Here’s an easy way for Medicare to save money

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 generally 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.

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?

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • JustADoc

    As internists and family doctors get squeezed more and more, now they want us to just do all the discussion with adults about mammograms, colonoscopies, pros/cons of PSA and prostate testing, vaccine discussions(pneumovax, zostavax, Tdap, Hep B, Hep A, menactra in certain patients, prevnar for some), PAP smear pros/cons as age, lung cancer screening pros/cons, screening for HIV/DM/Hep C(now for baby boomers), and the list goes on in the middle of another office visit.
    So Mr Doe your f/u of your hypertension/diabetes/heart disease/COPD and your concern about that skin lesion that was scheduled for 15 minutes is now only 3 minutes as I have to squeeze in all this other conversation as well.
    The purpose of the physical is not the ‘physical’. It is to keep up with all the above stuff.

    • querywoman

      Brilliant!

  • Skeptical Scalpel

    The ophthalmologists were using the more expensive drug. They had to buy it first so they were not pocketing all of the money. Why they didn’t use the cheaper drug, which is said to be just as good, is another question.

  • Skeptical Scalpel

    I happen to know that Medicare has indeed been paying for these visits. The patient has paid the co-pay only.

    I agree the new guidelines say that everyone over 65 needs to be on a statin, which seems a bit over the top to me.

    • southerndoc1

      If Medicare was paying, they were problem-related visits (E&M codes), not “routine physical exams” or “routine general health exams.”

    • PrimaryCareDoc

      Sure they were paying for them, but I’d bet they’re being coded as a 272.4 (hyperlipidemia) not a V70.0 (routine physical examination).

  • James O’Brien, M.D.

    Most of the cost is in the last six months of life.

    If you want big savings, a realistic advance directive should be a Medicare REQUIREMENT.

    This is so obvious it might be something Ezekiel Emanuel can agree on instead of death panels, which are not politically possible nor ethically desirable.

    Then watch the K Street nursing home trolls come out like rats to kill this idea.

  • LeoHolmMD

    HHS is an inept bureaucratic organization. Medicare continues to pay for things based on politics, not science. How can you deny an elderly old man a physical? You monster. Continue to expect Medicare to continue to pay for useless tests and procedures. The money is not theirs, so who cares. Their responsibility is to their corporate and political masters, not the public. Why rock the boat?

    • Skeptical Scalpel

      Agree. Just look at the uproar over mammography or PSA screening.

  • ethanspapa

    Wanna bet the ole timer had a can of bacon fat on his mom’s stove when he was growing up and after he was married. It was the way mom made it, so it must be good. .Plus all that second hand smoke he inhaled every day of his formative years. Add hereditary and you have a life ending stroke.
    The United States diet especially down south will take twenty years off your life span. Pass the gravy and chicken fried steak please.
    Oh and one diet soda. Gotta watch the weight ya know
    For breakfast 4 eggs a rack of bacon home fries and butter painted on soggy toast with a brush..Then a half dozen cups of caffeine every day. Then OMG the Sunday boiled dinner.

    • Dorothygreen

      Stop! you don’t know what you are talking about. First, this guy had Total lipo-proteins or cholesterol (which is used incorrectly) of 201, 20 years ago. 20 years ago the studies had not been done that show the LDL or even total lipo-protein measures are not good predictors. It is ratios of Total/HDL and Triglycerides/HDL and the new calculator doesn’t even use LDL. There are even some recommendations (The Wahls protocol) that say it is best to keep the cholesterol greater than 200. Cholesterol is a very important nutrient.

      Statin prescriptions are a Big Pharma cash cow and few, even with the studies will buck Big Pharma and the AHA. This doctor knows it and uses it as a reason to do such frequent tests. Further, do you follow any of the current news regarding saturated fat? it is not eggs, bacon, and butter which are the problem. If this guy ate those (but more sensibly than your imagination has provided), along with vegetable,s there would likely be no risk of CVD . Start reading current studies before you destroy your own brain with omega 6 fatty acids that oxidize, so called whole grain this or that, processed sugar, lo fat this or that. It is the carbohydrates – the high glycemic ones refined wheat flour and highly processed sugars that are the villians in this story.

      TIME magazine has stated in their June 23, 2014 edition (picture of butter on the cover) that they were wrong in supporting the idea that saturated fat and cholesterol were the risk factors in CVD.

      This guy may not have had any reason to be put on a statin and indeed may or will be having damage to his body because of them. Particularly the brain, as the brain makes its own cholesterol and what is made in the rest of the body does not generally cross the blood brain barrier, Statins do!

      As I see the story here, it is a doctor who has not kept up with current information and has been milking the system as well as the patient who is paying 20%. If Medicare as well as all health care was administered by a non-for profit insurance company (competition like the Swiss System) that could sell supplemental insurance for things outside the basic services), the fraud and abuse evidenced in the article could be stopped.

      It is time to reform both our health care and our eating culture.

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