Medicare Medical Necessity Sham: Don't Fix What Ain't Broke

The Medicare medical necessity sham is at the root of all that is evil with our Medicare National Bank.  Medicare medical necessity is the threshold used to determine if Medicare, the ultimate third party insurance company, will pay for any visit, procedure or surgery.  You can't just go to the doctor and talk about the basketball game last night and expect any insurance company to pay for it.  Medical necessity is the process by which Medicare determines that the office visit (evaluation and management codes) or if the surgery or the procedure or the laboratory was medically necessary.

Going to the doctor for chest pain is medically necessary. Chest pain has a CPT code.   For every contact you have with your doctor, a  CPT medical code is submitted to your insurance company by your doctor.  That CPT code must have an ICD 9 code attached.  That's how Medicare medical necessity is determined.  There is no ICD 9 code for talking about the basketball game.  There is an ICD 9 code for chest pain.

But Medicare medical necessity doesn't work.  Why?  Because any doctor could make any office visit or any procedure or any surgery medically indicated if they document the right words in the right place. We do too much in this country.  Some of it is legal driven.  Some of it is money driven.  Doctors get paid to do more.  We don't function like farmers.  We don't get paid to let our patients sit idle.  Some of it is ignorance driven by both doctors and patients.  As care gets more complicated, the permutations of outcomes can become overwhelming.  Sometimes doctors simply don't know what they are doing.  Some of it is IT driven.  It's easier to order another  x-ray than to wait for the report to show up the next day.

There are lots or reasons why we spend too much money on health care in this country.  But the fact remains, to order anything and have it get paid for by Medicare, it must have medical necessity.  After talking with a garden variety Medicare patients the other day, I have come to the conclusion that the process is a sham.  And the only way to curb health care  costs is to bundle the care.   What was my shocking conversation?  Read on...

I got to meet Frank the other day.    Frank has been in the insurance business for over 30 years.  He told me that in his experience at least 15-20% of all medical claims were probably unnecessary but that no insurance company has the resources to go through all claims with a fine toothed comb.  And the result is simple: costs rise and premiums rise. The more it costs to take care of patients, the higher the premiums will be.  That doesn't surprise me.  It makes the Medicare medical necessity sham even harder to tweak out. Having an indication  to do anything is easy.  Whether that indication is a bending of the truth or whether it represents reality is hard to figure out when you're looking at billions of pages of claims every year.

While talking with Frank, I learned that he always got a full physical exam every year for the last 30 years from his private insurance company. I told Frank that there is no data to suggest that having a yearly physical exam has ever been shown to improve outcomes.  If anything, it is a chance to keep in touch with the medical system and to make sure that all preventative recommendations are up to date.  But the act of a yearly physical exam has a very low yield for discovering critical pathology in the asymptomatic patient.  

He told me he tends to agree with that statement ever since one of his insurance executive bosses had an all expenses paid visit to the Mayo clinic for an executive physical.  Three days.  Unbelievable.  After three days of extensive testing he was given a clear bill of health.  I have no idea what they could have possibly done over a three day period, but this man had a massive heart attack and died as he was getting in his car to drive away from his clean bill of health.

Yearly physicals are not worth the time and money to look for  pathology.  They simply don't work and are not cost effective in asymptomatic patients.  If you are a smoker, you need to quit.  .  If you are a drinker you need to stop.  But if you're asymptomatic and up to date on all your preventative recommendations, the visit will unlikely offer you any benefit.

The same thing goes with yearly labs.  Even mama and papa Happy get their yearly labs drawn at a local lab fair, often paying cash.  They are not medically necessary.  Drawing yearly CBCs and basic electrolyte panels and TSHs and liver panels and sed rates and cholesterol panels have never been shown to have benefit  on a population basis.  Of course, if you are that one in one thousand patients who happen to find a myeloma from asymptomatic screening you would argue otherwise.  But I would also suggest that the lead time bias during your asymptomatic state of diagnosis would not likely have changed the outcome. 

The same lead time bias of detection goes for yearly chest x-rays or even CT scans.  There is no reason in the world to get a chest x-ray if you are asymptomatic.  Even if you are a smoker.  People who believe they get benefit are fooling themselves out of fear of the unknown.  There is no reason to get a CT scan, although some more current data suggests benefit in screening smokers for lung cancer with CT scans under select conditions.

