Retirees Sally Spencer, 70, and her 91-year-old husband, from upstate New York, recently encountered a concerning trend on a routine checkup of a pacemaker during their winter getaway in Florida. Despite having no symptoms, a cardiologist there insisted on scheduling several expensive tests. Fortunately, the couple was able to cancel the tests after their long-time doctor advised them by phone that none of them were needed.
This experience has prompted some doctors up north to warn their older patients before they depart for winter getaways to check in before agreeing to undergo exams and procedures. Furthermore, some patients have learned to be wary after being subjected to tests and expenses that their long-trusted physicians at home never suggested.
Medical testing is a booming industry in the United States, with prices that vary significantly between regions. While Medicare – the government insurance program for those over 65 or with disabilities – has strict regulations on the cost of tests and procedures, some doctors treating seniors have been found to increase their revenues by ordering tests of uncertain value and expanding the volume of services.
Retirees in Florida, Arizona, California, southern Nevada, South Texas, New Jersey and New York City are receiving more medical tests than the national average, according to a study by the Dartmouth Institute for Health Policy and Clinical Practice. Mike Miller, a part-time Florida resident, sought guidance from his physicians at Johns Hopkins in Baltimore.
The study, which looked at the number of tests and imaging studies received by Florida Medicare patients in the last two years of life, found that the number of nuclear stress tests, echocardiograms and vascular ultrasounds were more than twice the number of those ordered per Medicare beneficiary in doctor’s offices in Florida than in Massachusetts.
Dr. Elliott Fisher, director of the Dartmouth Institute for Health Policy and Clinical Practice, said that the high numbers cannot be explained by the presence of sicker patients, better outcomes or a desire by patients there for more treatment. He added that the results are “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.”
Cardiologists in Florida strive to practice evidence-based medicine, according to Dr. A. Allen Seals, president of the Florida chapter of the American College of Cardiology. He noted that the American Board of Internal Medicine’s “Choosing Wisely” guidelines provide questions for patients to ask if referred for cardiac testing. However, Florida has a history of Medicare fraud, with the Medicare Fraud Strike Force being formed in response to widespread fraudulent claims in South Florida.
High-volume testing is also a way for physicians to supplement income when insurers are cutting back on payments. From 1999 to 2008, as Medicare reduced reimbursement for many cardiology services, one study found that the number of Medicare claims increased significantly for certain types of testing. Claims for echocardiograms, peripheral vascular ultrasound tests, and nuclear stress testing all increased, even though the latter procedure takes hours, involves an injection and radiation exposure, and costs thousands of dollars.
Moreover, doctors often own the testing equipment or have a stake in a center where testing is performed. This is generally forbidden by Medicare law, as studies have found it encourages overuse of services. 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.
Exams in Years Before Death
Seniors in Florida face some of the highest costs for diagnostic tests and imaging in the nation during the last two years of their lives. A study by Christine Yee, an economist at the University of California, Berkeley, found that physicians who were on the boards of ambulatory surgery centers performed 27 percent more procedures than those who were not.
The law provides an exemption for “in-office ancillary services” that are directly related to care. This exception has been extended to include a wide range of tests, from X-rays to expensive cardiac testing to biopsy suites.
Eugene Levich, who is moving full time to Delray Beach, Florida, expressed concern about leaving his doctors. “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,” he said. Last year, Levich had a routine prostate exam in Florida and was told he should have a surgical biopsy. However, when he consulted his physician in New York, he was told there was no need for the procedure. Similarly, when he went to an ear, nose and throat doctor in Florida, he was immediately prescribed a hearing test and urged to schedule an M.R.I., despite having no trouble hearing. Levich was able to resolve his issue with a nasal spray from the pharmacy.
Medicare offers financial protection against high charges for individual tests, but out-of-pocket payments can quickly add up, as the government insurance generally requires a 20 percent co-payment for outpatient care. Mike Miller, who spends part of the year in Florida, recommends seeking recommendations from doctors at Johns Hopkins in Baltimore. He has found excellent surgeons and eye doctors this way, but when he visited a cardiologist to check out a slow heart beat, he was soon undergoing tests that his doctors in the North had never said he needed. All the results were normal.
