The ‘Vigilance’ That Is Crippling Medicare
Greetings from the aftermath of the Official Flu of the Millennium, where the recovering correspondent finds herself (cough, gasp, wheeze) with a sudden interest in medical news. This week’s headlines, for example, bring word that Medicare has been officially rescued for another election cycle. Seems tough anti-fraud crackdowns on the wily and cunning medical profession have slowed the growth in Medicare spending to the lowest level in the 35-year history of the program for the elderly and disabled. This would be the cue to praise the Lord and pass the handcuffs, except . . .
Except for stories like this one, from Robert Cappadonna, now 77. He has lived in the same house on the same street in Burbank for 50 years. For decades, he has suffered from chronic obstructive pulmonary disease--i.e., emphysema--and for decades, he saw the same family doctor. Then a tough anti-fraud crackdown “rescued” him.
“I went in for a general checkup,” the retiree recalls. “This was in 1996. I wasn’t feeling well, and my doctor--the best doctor I’ve ever had, no kidding--my doctor gave me a cardiogram.”
He hadn’t felt well, and the doc wondered if he’d maybe suffered a mild heart attack and not realized it. The electrocardiogram was, at that time, worth $34.87 under Medicare rules. Cappadonna’s doctor warned him that Medicare might not cover the test because his symptoms didn’t square perfectly with regulations. “I said, ‘Fine,’ ” Cappadonna remembered, adding that he paid upfront and signed a paper saying he’d been duly informed. The paper, a copy of which is still in the records, was submitted with the doctor’s claims for the rest of the visit’s costs and a request that Cappadonna be reimbursed for the EKG. Next thing everyone knew, reprimands were flying. The doctor was informed that not only was the test claim denied for lack of sufficient documentation, but that he’d better refund that $34.87 because the note didn’t specify why Medicare might not cover those charges, and if he kept that ill-gotten $34.87, he would be subject to “civil penalties of up to $2,000,” etc. It was the sort of routine hassle the doctor had dealt with for years, but something snapped this time. Here he was, a veteran physician, a pillar of his community, being treated like the village kleptomaniac.
“Some doctors would just, the next time, lie and claim that the patient had severe chest pains,” the doctor recalled, speaking on condition that his name not be published. “I just said, ‘No more Medicare patients. I refuse to do this anymore.’ ”
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Thus did Robert Cappadonna lose the best doctor he’s ever had to tough anti-fraud Medicare crackdowns, and end up in the competent-but-narrower hands of the emphysema specialist he relies on today. “The specialist is good--most of ‘em are good--but I’d been with my old doctor for more than 30 years,” he sighed. “He was the sort of doctor that always took time with you. When I lost him, it just tore me apart.”
And it turns out the hills are filled with Robert Cappadonnas--people whose confidence in the health care system has suffered thanks to government “vigilance.” Which turns out to be harder to quantify than the government lets on.
“The rule of thumb you hear in Washington is that 10 cents of every dollar we spend is lost to Medicare fraud, but the real truth is, nobody knows,” says Bill Mahon of the National Health Care Anti-Fraud Assn., a nonprofit that trains HMOs and insurers in catching cheats. Mahon’s organization estimates the loss is more like 3% to 5%--a figure they arrived at by surveying health care investigators, who documented a loss to fraud of 1.5% of payouts. They then tripled that number under the assumption that the enforcers don’t catch the half of it.
Except that experts also say a vast amount of what gets spun as “fraud” is actually genuine disagreement about medical necessity and confusion about poorly worded rules. Timothy Blanchard, a Century City lawyer who has written extensively on health care regulatory issues, calls this demonizing of the well-intentioned the “dark side of deterrence” and says this is why, when doctors take time to appeal denials, the government tends to lose.
Nobody wants fraud, but government phoniness is also corrosive. One of the biggest brakes on spending has been one that scarcely gets mentioned--broad cuts in Medicare reimbursement rates. So isn’t it time we stopped treating this complex issue as if it were some sophomoric game of cops and robbers? Last time I checked, the health care profession was filled with decent people struggling to do ever more with ever less money. And the hills were filled with sick people. Cough, gasp, wheeze.
(Correction: On Monday, I reported that the first Academy Awards ceremony was held at the Ambassador Hotel. Oops. It was the second.)
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Shawn Hubler’s column appears Mondays and Thursdays. Her e-mail address is shawn.hubler@latimes.com.