Archive for category Dartmouth Atlas Implications
Snowbirds: watch out for high medical costs in Florida, Texas, Arizona and California. According to Elisabeth Rosenthal in the New York Times 2/1/15 “Patients Find Winter Havens Push Costs Up”. She points out providers in Florida are the worst offenders — the same place notorious for Medicare fraud!
Ms. Rosenthal highlights one patient from New York wintering in Florida who had a checkup for his pacemaker but did not have any new symptoms. Many in-office tests were ordered by the substitute cardiologist — tests the patient’s regular cardiologist said were unnecessary.
To be very blunt: cardiologists, and other providers, who order in-office tests make a lot of money from those tests. Many studies show providers who profit from tests do more tests than providers who don’t profit from tests. A medical license is not a license to take advantage of patients or Medicare — profit motivation seems to blind some providers to this distinction.
The lure of profit is made greater by a patient not having any new symptoms, not having any record of previous tests, and not having plans for follow-up visits. It is like the patient has a sticker pinned on their back: “TEST ME”. The choice for the cardiologist is simple: either pay the nurse to spend time getting out-of-town records OR make money by repeating tests. Make money, right!
- If you are on vacation and have a sudden health problem your best bet is an urgent care center. They can send you to a specialist, if needed.
- If you have health problems and will be spending several weeks or months away from home:
- Talk to you primary care provider: they may want you to call in and give a report on the phone (diabetes is a good example). If so, no office visit may be needed while away.
- Get enough medication to last the trip. Or, get prescriptions with refills at WalMart or Target and have the prescription transferred to a store near your winter location.
- Identify a doctor to see in your vacation area before you leave. Ask friends or other people who winter in the area for a recommendation. Call the distant provider office and get a FAX number so records can be sent.
- If your primary care provider thinks you need a health care visit while you are away then make an appointment and have your records sent before you leave home — also take a paper copy!
- If tests or surgery are recommended then call your regular doctor’s office to see if they agree.
- Give any provider you see your regular provider’s name, address, phone number and FAX number (a business card is good). Request that results of visits, tests or hospitalizations be faxed or sent to them — and make sure it happens. Fill out a release of information form while you are at the office or other facility.
The above graph is from the Dartmouth Atlas of Health Care and shows the Medicare expenditure per patient for medical equipment in each state. As with most Dartmouth graphs, the point is to highlight tremendous variability across the country. The rules of payment are the same across the country yet the system fails to follow the rules. Consistency means reliability, but the opposite is also true, inconsistency means unreliablilty. Medical equipment includes such things as nebulizers, wheelchairs and walkers to name a few.
Sadly, the medical equipment business is a hotbed of fraud and incompetence. There are just as many elderly people per capita in Iowa as Florida, but Florida has no grip on costs. Arizona monitors Medicare equipment spending quite well, but Texas is out to lunch.
There are so many problems it is hard to know where to start, here are a few examples:
- The rules for equipment are incomprehensible (just look at the CMS web site for proof) so States have difficulty following the rules and crooks can easily submit fraudulent claims.
- Wheelchairs are essential for quality of life for many people. But, for many elderly people who have other people push them around the much less expensive “transport chair” is sufficient.
- Compressor/nebulizer equipment for asthma and COPD is 99% boondoggle and 1% needed. Patients who have a prescription for an inhaler do not need a nebulizer — but medical suppliers pass them out anyway. Medicare should not pay for nebulized medications in the first place since the usual medications are generic. There is near-universal agreement (except for suppliers) that a meter dose inhaler (MDI) is more effective than a nebulizer. So if Medicare is bent on providing inhaled medication at least provide the cost effective MDI. Canadian doctors rarely find a need for nebulizers because the government provides MDIs.
- Walkers are a good hedge against falling. A broken hip is a lot more expensive than a walker. But, why does Medicare pay $65 for walkers that probably cost $20 to manufacture?
- The idea of letting the supplier get the prescription directly is inviting fraudulent behavior. The local supplier does not have the staff to investigate the truck-loads of rules so what do you think happens? Forms are filled out like the ones that passed the system before, the equipment is delivered (mostly) and Medicare pays.
- Set a national Medicare budget for equipment with some sort of priority if the budget is tight.
- Medicare should nationally purchase large volumes of commonly used equipment then send it to people by UPS or FedEx (like Amazon)
- Physicians should prescribe equipment by computer directly to Medicare (or a national clearing house). Medicare and insurance companies could then monitor the indications electronically before providing the equipment. Also, this would allow contract bidding for the equipment. The equipment vendor makes no decisions except how to deliver the goods.
Graph from The Dartmouth Atlas of Health Care 2003 – 2007
Percent of cancer patients receiving chemotherapy during the last 2 weeks of life.
The Dartmouth Atlas is a great quality tool for US health care. The idea of small area analysis dates back about 20 years when researchers noticed a considerable geographic variation in care. Now it has become an accepted technique to show how different regions adopt different practice patterns. The patterns are almost always disturbing since they mean US health care is not consistent thus not reliable. When such a map reflects billing for unnecessary care it is even more disturbing. Such is the case in the map above: some oncologists stop giving expensive chemotherapy when the situation is hopeless whereas other oncologists give chemotherapy until the patient is dead. If the oncologists did not derive financial benefit from chemotherapy one might be able to believe they were just giving a heroic effort in the face of death. But, given the financial incentive another interpretation would be prescribing something of no medical value for profit. It seems unlikely market forces would change this practice except to make it more widespread.
Performance status is a measure of how the patient is doing generally. If the patient is bedridden the performance status is very poor. In that very poor condition no chemotherapy helps, and in fact may hasten death. So, from a quality assurance standpoint close attention is needed to make sure oncologists are documenting performance status and acting accordingly.
The current thinking is when the performance status is bad it is time to stop chemotherapy and talk about hospice.