The same goes for asymptomatic carotid artery stenosis and peripheral arterial disease.  The United States Preventative Services  Task Force recommends against screening for either in asymptomatic adults.  But you can find vascular surgeons and hospitals all across this country charging folks $100-$200 dollars cash for screening.  The reason no insurance will pay?  They are medically unnecessary and feed on the fear of the unknown.  

Only abdominal aortic aneurysm got a one time screening recommendation for adults aged 65-74, and then only for smokers.    And the USPSTF specifically recommends against  screening  low risk asymptomatic adults for coronary artery disease with EKG, stress test and electron beam CT (EBCT) for calcium scoring.

So I was disappointed to learn that one of my most respected internists in Happy's community has been doing a yearly chest x-ray and EKG on Frank for years and years and years.  I asked Frank why?  He's never smoked.  He has no cough.  He has never had angina.  He has no symptoms of pathology at all.  He exercises and has no issues with his cholesterol.  He is a healthy adult specimen doing everything right.  He is the perfect patient.

But his outpatient primary care internist has been doing an office based EKG and chest x-ray for decades and Frank just thinks that's the way it is.   I asked Frank if he feels good about the tests always being normal.  He said yes.   It's reassuring he said.   I have strong feelings about my  displeasure with doctors who own their own equipment and self refer patients for evaluations that get paid for using that equipment.  

There is an  inherent conflict of interest in any relationship between doctor and technology where the doctor gets paid to do more using the technology they own.  Medicare medical necessity is a sham.  We simply can't differentiate between real leather and the fake stuff anymore.   Primary care won't make a lot of money getting paid for thinking.  But they can if they own their own ancillary equipment.  Just like every other medical specialty on this earth.  Then Frank dropped another bombshell.

Frank received one of those EBCT cardiac calcium scans five years ago and his outpatient internist recently told him it might be time for another one.   My jaw dropped to the floor.  I told him about the massive dose of radiation these things have been shown to expose patients to.  Asymptomatic patients.  I asked him if he felt relieved when his last one was pretty negative.  He said yes.  Once again, it's reassuring.  I told him what he should expect to happen to him if his second EBCT scan came back abnormal.  

Here's a functional, healthy, asymptomatic guy who will go in to get a  CT scan that exposes him to large doses of radiation.  If the test is abnormal, he will likely get a heart catheterization, exposing him to more risk (dye allergy, groin pseudoaneurysm, renal failure, coronary dissection).  If a lesion was found in this asymptomatic  gentleman, what will happen to Frank?  Will Frank get a stent?  Probably so, despite the compelling data suggesting that stents offer no benefit beyond medication therapy in asymptomatic patients.  

So I told Frank, if he gets his calcium scan, heart catheterization and then ends up with a stent, he'll have to go on Plavix, which will create risk where no risk previously existed..  We would have created disease out of health and turned Frank from the perfect patient into the perfect patient for a hospitalist. I am the last person in the world Frank should ever have to see,  especially when he does everything right.   It's his doctors that have failed him.

This is the problem with American health care.  None of this should be paid for.  None of this madness is indicated.  But every last bit of it gets  paid for.  All of it.  Every time.    I asked Frank to ask his internist how he gets the yearly chest x-ray, EKG and labs to get paid for if he has no ICD code to bill it under.  I'm sure there's a code.  I'm sure it meets Medicare medical necessity somewhere, because it always does.  And as Frank the insurance guy admits, there aren't enough claims reviewers to go through charts with a fine tooth comb. 

I am extremely disappointed in the actions of this community internist.  I have a high respect for his capabilities.  But the fact remains, none of this should be paid for.  It's medically unnecessary, but yet it is.  Because it  will always be necessary.  And the only way to get this  excess out of the fee for  service system that is American health care is to stop paying for it.  And the only way to do that is not to hire one million government workers to comb through doctor charts with a fine tooth comb.  The solution lies in bundling the care.  If a doctor is making money on their x-ray machine or their EKG machine, or their lab equipment, they have every incentive in the world to maximize Medicare medical necessity.  And most patients find relief in the comfort of knowing that everything came back normal

All thirty chest x-rays were normal
All thirty ECGs were normal
All thirty years worth of labs have been normal.

And yet, every year, the comfort of knowing it's still normal supersedes the knowledge that for thirty years Frank has received care that was medically unnecessary, and yet fully paid for by his premiums, and now the Medicare National Bank.  And that's why nobody can afford health care.  Don't fix what ain't broke.  It's time to abandon the idea of Medicare medical necessity and actually pay for care that is needed.  What we need and what we get are two incongruent pathways.   Bundled care fixes that instantaneously.

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