Why is Medicare Wasting Away?
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When I moved to the Midwest from the West coast to be with my family, I accepted a position as a home care physician for a company which provided health care services to homebound patients. The patients were elderly, most of them bedbound or with a debilitating condition which prevented them from driving. Most of these patients were on a limited income, mainly Social Security benefits, and had Medicare and Medicaid insurance.
In my new employee orientation, I was encouraged by a company physician and the local office manager (a registered nurse) to order echocardiograms and Doppler studies every six months for all patients with a history of hypertension.
In the beginning I was uncertain about the reasoning behind obtaining echocardiograms every six months, but they did quote guidelines from experts in the field. The practice owned the echocardiogram equipment and the echocardiogram technician was an employee of the company. The echocardiogram tapes were mailed to out–of–state cardiologists. The echocardiogram reports were mailed back to the office in 3–4 weeks. Being new to the job, I ordered the tests as recommended, despite my misgivings. I felt uncomfortable, as most of the tests ordered were on stable hypertensive patients. Even after reviewing the echocardiogram results, I rarely needed to change my management of the patient.
My apprehension grew when I heard patients worrying about the copayment bills they had received. One patient said, “I will pay the bill because I do not want to lose the services you are providing.” I felt no better when an acquaintance of mine mentioned that a patient had complained to her saying, “the house call doctor ordered an expensive test but I did not hear the results of the test for [End Page 74] six weeks.” I realized that patients were worrying while waiting for their echocardiogram results, and I did not feel this burden was in any way justified by the little information the testing provided.
I started attending weekly morning physician and office manager meetings. Every physician was given weekly productivity reports and Relative Value Units (RVUs) generated were mentioned during this meeting. Medicare compensates physicians for services they provide under the Supplemental Medical Insurance program, or Medicare Part B, on the basis of a fee schedule that specifies payment rates for each type of covered service. Payment rates are calculated in three steps: First, the fee schedule stipulates relative value units (RVUs), which measure the resources required to provide a given service. Second, payments are adjusted to account for geographical differences in input prices. Third, a “conversion factor” translates the geographically adjusted RVUs for a particular service into a dollar amount.
I learned each echocardiogram generated RVUs 3–5 times higher than that of a simple physician home visit. The manager encouraged us to meet a target of a certain number of RVUs per week by ordering blood tests, echocardiograms or Doppler studies.
The director from the company headquarters would visit the local office and encourage physicians to order more tests to boost up the low Medicare reimbursements. At every meeting, the director would make it a point to mention the company was unable to support expenditures with current insurance reimbursement rates, and needed additional ways to increase the reimbursements. Many times I felt that I might lose my job if I did not keep up my RVUs with the rest of my colleagues. I began to feel pressured to generate more revenue in competition with the other physicians employed by the company. I found myself ordering more laboratory investigations and radiological investigations to keep up my productivity on par with my colleagues. Wherein the patient expected honest and appropriate advice from me, I failed them in my responsibility by ordering more investigations in order to satisfy the company’s demands and relieve my own financial and employment concerns.
Motivated out of my sense of discomfort with this process, I had discussions with my colleagues, who reassured me this approach is legal. But I did not feel this was sufficient justification for practices I was beginning to question as unethical or unprofessional and I worried whether I...
