Elisabeth Rosenthal at the New York Times has a gift for taking what is right in front of us and unnoticed and making it evident. She does it again in this story about elderly "snowbirds" in Florida who are persuaded by doctors there to undergo unnecessary tests. The lede:
The Medicare Fraud Strike Force, a joint initiative of the Department of Health and Human Services and the Department of Justice, was formed in response to widespread fraudulent claims in South Florida, and its periodic “takedowns” have charged far more providers in Miami than in the other cities where it operates.
But the practices apparently persist. It is hard for a government agency to diligently review the practices of each doctor--although some "big data" algorithm could likely prove helpful to find enforcement targets.
Now, my economist friends will say that the solution to the problem would be to move away from fee-for-service payments to doctors, substituting some kind of capitated approach, in order to eliminate incentives for overuse. Elliott Fischer, for example, is quoted in the article:
“It’s mostly based on how much doctors do in a system where you make more by doing more. Financial incentives and more entrepreneurial doctors are very important to what we’re seeing.”
An alternative risk-based pricing method, however, would require patients to be part of a closed managed care system or accountable care organization. For political reasons, though, Congress will not limit patient choice in that manner, retaining instead a PPO format for Medicare. In this environment, the northern "home" ACO can have little influence over the patient or doctor while the patient is in the warm states.
So the only answers to this problem are more vigorous enforcement by CMS and more diligence on the part of patients. It is in the latter arena that CMS could be more proactive. What if CMS took a step to help patients shop around and be alert to potential over-testing--transparency. For example, what if the agency simply published, for each doctor in these jurisdictions, the rate at which they conducted the top third or fourth ranked tests, compared to an acceptable benchmark. Let's give some useful tools like this to consumers so they can be more diligent for themselves.
Like many retirees, one couple from upstate New York visit doctors in their winter getaway in Florida. But on a recent routine checkup of a pacemaker, a cardiologist there insisted on scheduling several expensive tests even though the 91-year-old husband had no symptoms.
“You walk in the door, and they just start doing things,” said Sally Spencer, 70, who canceled the tests after her husband’s longtime doctor advised her by phone that none of them were needed.
The couple’s experience reflects a trend that has prompted some doctors up north to warn their older patients before they depart for Florida and other winter getaways to check in before agreeing to undergo exams and procedures. And some patients have learned to be leery after being subjected to tests — and expenses — that long-trusted physicians at home never suggested.
This is truly disturbing and disgusting behavior. And it's not like it takes a complicated analysis to prove:
When researchers from Dartmouth last year looked at the number of tests and imaging studies received by Florida Medicare patients in the last two years of life, with the exception of the panhandle, totals were far above the national average, said Dr. Elliott Fisher, director of the Dartmouth Institute for Health Policy and Clinical Practice. Other areas that showed high rates of testing and imaging in the study included Arizona, California, southern Nevada and South Texas, all also popular for sun-seeking retirees; New Jersey and New York City also scored high, though, too.
You would have thought that CMS, the Medicare agency, would have noticed it and engaged in some kind of enforcement action. Apparently it has:
The Medicare Fraud Strike Force, a joint initiative of the Department of Health and Human Services and the Department of Justice, was formed in response to widespread fraudulent claims in South Florida, and its periodic “takedowns” have charged far more providers in Miami than in the other cities where it operates.
But the practices apparently persist. It is hard for a government agency to diligently review the practices of each doctor--although some "big data" algorithm could likely prove helpful to find enforcement targets.
Now, my economist friends will say that the solution to the problem would be to move away from fee-for-service payments to doctors, substituting some kind of capitated approach, in order to eliminate incentives for overuse. Elliott Fischer, for example, is quoted in the article:
“It’s mostly based on how much doctors do in a system where you make more by doing more. Financial incentives and more entrepreneurial doctors are very important to what we’re seeing.”
An alternative risk-based pricing method, however, would require patients to be part of a closed managed care system or accountable care organization. For political reasons, though, Congress will not limit patient choice in that manner, retaining instead a PPO format for Medicare. In this environment, the northern "home" ACO can have little influence over the patient or doctor while the patient is in the warm states.
So the only answers to this problem are more vigorous enforcement by CMS and more diligence on the part of patients. It is in the latter arena that CMS could be more proactive. What if CMS took a step to help patients shop around and be alert to potential over-testing--transparency. For example, what if the agency simply published, for each doctor in these jurisdictions, the rate at which they conducted the top third or fourth ranked tests, compared to an acceptable benchmark. Let's give some useful tools like this to consumers so they can be more diligent for themselves.