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.
Medical testing is a huge industry in the United States, with prices that are highly variable in different parts of the country. And while Medicare — the government insurance program for those over 65 or with disabilities — strictly regulates the price of tests and procedures, doctors who treat seniors can increase revenues by simply expanding the volume of such services and ordering tests of questionable utility.
In some areas where many retirees live, most notably Florida, the data suggests that they do. In 2012, according to a New York Times analysis ofMedicare data released last year, more than twice the number of nuclear stress tests, echocardiograms and vascular ultrasounds were ordered per Medicare beneficiary in doctor’s offices in Florida than in Massachusetts.
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.
Those high numbers cannot be explained by the presence of sicker patients, better outcomes or a desire by patients there for more treatment, Dr. Fisher’s studies have found. He added: “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.”
Many cardiologists in Florida practice careful medicine and do not perform unusually high numbers of tests, of course. Dr. A. Allen Seals, president of the Florida chapter of the American College of Cardiology, said in an email that testing should be based on “evidence-based guidelines at the point of care while accounting for individual patient preferences and values.” He noted that the American Board of Internal Medicine’s “Choosing Wisely” guidelines included questions patients could ask if referred for cardiac testing.
Some extra testing may be understandable as doctors see new patients and may not have full access to prior records or trust testing performed elsewhere. Last year, the North Shore-Long Island Jewish Health System signed a three-year affiliation agreement with Boca Raton Regional Hospital in part to provide better continuity of care for patients who live in both areas.
But Florida has emerged over the years as an epicenter of Medicare abuse: 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.
And high-volume testing is also a good way for physicians to supplement income when insurers are cutting back on payments for individual services. From 1999 to 2008, as Medicare reduced reimbursement for many cardiology services, one study found that the number of Medicare claims soared for the types of testing recommended to Ms. Spencer’s husband. Claims for echocardiograms (which use sound waves to produce pictures of the heart’s wall and valves) increased by 90 percent. Peripheral vascular ultrasound tests (which look for clogged arteries) nearly tripled. Nuclear stress testing (a complex test for coronary artery disease) more than tripled, even though the procedure takes hours, involves an injection and radiation exposure, and costs thousands of dollars.
Doctors now often own the testing equipment or have a stake in a center where testing is performed. Medicare law generally forbids such self-referral because studies show it encourages overuse of services.
(While studies have not looked specifically at testing in Florida, one studythere, by Christine Yee, an economist at the University of California, Berkeley, showed that physicians who were on the boards of ambulatory surgery centers did 27 percent more procedures than those who were not.)
But the law permits an exception for “in-office ancillary services” directly related to care. As doctors have moved more equipment and technology into their offices, that once-limited category has grown to include a wide range of tests, from X-rays to expensive cardiac testing to suites where biopsies can be performed.
“One of the things I worry about most is leaving my doctors,” said Eugene Levich, who is selling his house in Liberty, N.Y., and moving full time to Delray Beach, Fla., where he and his wife have long wintered. “People are old. They’ve just moved. So it’s very easy for doctors and dentists to take advantage of this population — and they do.”
After Mr. Levich had a routine prostate exam in Florida last year, the doctor there told him that he should have a surgical biopsy. Mr. Levich delayed until he could see his physician in New York, who told him that there was no reason for the procedure.
Likewise, when Mr. Levich went to an ear, nose and throat doctor in Florida because his ear felt clogged after an infection, he told the doctor that he had no trouble hearing. The physician nonetheless immediately ordered ahearing test, and urged him to schedule an M.R.I. as well. Instead, Mr. Levich went to a pharmacy and bought a nasal spray that cleared up his problem.
Despite the financial protection against high charges for individual tests offered by Medicare, out-of-pocket payments can quickly add up, since the government insurance generally requires a 20 percent co-payment for outpatient care.
Mike Miller, 74, who splits his year between Maryland and Florida, said that when possible he sought recommendations from his doctors at Johns Hopkins in Baltimore. “You don’t visit doctors in Florida unless you have really good references from other doctors or people who are really trustworthy,” he added.
He said he had found excellent surgeons and eye doctors this way. But when he visited a cardiologist to check out a slow heart beat (one he has had all his life) he was soon undergoing the same three tests as those prescribed to Ms. Spencer’s husband — as well as being placed on a 24-hour heart rhythm monitor.
“They were aggressive in encouraging me to have tests even though my doctors in the North never said I needed them,” he said. “And of course the results were all normal.”