician's signature more important than the nurses'. For example, in the 42 CFR§410.40 guidelines, the official guidelines for PCS forms from the HHS, the physician is required to "[certify] that the medical necessity requirements of [the HHS] are met," and if the physician is not available, "either the physician assistant…or nurse" must sign (HHS 42 CFR§410.40 (c) 3 111). The guidelines in 42 CFR§410.40 serve as official policy that private ambulance companies, physicians and even nurses must obey; in the way in which the voice of the nurse is under that of the physician, the HHS guidelines are maintaining a hierarchy that begins with the government and ends with the patient. This is consistent with Foucault's discussion of speaking individuals' discourse in The Archaeology of Knowledge: "The status of the doctor involves... institutions, systems, pedagogical norms; legal conditions that give the right — though not without laying down certain limitations…" (Foucault 50). The limitations that are present in this case are implications in which the patient is defined as not in Medical Necessity as a means to make money for a private company or to aid in the HHS budget. Thus, there is the inclusion of a private business into this hierarchy, the ambulance company supplying the PCS form according to HHS guidelines, to a physician to legitimize their transaction with the medical staff and the government. The ambulance company is also responsible for procuring the PCS form at the risk of not being compensated; however the ambulance company stands to profit more in some instances by treating Medicare or Medicaid patients. Finally, the patient participates but only as a subject from which the status of aid worthiness is defined and promoted, and thus the patient as a subject is dispersed between the merit and incentives of different voices involved with the patient's care. The structural effect of wiping out the patient's voice serves the interest of profit for a private ambulance company, and, through the power of shaping a physician to reject Medicare or Medicaid approval, to minimize the number of patients on Medicare or Medicaid who actually are authorized to use their coverage. This has an effect of all parties dehumanizing the patient and treating healthcare as a subsidized product rather than a right.

The authorization of power from institutional sites to the physician and the worth of that power are also observed in the use of the PCS form. Considering the hospital as an institution, the patient's condition in needing an ambulance to be transported is only available inside the hospital to or from which the patient is being transported. For example, the HHS guidelines say, "the individual [signing the PCS] must be employed by the beneficiary's physician or by the hospital or facility" (HHS 42 CFR§410.40 (c) 3 111). This condition that is imposed upon the patient is from the government and cedes power to the hospital as an institution Foucault described as being "a place of constant, coded, systematic observation" (Foucault 51). That is that the patient's condition and clearance for receiving aid from the government is mitigated only to a hospital containing the patient's physician — the fact that the hospital comes secondary to the necessary condition that the physician of the patient is part of that hospital shows that the government is acknowledging the hospital as a capable institution only as an extension of the physician. The documentary institution plays an important role in the PCS as being used to mitigate power over the patient to the government's liking. Consider the process of the production of the PCS form: the PCS form is not a certified document itself but can be any document adhering to the conditions of the HHS guidelines. The fact that the form of the PCS is unimportant while the status of the individual signing the document is considered important reveals that the power of the physician is being characterized through widespread use of the PCS form. But more importantly, this process reveals the ultimate power of Medicare and Medicaid, which create the specific guidelines for the physicians to follow; therefore, the physicians are offered an illusion of control, while their decisions are still being factored by the HHS algorithm.

The implications of creating a legal document that is legitimized by a physician to serve the transaction of business between the government and corporations suggest that the government is not truly operating in favor of the patient but instead in appeal to the physician, who requires a marginal amount of power to the government, who tries to cut expenses from the bottom up and who maintains its absolute power, and to the corporation, who has a de facto right to make money off of a patient's misfortune and who stands to make even more money if the Medicare or Medicaid authorizations are rejected. The modalities discussed in Foucault's The Archaeology of Knowledge were used to show that the power of the patient exists in a hierarchy that the PCS form supports and that various institutions benefit from using and serve to legitimize the PCS form. Finally, this suggests that the PCS is being used to maintain profits of a private corporation, to alleviate government budget, and to appease the ego of the physician — all of these at the patient's expense, as they are now being treated as any other trade and enter the rules and logic of economics.

Works Cited

42 CFR§410.40 Date Unknown. The US Department of Health and Human Services. 1 Feb. 2008. [http://www.cms.hhs.gov/AmbulanceFeeSchedule/downloads/ cfr410_40.pdf]

Foucault, Michel. The Archaeology of Knowledge & the Discourse on Language. Publisher Unkonwn: City Unknown: Date Unknown

Tri-Med Ambulance. Date Unknown. Tri-Med Ambulance & Transportation, LLC. 1 Feb. 2008. <http://www.trimedambulance.com/pages/pcsform.pdf>.

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