Monday, April 16, 2007

The First Salvo Is Fired
...Self-Dealing in Medical Imaging: Call for Action

The Battle of Fort Sumter, the beginning of the Civil War

Image courtesy of

Dr. Murray Reicher is well-known in PACS circles as the founder of DR Systems and their famous Catapult technologist workstation. Dr. Reicher has made his mark on imaging.

In a guest editorial in the Journal of the American College of Radiology (JACR, the Blue Journal), Dr. Reicher takes aim squarely at self-referral:

I have great concern over the possible destruction of my profession caused by self-dealing in medical imaging. Self-dealing occurs when a referring doctor makes money, directly or indirectly, simply by referring a patient for a medical imaging procedure, especially by gaining a financial benefit from the technical component of the procedure. . .Do you care about the future of the medical imaging field? Are you appalled by doctors who refer on the basis of personal economic gain? Do you realize that this practice not only threatens your profession but impairs the health care of your community and sucks resources away from legitimate health care providers and hospitals?

Wow. Pretty powerful stuff. Dr. Reicher goes on to provide us with a battle cry of sorts:

No machine fee for self-dealing in medical imaging.

This position is written in plain language because nonphysicians must understand it. The statement means that no referrer should make money, directly or indirectly, through ownership or lease, from the technical component associated with a medical imaging examination.

Dr. Reicher goes on to explain why the practice should bother you:

As a result of these legal loopholes (Stark in-office exception, etc), this practice of referring patients to self-owned or leased imaging equipment has again become rampant. Self-dealing radically raises costs . . . and subjects patients to unnecessary procedures. Technical and professional quality is lowered when radiologists are not directly involved. . . Opponents of legislative or private restrictions on self-dealing see self-referred medical imaging as an opportunity for physicians to add an income source in their own offices. They cloud the issue with demands for more study and statistics. Statistics can show us how much self-dealing is costing us but can never prove that it’s ethical, because it isn’t.

In medical imaging, first, we had no rules against self-dealing. Then, we adopted rules with loopholes. Surprise: the greedy and unethical minority of physicians have jumped through the loopholes, and if we don’t close them, the reputation of all health care providers will suffer. The truth will come out, eventually.

Italics are mine. Basically, this is what people have been saying all along concering the DRA-2005 fight. But that situation took a markedly tangential course when non-self-referring radiology-owned operations were tainted with the same tar-brush. I cannot help but think that this was a result of the ACR's incomplete job of educating Congress about self-referral. Maybe they should have brought Dr. Reicher with them to the various hearings.

Dr. Reicher goes on to dismiss many of the arguments out there that support self-referral/self-dealing. First, he makes it clear that this is not a "turf" issue, which is how the ACR managed to lose the interest of Congress:

To most people, even doctors, the discussion of professional turf isn’t relevant, and nobody feels qualified to make turf judgments. But most people can understand that when your doctor collects a technical component or “machine fee” just for ordering an examination, your doctor has lost the ability to independently advise you with regard to the right test or the right facility.

He notes that it is indeed not a matter of radiologists protecting our turf, since they stand to make a significant amount of money by reading the self-referred scans.

Dr. Reicher then very accurately points out that self-referral is anticompetitive:

In fact, the practice of self-dealing exposes patients and payers to a monopolistic, anticompetitive practice. When orthopedic surgeons send patients to scanners they lease, neither the patients nor their referring doctors select the facility on the basis of normal competitive merit; the doctors do not ask which facility in the region has the best technology, the best professionals, the best pricing, or the best service. Instead, they send the patients to the facilities with which they have business agreements that provide them a profit’s interest in the fees. Restricting the anticompetitive practice of self-dealing in fact favors competition.

So, what do we do about this lovely situation? Dr. Reicher gives us several approaches. He advocates asking the ACR to help fight this battle. Personally, I still harbor grave doubts about their ability, and even their willingness to do so after they have "hooked-up" (love the kids' phraseology) with every outfit that promotes self-referral under the guise of AMIC. What else can we do? Talk to vendors, and tell them:

. . .that if they support self-dealing, they don’t support you, and you won’t support them. Referring doctors who have purchased medical imaging equipment for their offices to self-deal in medical imaging via the “in-office” Stark safe-harbor clause have sales representatives from equipment vendors whispering in their ears, supported with beautiful color collateral materials and spreadsheets. If you want vendors to stop this behavior, you must show them that biting the radiology hand that feeds them is bad business.

Sadly, I don't think there would be any vendors left to deal with if we cut off those who pushed this agenda. Still, it doesn't hurt to make them squirm a little.

Perhaps the most effective approach is that of educating the payers, and somehow forcing physicians to disclose their financial conflicts of interest. How about this for a consent form?

Attention All Patients: We make money whenever we refer you for MRI (or PET, or CT) to the following facilities: _____. As a result, you cannot trust us to impartially consider when we send you to these facilities if the tests are really needed, if there are tests better suited for your problem, if there is a more qualified facility or imaging specialist in the area, or if competing facilities offer better pricing. Because we make money by referring you to the facilities we own or lease, you should consider the need for a second opinion from an independent provider before undergoing the test. We are required to provide you with a list of competing facilities in this community that may offer safer, more accurate, or less expensive medical imaging. They are _____.

I'm not holding my breath waiting to see that one out in public. There is a huge problem with this facet of the situation. Patients trust their doctors implicitly and explicitly. This is certainly a good thing, especially for those of us who grew up watching Marcus Welby, M.D. Is it right to point out to the patients that their trust in some cases is misplaced? Are we interfering in the doctor-patient relationship, one which I once thought sacred (before getting out into the real medical world) when we point out that their beloved doc just might be taking advantage of their trust and ignorance? I honestly don't know. On those rare occasions when I have broached the subject, I mainly get the response, "Oh, I trust my doctor. If he/she says I need a scan, I'll do it anywhere he/she suggests. It's so convenient to have the scan done in his/her office!" Maybe a little brainwashing, maybe a little hostage mentality. Either way, there is probably more of an uphill educational struggle on this front than you might think.

Perhaps the hardest pill for many radiologists to swallow is the fact that they are collaborators in this practice. The self-dealers ask them to read their scans, and they are happy to do so. After all, they reason, if they don't, someone else will. They might as well keep the otherwise lost revenue, and provide the patients the best of care. Right? Dr. Reicher answers:

I owe it to my community to behave in a trustworthy manner. Businesses that maintain the respect of their customers are the most successful in the long run. The “secret” of self-dealing is ultimately going to be widely understood by the public. If you are a collaborator, you are going to be seriously embarrassed at the least, and potentially personally liable.

Gulp. Not much I can say to that, is there?

There have been several objective articles before this, discussing the costs of self-referral. However, I have never before seen such a passionately-written article on the topic, one which calls a spade a spade, in this case blatantly declaring self-referral unethical. All I can say is, "BRAVO!" The problem is, sadly, I don't think too many folks are listening just yet. But, maybe that will change, and I hope that happens before Hillary uses this sort of information to justify destroying the American Health Care system.

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