Friday, August 1, 2014

Medicare spends a lot of money unnecessarily

You may find this story hard to believe, but it's true.

A 75-year-old non-smoking man with no serious medical problems and a relatively low-risk family history [father, a life-long smoker, died of a stroke at age 76] has been undergoing routine physical examinations by his primary care physician in Florida every 6 months for several years.

The visits include a full battery of laboratory studies, nearly all of which have been completely normal on every occasion.

The patient told me that he has been on a statin for about 20 years. At the time it was started, his total cholesterol level was 201 mg/dL. The genrally accepted upper limit of normal is 200 mg/dL.

After his last visit, the doctor told him to take his pill every other day because his most recent total cholesterol was 109 mg/dL.

Can hypocholesterolemia cause health problems? How low is too low? No one knows for sure, but cholesterol is a constituent of cell membranes and many hormones.

I've blogged before about the overuse of medical care, particularly Pap smears, in Florida.

Why does Medicare pay for all these unnecessary tests and drugs? Medicare probably has no way of knowing that a statin was started and is being continued for no good reason. But what about the cost of the office visits and routine blood work every 6 months?

It's probably not much money per person, but of all the states, Florida has the greatest proportion of people who are at least 65 years old (17.3% in 2012).

The population of Florida in 2012 was 19.32 million so it has 3.28 million people over the age of 65. There's potential for a lot of money to be wasted.

As one of its Choosing Wisely items, the Society of General Internal Medicine has recommended that routine general health exams not be done for asymptomatic adults.

A Cochrane Review of 14 studies comprising 182,880 patients came to the same conclusion and noted that important harmful outcomes of routine check-ups were often not studied or reported.

In June I wrote about the doctors who received seemingly excessive Medicare payments identified by various journalists and wondered why Medicare couldn't have discovered these obvious outliers on its own.

Routine check-ups every 6 months seem easy enough to identify and squelch. Why can't Medicare do something?

PS: For all you fans of rating doctors according to patient satisfaction scores, the patient in the above anecdote really likes his doctor and is worried that, because he is fed up with everything about the practice of medicine, he may retire.


Unknown said...

Yes, this "patient satisfaction" paradigm is proving counter-productive, diverting hospital funds from better patient safety measures to valet parking. People like attention - even if they're being exploited as in the case you cite.

And Medicare's not the exception here - there's plenty of comparable exploitation and endangerment going on with younger, and better-paying, patients as well. Your question about why Medicare can't improve its ability to curtail these practices applies equally to private insurers.

Skeptical Scalpel said...

John, you are right. I shouldn't have singled out Medicare. It goes on with all insurers. This was just a nice example.

Vamsi Aribindi said...

Hmm, looking at the position by the SGM, I wonder if they've considered the effect of annual physicals on compliance with other recommendations. I think the evidence is clear that the "standard" blood tests don't work, and that the physical exam is unlikely these days to pick up anything, but what about the chance to chat about health in general?

If the average person isn't coming in once a year, will they remember to seek a colonoscopy/FOBT starting at 50? Or Shingles and other vaccines? For that matter, will their depression go untreated?

This is similar to the recent ACOG dispute with the AAFP over the pap smear- ACOG insists that the annual pap smear is an opportunity for women to talk about their health and things that they wouldn't otherwise share, while the AAFP didn't think this was a good enough reason to subject so many women to an apparently unnecessary procedure.

Vamsi Aribindi

Skeptical Scalpel said...

Vamsi, those are good points, but I'm not sure they justify what is clearly not only valueless as a way of maintaining health, it is also a source of potential harm from false positive tests,

Moose said...

Geez, where are these doctors? As a non-elderly person on Medicare due to disability, I struggle to find a doctor who will do more than verbally pat me on the head and rush me back out the door.

Skeptical Scalpel said...

The one I wrote about is in Florida. I'm not sure it's worth moving there as he says he is going to retire.

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