D.C. Medicaid officials, after receiving the findings of a medical review team, are seeking to recover a significant part of the $744,000 they have paid to an Anacostia physician over the last four years for helping obese patients lose weight.
The review panel said that the doctor, Robert S. Beale Jr., did not justify the frequency of his treatments or his practice of injecting most of his overweight patients with drugs designed to suppress their appetites.
The report by the National Capital Medical Foundation, the city's peer review group, said Beale had achieved relatively good results in weight reduction. But noting that Beale treated many of his patients twice a week, the panel said, "The frequency of visits was not justified as medically necessary."
As for Beale's use of drug injections, the report said: "In general, the use of medications was found to be inappropriate and their use was found to be not medically necessary."
The Washington Post reported last March that city officials had been trying to decide whether Medicaid, the federal-local health care program for the poor, should pay for these kinds of obesity treatments. The program has paid Beale about $200,000 a year, primarily for weight reduction. The average city doctor receives about $12,000 annually from Medicaid.
Beale said he disagreed with many of the report's findings, and that the panel was not qualified to evaluate his practice because none of the six physician members is a specialist in obesity.
"They did understand that I got good results," Beale said. "It's kind of hard to say that I got good results but none of the stuff I did was necessary, which is what the report says.
"I don't intend to stop treating patients," Beale said. "If they change the Medicaid rules, I will abide by the rules as they're changed. There's no question that I will do what's best for the patients, whether I get paid for it or not." Beale said that until the city formally notified him of some official action, he could not comment on whether he will return any disallowed payments.
Peter B. Coppola, director of health care financing for the D.C. Department of Human Services, said he has decided to disallow both past and future billings for more than one patient visit a week, unless Beale can justify the extra visits in individual cases. The review panel said one visit a week was adequate.
Coppola also said he will disallow all payments after seven weeks of treatment -- some patients were treated as long as a year -- unless Beale can justify the additional sessions.
The report said that Beale's treatments were "of marginal effectiveness" beyond seven weeks, after which 44 percent of a sample of patients gained weight or stopped losing weight.
"I'm going to start taking that [money] back," Coppola said. "He as a physician should have known these services were not medically necessary and therefore he should not have rendered them. That's a judgment his peers made."
Beale can appeal Coppola's decision to the department director, to an administrative hearing and finally to the courts. If Beale ultimately declines to return the money, Coppola said he would have two options: to deduct it from Beale's future Medicaid billings or ask the city's corporation counsel to recoup it in a civil proceeding.
Based on a review of the report's findings, Coppola said he estimates that his office would try to recover as much as one-third of the Medicaid payments made to Beale over the last four to five years. He also said he will look at other doctors and clinics and disallow similar billings.
Doctors say that severe obesity puts additional strain on the heart, increases blood pressure and aggravates other conditions. While Maryland Medicaid officials pay for weight reduction, most state Medicaid plans and private insurance firms do not unless it is related to other illnesses.
Beale, 40, who opened his obesity clinic on Martin Luther King Avenue SE in 1978, says in a brochure that "excess weight is dangerous and unattractive." His various regimens include dieting, liquid protein, diet pills, vitamins and exercise, along with regular injections of phenylpropanolamine, an appetite suppressant found in many over-the-counter diet pills.
The report noted that Howard University's obesity clinic, which also treats many poor patients, relies solely on diet and exercise, and it said Beale's practice "differed significantly from commonly accepted treatment patterns in the community."
The panel said that Beale's patients did about as well as Howard's. A randomly selected group of Beale's patients lost an average of 9.7 pounds over 96 days, while a second group chosen by Beale lost an average of 42.1 pounds over 165 days.
The panel expressed concern that Beale had given injections of phenylpropanolamine to several patients with hypertension. Some doctors discourage the drug's use because of side effects such as high blood pressure.
Beale responded that he uses a higher standard to measure hypertension, that he carefully monitors these patients and that anyone who can lose weight without drugs can visit a health spa instead.
The report said there was no evidence that Beale had adequately checked his patients for possible complications, but Beale said this was mainly a record-keeping problem. He also disputed the panel's finding that several of his patients were not seriously overweight.
The report said Beale had treated 2,582 Medicaid patients during a 33-month period.