Posted on 09/13/2003 2:07:02 AM PDT by sarcasm
OCA RATON, Fla. — It is lunchtime, and the door to Boca Urology's office is locked. But outside, patients are milling about, calling the office on their cellphones, hoping the receptionist will let them in. To say they are eager hardly does them justice.
"We never used to lock the door at lunch, but they came in an hour early," said Ellie Fertel, the office manager. "It's like they're waiting for a concert. Sometimes we forget to lock the door and they come in and sit in the dark."
Yet few have serious medical problems, let alone emergencies. "It's the culture," said Dr. Jeffrey I. Miller, one of four urologists in the practice.
Doctor visits have become a social activity in this place of palm trees and gated retirement communities. Many patients have 8, 10 or 12 specialists and visit one or more of them most days of the week. They bring their spouses and plan their days around their appointments, going out to eat or shopping while they are in the area. They know what they want; they choose specialists for every body part. And every visit, every procedure is covered by Medicare, the federal health insurance program for the elderly.
Boca Raton, researchers agree, is a case study of what happens when people are given free rein to have all the medical care they could imagine. It is also a cautionary tale, they say — timely as Medicare's fate is debated in Congress — for it demonstrates that what the program covers and does not cover, and how much or how little it pays, determines what goes on in a doctor's office and why it is so hard to control costs.
South Florida has all the ingredients for lavish use of medical services, health care researchers say, with its large population of affluent, educated older people and the doctors to accommodate them. As a result, Dr. Elliott Fisher, a health services researcher at Dartmouth Medical School, said, patients have more office visits, see more specialists and have more diagnostic tests than almost anywhere else in the country. Medicare spends more per person in South Florida than almost anywhere else — twice as much as in Minneapolis, for example.
But there is no apparent medical benefit, Dr. Fisher said, adding, "In our research, Medicare enrollees in high intensity regions have 2 to 5 percent higher mortality rates than similar patients in the more conservative regions of the country."
Doctors say that Medicare's policies are guiding medical practice, with many making calculated decisions about whom to treat and how to care for them based on what Medicare covers, and how much it pays.
"The bottom line is that the stuff that reimburses well is easier to get done," Dr. Carl Rosenkrantz, a Boca Raton radiologist, said.
Thomas A. Scully, administrator of the Centers for Medicare and Medicaid Services, said he knew the situation all too well.
"We have a system that does nothing to look at utilization," Mr. Scully said in a telephone interview. "If you send in a bill and you are legitimate, we pay it."
The effect shows up in the way doctors deal with office visits, for example. Medicare in Boca Raton pays $52.46 for a routine visit, in which a doctor sees a patient with no new problem. That is not enough, doctors say; it costs about $1,500 a day to run an office there, they explain. Payments in other states are different, adjusted for cost of living, but doctors say, and Mr. Scully agrees, that they are generally inadequate. Doctors who try to make a living seeing only Medicare patients for routine visits, he said, "have a very rough time."
Medicare bases its payments on a system in which each kind of service is assigned a "relative value," Mr. Scully said. To increase the payment for routine office visits and stay within its budget, Medicare would have to decrease the relative value of other services.
A committee of doctors meets each year to suggest relative values, he said, but "the most aggressive and active groups tend to be the specialists."
"Year after year," Mr. Scully went on, "the specialists come in and make a very strong argument for higher reimbursements. There's eventually a squeeze on the basic office visit."
In many areas of the country, private insurers pay more for office visits than Medicare does, so doctors can essentially subsidize their Medicare patients.
"If we just saw Medicare patients and didn't see anyone with regular insurance, we wouldn't be able to pay the bills," said Dr. James E. Kurtz, an internist at Chatham Crossing Medical Center in Pittsboro, N.C.
Elsewhere, many doctors are refusing to see Medicare patients. "Some counties in Washington have no doctors who take new Medicare patients," Dr. Douglas Paauw, a professor of medicine at the University of Washington, said.
Doctors in South Florida do not have a choice. Private insurers there pay the same as Medicare or less, and so many old people live in the area that if doctors want to practice, they must accept them. But how to make a living?
One way, Dr. Robert Colton, an internist in Boca Raton, said, is to see lots of patients, spending just a few minutes with each and referring complicated problems to specialists.
Dr. Colton did that for a while, seeing as many as 35 patients a day. A typical busy internist, he said, would see 20 patients a day. "I felt like a glorified triage nurse," he said.
"If you try to handle a complex problem, it slows you down," Dr. Colton said. "You have to sit down with the family, meet with the patients, talk to them. If you say you have coughing and you are short of breath and your knee hurts, I might have sent you to two different specialists."
The goal, Dr. Rosenkrantz said, is to move the patients on. "The worst thing that can happen is for someone to walk into your office and say, `I have an interesting case for you.' Financially, you'd be dead."
Even seeing patients in the hospital can become an exercise in time management, Dr. Rosenkrantz said. "We have doctors who do rounds at 4 a.m."
A second driving force behind medical care in Boca Raton is the demands of patients. They want lots of tests and specialists, they refer themselves to specialists, they ask for and get far more medical attention from specialists than many doctors think is reasonable or advisable.
