Government

GAO finding on potential Medicare overuse attracts lawmaker attention

Some areas of the country have high and growing use of E&M, minor procedures and imaging, but the AMA cautions that doesn't necessarily mean overuse.

By Chris Silva — Posted Oct. 12, 2009

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Backed by a recent government watchdog report, one key lawmaker is making the case that not only is beneficiary access to Medicare doctors good, in some areas patients might be accessing too many services.

Senate Finance Committee Chair Max Baucus (D, Mont.) commissioned the Government Accountability Office to assess the level of physician services used in the program. The agency determined that Medicare patients experienced few problems accessing doctors, and the use of services increased nationwide from 2000 to 2008. Physician willingness to accept Medicare patients also increased during that time, as did payments.

But the report, released Sept. 28, detected a pattern of potential overuse of services, especially in more densely populated urban regions and in the eastern part of the U.S.

Large metropolitan areas were much more likely to be "potentially overserved" than were rural areas, the GAO found. Patients in these areas received substantially more evaluation and management services, minor procedures and imaging services than did those living in other areas.

Beneficiaries in potentially overserved areas on average received 44% more minor procedures in 2008, including ambulatory procedures, eye treatments and colonoscopies. They also had 29% more laboratory tests and 19% more imaging services than those in other areas, the GAO reported.

These findings of potential overuse did not sit well with Baucus. Part of the health system reform effort he is leading in the Senate is focused on squeezing dollars out of Medicare without harming beneficiary access.

"This report makes clear that serious work remains in determining why the use of certain services under Medicare -- like imaging and minor procedures -- is much higher in certain parts of the country than others, irrespective of a patient's real need, health status or the availability of doctors," he said. "Moreover, the potential abuse and excessive spending revealed in this report is further evidence the status quo of rising health care costs is unacceptable for America's seniors and the long-term fiscal health of the Medicare program."

But physician organizations said the situation was more complex than it might appear. For instance, some services may seem to be overused in certain areas of the country simply because they are medically necessary for the higher volumes of patients that live there, said American Medical Association President J. James Rohack, MD.

"The medical profession is committed to addressing variations in care, but it's important to note that high growth in services does not always equal overuse," Dr. Rohack said. "For example, services that the GAO identified as growing rapidly, like colonoscopies and office visits, are encouraged by Medicare policymakers to promote early detection, prevent disease and manage chronic conditions."

Dr. Rohack noted that the issue is too complicated for such broad solutions as redistributing funds from low-spending to high-spending areas. He said the most successful interventions on the utilization issue will be based locally.

"Through the AMA-convened Physician Consortium for Performance Improvement, physicians are developing evidence-based appropriateness measures that can be implemented at the point of care, and are working to integrate these and other quality measures into electronic medical records," he said.

The argument against cuts

While the GAO found that very few Medicare beneficiaries reported significant problems accessing physician services, the agency did note that the legislative uncertainty surrounding doctor fees points to an ongoing need to monitor access. Medicare physician payments are projected to be cut by 21.5% in January 2010 unless Congress intervenes, and additional years of reductions are set to follow.

"Absent congressional action, the Medicare trustees project payment cuts of about 40% over the next five years to physicians caring for Medicare patients," Dr. Rohack said. "Our concern, shared by AARP and lawmakers, is that these looming cuts will make it difficult for physicians to care for today's seniors and the huge influx of baby boomers into the Medicare program. Permanent repeal of the current payment formula should be part of health reform to keep physicians caring for seniors."

Despite the report's findings on imaging, the American College of Radiology said the overall growth rate for medical imaging in the Medicare system is down dramatically. The Medicare Payment Advisory Commission, for example, found the nationwide imaging growth rate for 2006-07 to be only 2%, which is less than the figure for the growth of physician services as a whole, said Shawn Farley, an ACR spokesman.

"The ACR has addressed unnecessary utilization for the last 20 years via the development of extensive practice guidelines, facility accreditation programs and appropriateness criteria to aid referring physicians regarding which, if any, scan should be prescribed for a given indication," Farley said. "Our highest legislative priority has been to get the Congress and the administration to adopt these utilization strategies for the Medicare program."

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ADDITIONAL INFORMATION

Tracking physician service use

The Government Accountability Office identified areas of the country where Medicare beneficiaries are potentially overserved. Those areas were in the top half both in utilization of physician services in 2000 and in growth in service use from 2000 to 2008. Here's how Medicare physician service use compared last year.

Per 1,000 fee-for-service beneficiaries
Service category Potentially
overserved areas
Other areas
All services 2,247 1,812
Evaluation and management 1,188 969
Major procedures 25 22
Minor procedures 191 133
Imaging 457 385
Laboratory tests 44 34

Source: Government Accountability Office, September (link)

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