Thursday, October 11, 2012

Is It Fraud to Order Tests?

     Once I start asking patients questions, a relationship begins.  "This doctor cares about me," is what most patients comprehend.  "Therefore, maybe I can tell her about x, y and z."
     X, y and z are usually topics that remain top-secret unless a doctor sits down and spends time with a patient.  Most patients don't visit a doctor to ask questions related to their top-secret concerns.  Some patients aren't even aware of the erosive quality of deep-seated worries, and might not realize that there are ways to put them to rest.
     Here are examples of the concerns patients harbor, for which a discussion with their doctor is far superior, I believe, than an internet search.

     Am I going to get Alzheimer's, like my mother?
     Is there anything I can do about leaking urine every time I laugh?
     Is my memory loss normal?
     Does smoking marijuana cause cancer?
     Could my headaches be a brain tumor?
     Should I take Viagra?
     Why don't I have any energy?
     Why can't I lose weight?
     Why does it hurt when I have sex?
     Could I have ovarian cancer?
     My father had a heart attack at 56.  I'm 55, and I'm worried.
     My wife thinks I drink too much.
     I'm ashamed of being attracted to children.
     I never sleep through the night--why?
     I have this weird chest pain.
     Sometimes I just wish my life would end.
     I'm worried my partner is cheating on me.
     Is lupus hereditary?
     I'm afraid of the radiation from yearly mammograms.
     Nothing I do in my marriage is good enough.
     Do cell phones cause brain deterioration?
     What's so bad about oxycodone, if I'm in pain all the time?

     Is it fraudulent for a physician to entertain--even solicit--these questions and concerns?  If so, I'm practicing medicine all wrong, and this style of practice is going to disappear.
     Once the questions are out of the bag, and hovering in the space of the exam room, is it wrong to analyze patients' risks, and order tests to identify problems, if there are any, and put their minds at ease, if there aren't?
     Here are the tests and procedures I order most frequently, and for which I have purchased equipment to make testing easier, and results available immediately:

     Cardiac stress test
     Chest x-ray
     Bone density test
     Abdominal ultrasound
     Pelvic ultrasound
     Skin lesion biopsy
     Thyroid ultrasound
     Vestibular testing
     "You say you have chest pain," I said to a patient today. "I don't think it's your heart--but let me ask you a few more questions about the pain.  And let's do a stress test.  If your heart is the problem, we'll find out.  If not, you'll know for sure.  Then, you can get on with your life--and start an exercise program."
     Most patients are grateful for this approach.  Yes, they got more than they came for, and I spent more of the patient's insurance money than I might have, if I'd avoided all those background fears and low-grade symptoms.  I also spend more time with patients when they unload their worries.  Directing the patient visit is an art, and reassuring the patient is a process that must be grounded in facts and information.  I can't tell a patient that his chest pain is "probably nothing," and send him out the door.   The stress test is proof that the chest pain is non-cardiac.  My assumption is that doing a stress test in my office will keep the patient out of the hospital one weekend at 5 am (most heart attacks and strokes occur in the early morning hours), when chest symptoms that haven't been addressed send him into a panic.
     Unfortunately, this makes me unpopular with insurance companies, whose main objective is to save money--and whose tacit directive to me is not to spend money on patients.  "Don't find something--because it will cost too much," is the approach insurance companies take.  They don't expect to be responsible for the patient for a lifetime, since insurance coverage changes yearly for many people.
     The general public is unaware of the pressures on doctors from insurance companies, and from the government, which "manages" Medicare and Medicaid.  Pressures are exerted in various ways:  frequent audits, refusals to pay--using a rationale based on unavoidable ambiguities and peccadilloes in the documentation, and dismissal of physicians from the "network" without explanation.
     Once, several years ago, I was dismissed by Blue Cross for an entire year.  Suddenly, all 1,500 of my Blue Cross patients had to find another physician.  When I pressed the administrators at Blue Cross for their reason, I was told:  "Our contract states that either party may nullify the contract, giving ninety days' notice, without cause."  Last week another solo physician told me that he was similarly dismissed by Blue Cross.  I suspect the decision is purely economic for Blue Cross.  Certain doctors simply cost them too much money.  Blue Cross prefers physicians who intervene very little--better (i.e., cheaper) to allow early disease states to become full-blown once the patients age into the Medicare.
     Well-chosen diagnostic tests are invaluable for managing patient complaints.  In the long run, such testing saves everyone money.  But we don't have a formula for calculating the savings that accure when patients don't go by ambulance to the ER, or don't have a DUI or cell phone-related car wreck, or don't get emphysema, pneumonia, hepatitis C, or stage IV ovarian cancer--all because a doctor asked questions, scouted around, did tests, and forestalled disease.
     Therefore, until doctors are paid for how well they manage chronic conditions, or prevent illness, those who are proactive--as I am--will be dismissed from insurance plans for doing too many tests, and become targets of fraud investigations.


  1. There is nothing wrong with your practice philosophy other than it appears to be incompatible with our current system in which patients rarely pay for the services they receive. Your approach might reduce lifetime medical expenses, although this assumption is being challenged as patients that live to 90 probably rack up higher lifetime expenses than patients that succumb to disease much earlier. If an insurance pool included every adult, it would be more economically viable, as it would include a large share of healthy adults. Likewise, if a single pool included every adult over the course of their lifetime, the insurer would be concerned with promoting long-term health and reducing lifetime medical expenses.

  2. Well said Dr Colasante.... It's a shame how much money you are saving the insurance companies by taking a proactive approach to find the medical problems before it is too late. Once it's too late, medical expenses paid by Insurance carriers are astronomical. I guess Insurance carriers prefer their current approach to insure mega bonuses are given to the Executive Staff.
    How sad and shame on them for making a patient suffer for an illness that could probably have been resolved had testing been performed prior to the onstage of the disease.

  3. Did I tell you how great you are? Why yes I did I believe, in your ear :-)

  4. AnonymousOctober 11, 2012 7:10 PM,

    You don't understand the trajectory of most patients with regards to insurance.

    Private insurers aren't concerned with controlling lifetime medical expenses, they are concerned with controlling THEIR expenses. Take a 60 year old patient that is covered by Anthem through their employer. Anthem knows that patient will be a Medicare patient in a few years and is not served to address all of the patients long-term needs or reverse chronic conditions.