Medicare Home Visits Deeper into the iceberg
My last article covered a study by the Wall Street Journal regarding Medicare home visits and the sometimes-questionable results of these visits. ?In a 2021 report, the inspector general that oversees Medicare found the agency spent billions of dollars based on insurer-driven diagnoses for which patients received no care from doctors.
For the study, the Journal reviewed the Medicare data under a research agreement with the federal government. They also consulted more than a dozen experts, including academics, actuaries and policy analysts, about its analysis of the Medicare data. ?These experts agreed that the WSJ methodology was sound.
The conditions that were “discovered” by some of the home visits were costly for insurers and the government is paying insurers additional dollars for covering them. One of the common conditions, diagnosed at home visits and added by insurers, was diabetic cataracts. The government paid insurers more than $700 million from 2019 to 2021 for diabetic cataracts. It was reported that more than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they already had cataract surgery, which replaced their damaged eye lens with a plastic insert.
Most of the diagnoses were added by insurers who interpreted U.S. guidelines for recording diagnoses in the broadest possible way, “labeling patients with diabetes and any kind of cataract with the more lucrative diagnosis”. They did it even when doctors said the patients only had the old-age form of the disease or had no diabetic complications at all.
Another condition diagnosed solely during home visits was more than 700,000 peripheral artery disease cases. The WSJ reported that these cases added $1.8 billion in payments. This got my attention because a family member just underwent a month of testing- multiple ultrasounds at vascular centers testing ankle-brachial index (ABI), comparing the blood pressure in the ankle with the blood pressure in the arm after walking on a treadmill. In addition, they had ultrasound of the legs and feet with sound waves showing blood moving through the blood vessels. Finally, they had a doppler ultrasound, a special type used to spot blocked or narrowed arteries. Diagnosing PAD at home visits is unlikely without some of these specialized tests.
Some conditions are costly to treat and those have given some insurers an incentive to search for them. Morbid obesity is one condition and in 2019, Medicare added dementia to the list of diseases that pay more. That same year, the reported rate of the disease among members jumped 7.8%
Medicare administrators are overhauling the list of diseases for which insurers earn higher payments. Some of the “most heavily used diagnoses, including diabetic cataracts, will pay less or nothing extra after the changes take full effect in 2026.” But new diagnoses, including asthma, were added to the list of conditions warranting extra payments.
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A CMS spokesperson told WSJ that the agency recently ramped up audits to verify diagnoses, and that it is eliminating some diagnoses -- including peripheral artery disease -- from those that qualify for extra payments.
John Gorman, a former Medicare official and founder of two companies that review records and conduct home visits on behalf of Medicare insurers, doesn’t think the changes will solve the problem. “Any time you base a system like this on diagnosis codes, there’s going to be rampant abuse of the system,” he said. Insurers “will find something else to make up the revenue.”
My wife and I have had annual home visits by a United Health nurse practitioner since 2015. She has given us sound advice consistently, everything from physician recommendations to health maintenance tips to specific health conditions. In 2019 she alerted me to the need to see a cardiologist asap due to bradycardia, and he subsequently determined the need for a pacemaker. This is but one example. I suggest that the costs generated by this program be weighed against the costs forgone by avoiding a condition from becoming more serious. Perhaps the necessary analysis is of the costs and outcomes of revenue mill of traditional Medicare, which is much more relaxed as to service authorizations.