Sunday, February 01, 2015

Help the snowbirds: Transparency as an enforcement tool

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:

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.


nonlocal MD said...

Well, I would think it would be hard for CMS to police this, since many of these tests and procedures, particularly in the cardiology arena, fall in a gray zone where it would be difficult to make accusations of outright fraud. Not to mention the staff needed for such reviews, which will become more problematic in the current political climate. I would rather see us concentrate on overcoming the obstacles you cite in the migration away from FFS, which would solve the problem closer to the source.

Barry Carol said...

While there is clearly an issue with fraud in Southern FL and some doctors are more money driven than others, I think the main issue here is a culture of aggressive practice patterns in all of the areas mentioned in the article including NY and NJ. I don’t know how these regional practice patterns evolve though some of it may relate to geographic differences in the litigation environment. Doing more may be mainly driven by defensive medicine though getting paid more for doing more gives it an extra push.

Fee for service creates incentives to provide too much care while capitation provides incentives to provide too little care. I’m not sure what the answer is but I am sure that I would like to see sensible tort reform that would provide doctors with safe harbor protection from failure to diagnose lawsuits if they followed evidence based guidelines and protocols where they exist. Affiliations that would allow sharing medical records with the patients’ northern hospitals and doctors would also be helpful.

Anonymous said...

If all medicare patients, even those with PPO plans had a "medical home", as I think has been discussed by medicare, then providers in florida would be obligated to call " medical home" physicians in home state and discuss what tests are medically necessary.

That could curb some of the abuse of the system.

If tests had been recently done in home state, that information could be shared also....

just a thought

Paul Levy said...

Thanks to all of you for your thoughts; but I guess I wasn't being very clear or persuasive. I was looking for something simple and elegant that could be used by consumers in thinking about this issue. Moving from FFS is complex and uncertain; creating medical homes, likewise. Why not use the data that CMS already has to create a simple listing of MDs and their relative use of tests--one that members of the public could easily survey?

nonlocal MD said...

Because, Paul, as you yourself have pointed out in the past, consumers don't/can't use this information. That's another whole subject - do they have enough financial skin in the game, are they cognitively aware enough (particularly in the snowbird demographic group), and are they just plain aggressive enough with their doctors to use that information productively. Having seen the medical offices and clinics on every corner in FL, I think they are sitting ducks.

Anonymous said...


the types of "big data" analysis you are describing could be done for CMS by outside groups that are given a "bounty" based on savings and prosecution.

Or conversely non-profit groups that have deep and strong statistical analysis capabilities in health care, like Harvard School of Public Health, Brown's or Dartmouth's Medical Schools and Tufts Medical Center could be given research NIH research grants to analyze CMS data and identify groups which CMS should target for clawbacks and prosecution.

Peter said...

Amen. The closer we can get to direct involvement by medical care ‘consumer-patients’, particularly by rational use of in-place regulatory apparatus, the sooner physicians will be convinced that they have a direct responsibility for policing their own.

Dennis Byron said...

This is always a reasoned blog with reasoned comments. But everyone is missing the ball on this New York Times non-story about Snowbirds and Medicare-financed testing. The story itself is a mishmash and then the commentary seems to avoid the basics of how Medicare works.

The Times is off base because it inappropriately melds some anecdotes about a few hypochondriac snow birds in Florida now, some undefined proprietary Times analysis of three-year-old data (because I assume it's the Part B info released last year, which indicated possible testing fraud in both Florida and the place the snow birds came from, NY), and some questionable five or more year old Dartmouth data about end of life issues (questionable because it says Massachusetts is one of the least expensive places for testing). Perhaps a small subset of snowbirds decide to go to Boca for their final days and get talked into a prostate exam by a drive-in urologist clinic while worrying about the end but – really -- these are three very different subjects.

As for the comments. CMS already pays a dozen insurance companies nationwide to pay all Medicare fee for service claims and to police the claims for the alleged fraud. There is no need for new staff at CMS and CMS itself has never staffed for either function in Medicare’s 50-year existence. It sounds like there is a need for better policeman if there is anything to the undated, unsourced New York Times analysis we can’t see. But when third parties were hired to look for fraud on a bounty basis a couple of years ago (2008 law I think) as one comment suggests, everyone screamed bloody murder. The anecdotes themselves don’t really indicate any fraud to me. What kind of cardiologist would tune up a pacemaker implanted by someone else without testing (and how often do you have a routine pacemaker check-up anyways? why didn’t the 91 year old do it in New York before he went south?).

As for how transparency relates, almost everyone on fee for service Medicare (especially people who can afford two homes and can afford to winter in an expensive location) has dollar-one supplemental coverage; they do not check prices or really care how often a doctor prescribes tests. The last thing they want is the government telling them they can’t get their prostate checked.