D.C. Medicaid officials are questioning whether they should continue payments to an Anacostia physician who has received $623,000 over the last three years from the city government, primarily for helping obese patients lose weight.
The doctor, Robert S. Beale Jr., operates what he calls a "medical obesity center" at his modern, carpeted office in Southeast Washington, where he injects dozens of patients each day with a drug designed to suppress their appetite. More than 60 percent of his patients are covered by Medicaid, which is paying for a regimen that includes dieting, liquid protein, diet pills, vitamins and exercise.
City officials are reviewing the large volume of patients that pass through Beale's office and the way in which he treats them -- an effort that also could determine whether the city continues to pay any doctors who treat poor patients for obesity.
For more than a year, these officials have been trying to decide whether helping people to lose weight is a "medically necessary" service that they ought to pay for under the federal-state health care program for the poor. They also question whether Beale's twice-a-week billings for most of his patients are excessive -- an inquiry that began when their computer found that he was receiving an unusually large amount of Medicaid money.
"He sticks out pretty much like a sore thumb," said Peter B. Coppola, director of health care financing for the D.C. Department of Human Services. "He is a high-volume provider, if not the highest in the city."
As a result, Coppola said, he has asked a review panel of doctors to decide two questions: whether Medicaid should cover weight reduction services, and whether Beale's method of providing those services is adequate.
Beale, who is black, said his practice is getting special scrutiny because many of his patients are poor and depend on Medicaid. "The basic issue is, 'How the hell are we going to pay this colored guy $200,000 a year to deal with fat women, all of whom are colored?'
"You could say this is obviously too much money for one doctor to make, but it doesn't all end up in my pocket," Beale said, adding that much of his income from Medicaid pays for costly exercise equipment and supplies for his office on Martin Luther King Jr. Avenue SE.
"I'm not doing anything that isn't accepted medical practice. Obesity is an illness, and there's no question that what I'm doing is effective. People wouldn't come to me if I didn't have a good reputation and good results."
While diet services generally are only a small part of the services provided by many other D.C. doctors, they have become a significant cost for the city's financially strapped Medicaid program. If the review panel decides against Beale, Coppola said, the city will try to recoup his previous Medicaid payments and will stop paying other local doctors for weight reduction as well.
According to Dr. Irving Burka, medical director at the National Capital Medical Foundation, which is reviewing Beale's practice, severe obesity generally is considered an illness, but there is wide disagreement about how to treat it. He said severe obesity puts additional strain on the heart and other organs, increases blood pressure and aggravates such conditions as arthritis.
Medicaid officials in Maryland also pay for weight reduction services, but most state Medicaid programs, including Virginia's, do not. Medicare, the federal health care program for the elderly, and nearly all private insurance companies also refuse to pay for weight reduction unless it is related to a specific illness. "It's very hard to pin down, and that's why we don't pay for it," said a spokesman for Blue Cross-Blue Shield here.
At the same time that D.C. officials are cutting back on hospital clinic services, they continue to pay for weight reduction, even though their rules do not mention obesity.
In a sample review of 15 of Beale's patients, city officials found that seven lost 15 to 26 pounds, seven lost less than five pounds and one gained weight. The records show that one patient visited Beale 44 times in eight months, but dropped only from 201 pounds to 199 1/2. Another patient made 30 visits in a year but rose from 191 pounds to 206.
In an official questionnaire, city officials say, Beale reported that he sees an average of 90 patients a day, or an average total of 1,800 a month. Beale disputed those figures in an interview, saying that he generally sees no more than 45 patients a day, even on a 12-hour shift.
Beale said he injects all his diet patients twice a week with phenylpropanolamine, an appetite suppressant found in many over-the-counter diet pills. Some doctors discourage its use because the drug often results in only temporary weight loss and because it can cause such side effects as high blood pressure.
City officials have asked the review panel to evaluate the kinds of drugs that Beale prescribes. James F. Harris, a medical consultant for the city, said in an internal memo that "no literature was found to support the use of phenylpropanolamine as an injection," except when used with other drugs as a decongestant.
D.C. officials say they know of no company that manufactures the drug as an injectable solution, and Beale has declined to show them the drug or disclose where he buys it. They also questioned why Beale does not counsel some of his overweight patients simply to exercise and eat less.
"If you can stay on a diet without drugs, you don't need to come to me," Beale replied. "You can go to a spa."
Beale said the drugs he uses are safe and effective and that he accepts only Medicaid patients who are at least 25 percent over their medically acceptable weight. He said patients who fail to follow one of his special diets -- most of which include either liquid protein or diet pills and injections -- are thrown off the program. He said he also encourages patients to use his exercise room, which features a bicycle, treadmill, barbells and other equipment.
While Beale does give some patients diet pills, a sign in his office says he will not prescribe Valium, Ritalin or Preludin, also known as "bam," which is sometimes used as a heroin booster. He said the sign is meant "to keep the drug addict population out of my office."
Beale, 40, a native of North Carolina, graduated from Howard University Medical School and is one of 600 members of the American Society of Bariatric Physicians. He began practicing in the Washington area 10 years ago and opened the obesity clinic in 1978, telling patients in a brochure that "excess weight is dangerous and unattractive" and he can help them lose 12 to 25 pounds a month.
Beale charges Medicaid up to the maximum fee of $20 for each office visit, which has netted him more than $200,000 a year, or considerably more than the $12,000 a year the average local doctor receives from Medicaid.
In their review, city auditors found that about 65 percent of Beale's records contained discrepancies, mostly involving lab tests, and that the doctor had "insufficient documentation" for some of his patient visits. But Coppola said that Beale appears to be personally treating each of his patients.
In 1980, Coppola asked the National Capital Medical Foundation, the city's medical review group, to review Beale's case at a cost of about $8,000. But the foundation is in danger of losing its funding from the federal government, which has refused to pay for the review, and the case languished for the last six months until the city agreed to pick up the remaining cost.
Even if the panel rules against Beale, it is not clear whether city officials would recover any money. They still are trying to collect $100,000 from another doctor who the foundation said was billing Medicaid for excessive services last year.
Beale, for his part, is tired of the inquiry. "Were I doing something illegal, unethical or crooked, they could have stopped me by now," he said.
"I put a nice office in Southeast because I'm a black physician and I can see the need. I could be treating white patients on 19th Street and be making twice as much money in half the time. I guess dealing with the Medicaid investigators is part of the price I have to pay."