"This Medicare card is like a gold card that lets you go to any doctor you want," Dr. Colton said. "I see it every day. When there's no control on utilization, it's just the path of least resistance. If a patient says, `My shoulder hurts, I want an M.R.I., I want to see a shoulder specialist,' the path of least resistance is to send them off. You have nothing to gain by refusing."
Patients here say they have mixed emotions. They complain about rushed primary care doctors but readily admit that they seek multiple specialists and multiple procedures.
The primary care doctors are often irritatingly busy, patients say. "In waiting rooms sometimes they are standing against the wall," said Marvin Luxenberg, a retired lawyer who lives in nearby Boynton Beach. Then, he said, "when you get in to see the doctor, you get just three or four minutes of time."
Dr. Colton says he found a way to give his patients more time. He joined a "concierge" practice, in which patients pay an annual fee in addition to the normal charges for medical services. Dr. Colton's group, MDVIP, charges patients $1,500 a year and limits the number of patients each doctor sees.
But not everyone wants to pay that kind of fee. Many patients just spend their time in specialists' offices. Each specialist handles a different aspect of their care, with no one coordinating it.
Specialists get no more than primary care doctors for an office visit, but they provide tests and procedures that demand higher Medicare reimbursements. Doctors say those payments allow them to stay in business, especially if they provide the procedures in their own office.
Medicare pays the doctor and the facility where a procedure is done. For a nuclear stress test, for example, the doctor gets about $200 and the facility gets about $1,200.
"Doctors have incorporated these tests as much as possible into their offices so they can gain from the facility fee," Dr. Thomas Bartzokis, an interventional cardiologist in Boca Raton, said.
Patients say they have lots of specialists, and lots of tests. Asked how many doctors he saw, Leon Bloomberg, 83, a patient of Dr. Miller, thought for a minute and looked at his wife, Esther.
"Between us, we have 10 or 12," Mr. Bloomberg said, including a pain specialist and a neurologist for his neuropathy, a cardiologist for his heart condition, "a pulmonary man" for his asthma, a rheumatologist for his arthritis and Dr. Miller for his prostate. Mrs. Bloomberg has her own doctors, including ones for heart disease and for diabetes. "We have two to four or more doctors' appointments a week," Mr. Bloomberg said.
It is easy to find all these specialists, he said. "You get recommendations at the clubhouse, at the swimming pool. You go to a restaurant here and 9 times out of 10, before the meal is over, you hear people talking about a doctor or a medicine or a surgery." And of course there are the other patients in all those waiting rooms. Mr. Bloomberg even recommends specialists to his own doctors.
But some patients say they are frustrated by what they call a waste of resources. "The doctors are raping Medicare," said Louis Ziegler, a retired manufacturer of flight simulators who lives in Delray Beach.
Mr. Ziegler recalled going to a doctor for a chronic problem, a finger that sometimes freezes. All he wanted was a shot of cortisone. But he got more, much more: "I had diathermy. I had ultrasound. I had a paraffin massage. I had $600 worth of Medicare treatments to get my lousy $35 shot of cortisone."
Dr. Colton, the internist here, is frustrated, too.
"The system is broken," he said. "I'm not being a mean ogre, but when you give something away for free, there is nothing to keep utilization down. And as the doctor, you have nothing to gain by denying them what they want."
I don't get your point. This article is slamming Medicare and it's coming from the Slimes. (How often does that happen?) Boca just happens to be the place where there is the most waste.
You're right. The patient is behaving precisely the way economics dictates they would behave. Until the patient is given some sort of financial responsibility for their care, they will continue to soak the system. The first place to start is to charge them for "routine" visits.
It is preposterous to think that an ambulatory senior needs to see several doctors per week. Seeking an MRI for shoulder pain? Please. The bottom line is that while these patients aren't "bad" people, their behavior is costing all of us a fortune.
We evolved a system of office-based primary care by 1965 that was the envy of the world.
Those who voted against Medicare predicted that it would destroy our system.
They were correct.
The politicians responsible will now get what they want-nationalized doctors and hospitals-but the system they started out to take over is gone.
Dr. Welby has left the building.
How can a patient prescribe themselves an MRI?
By raising the question of how a patient prescribes themselves, you have illustrated the point. Diagnostic evaluations and surgical procedures paid for by the public should not be granted on the whim of the patient. Mere shoulder pain in an elderly individual is not cause for an MRI. And if you must know, there is currently huge stresses on imaging departments trying to accommodate the people who actually need MRI's. Some old codger with his arthritis acting up is consuming a finite resource: time in the scanner.
Patients on the dole should have some restraints on them.
Patients on the dole????? The doctors shove them around between offices, agree to their requests, charge medicare, split payments with the referred office, overwrite copays so patients return more often, double bill for clinical work and you're saying the patient is on the dole?
The dole for what? Medical care?
How can a patient prescribe themselves an MRI?
Some doctors will prescribe the MRI referral to justify their fee for the exam.
Also the MRI is probably performed at the hospital where the doctor has privileges, keeping him in good standing as a hospital supporter. This is more true in an HMO.
Exactly!
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