America The Porcine, or, It's All Mr. Rogers' Fault

Pigs get a bad rap. They are actually rather clean, intelligent creatures, but since they lack sweat glands, they need to cool off by sitting in water, or mud.

When we say that certain people act like pigs, this is truly insulting...to pigs.

I have written here for several years about self-referral, and it seems that little has really changed. Oh, yes, there is a little more publicity about it here and there, some legislators somewhere "get it" and are trying to do something about it, others fall for the "convenience" argument, and refuse to do the right thing.

There is a glimmer of hope in the otherwise dismal outlook for medicine for the next few years in that self-referral is probably going to be attacked in the process of running roughshod over the remainder of the field. A preliminary health care plan from Senator Max Baucus of Montana (that may be adopted by President-Elect Obama) notes the following in regard to self-referral:

Physician Self-Referral. Physicians, like most professionals, expect to get paid for the work that they perform. Some physicians, however, have found a way to game the system so that, in addition to getting paid, they reap additional financial benefits from the provision of certain health care services. Physicians can accomplish this by having ownership or other financial interests in equipment or facilities — such as an MRI machine or a hospital — that provide health services. When those physicians refer their patients for services from which the physician reaps the additional financial benefits — a practice known as self-referral — there is reason to be concerned about the physician’s motives. Physician self-referral is generally prohibited by Federal law when the patient is covered by Medicare or Medicaid.25 Self-referral creates conflicting incentives for physicians, because the financial incentive to increase utilization of the financially rewarding services may conflict with otherwise sound medical and professional judgment. Ultimately, this practice often results in an “increased use of services and higher payments from third party payers.”26

Congress has enacted several laws to confront this problem. In 1972, Congress enacted the Anti-Kickback Statute, which “broadly prohibits the purposeful offer, payment, or receipt of anything of value to induce the referral of patients from services reimbursable by a federal health care program.”27 Few prosecutions occurred, however, and referrals to imaging facilities or medical laboratories were not deterred.28

In 1989, Congress enacted the Ethics in Patient Referrals Act (known as Stark I), which prohibits physicians from “referring Medicare or Medicaid patients for clinical laboratory services to labs with which the physician has a financial relationship…unless the relationship fits within a specified exception.”29 In 1993, Congress enacted amendments (known as Stark II) expanding the prohibited services to “physical and laboratory therapy, radiology, radiation, home health care, hospital, outpatient prescription drugs, and many types of medical equipment and supplies.”30

The Baucus plan would scrutinize physician self-referral to ensure that physicians are not engaged in financial arrangements that place financial interests ahead of the needs of patients and the American taxpayer. Physicians deserve fair pay for providing services, but they should not be able to game the system unfairly. Increased transparency to both patients and payers in the form of disclosure of physicians’ financial interests is first step.

One example is physician ownership of hospitals. There is concern that physician ownership of hospitals leads to cherry-picking the patients who are healthiest and most able to pay, while leaving the patients who are sickest and least able to pay for community hospitals to treat, often without much compensation, if any. This cherry-picking only exacerbates the cost shifting to those Americans with insurance. This concern is heightened by the fact that the patient often is unaware of a physician’s financial interest in providing services at a hospital in which he or she has an ownership interest.

Physician-owned hospitals are often smaller and more specialized than community hospitals. They tend to focus on lucrative lines of service. Community hospitals, on the other hand, tend to provide all service lines, including emergency departments. Community hospitals find it difficult to compete with their more cash-rich physician-owned counterparts. Over time, the trend of increasing physician ownership of hospitals jeopardizes the continued viability of community hospitals.

The issue of self-referral must be reviewed in light of how health care is and will be delivered. No serious effort at reform can ignore the potential gaming that financial conflicts may create.

So, yeah, they know it's out there. And they're going to do something about it. Eventually. Likely the solution, if and when it comes, will be worse than the problem.

What we are fighting here is greed and entitlement, traits manifested by more and more Americans over the past few years, to the point that they are becoming normal behavior, to be ignored, or even applauded, envied, and emulated.

Elizabeth MacDonald, writing in her blog on FoxBusiness.com, puts the blame of our current financial woes and subsequent bailouts at the feet of the beloved Mr. Rogers.

Mister Fred Rogers, the children’s TV star, who, beginning in 1968, started every show telling us that we were “special” just the way we were.

When we weren’t.

Blame all of those preening child-rearing experts who encouraged an excruciatingly costly culture of entitlement, a culture of narcissism, of excessive self-righteous self-indulgence, where generations grew up believing they were entitled to follow their own codes of conduct, a chronic “me first, I get what’s mine first” attitude–to the point where one survey shows one in three teenagers expect to be famous.

Better yet, blame the bailouts on everyone who forgot the most important part of the Mister Rogers’ Neighborhood show, a willful ignorance that has led to a mass dereliction of civic duty, of civic vision–Rogers’ emphasis on “neighborhood.”

Blame it on a post World War II culture of “me-ism,” of individuality over community, of “I’m special, you owe me,” a culture of anything goes in this Age of Aquarius.

And what did this mentality yield?

*Ten million borrowers, many of whom should never have borrowed what they did to begin with, could go bellyup on their mortgages when all is said and done. Monthly foreclosure filings, most of which are in suburban middle class neighborhoods, could grow to 303,000 monthly from 259,085, says RealtyTrac.

*In Bakersfield, California, a Mexican strawberry picker with an income of $14,000 and no English was lent every penny he needed to buy a house for $720,000. A nanny for a mortgage-bond trader at Deutsche Bank bought, along with her sister, five townhouses in Queens, New York after lenders got them to refinance to keep buying.–Michael Lewis, “The End of Wall Street’s Boom.”

Proving that when people are free to do as they please, they usually imitate each other.

Why not accept a loan for something you know you can't afford? Why shouldn't I live in a McMansion, too? Personal responsibility? Bah, Humbug!

Take as another example the recent revalation about Bernard Madoff. Basically, Madoff ran a huge scheme wherein he used the money coming in from new investors to pay old clients:

New potential victims emerged of Wall Street veteran Bernard Madoff's alleged giant Ponzi scheme, with international banks, hedge funds and wealthy private investors among those sorting out what could amount to tens of billions of dollars in losses.

New York Mets owner Fred Wilpon, GMAC LLC Chairman J. Ezra Merkin and former Philadelphia Eagles owner Norman Braman were among the dozens of seemingly sophisticated investors who placed money on what could prove to be history's largest financial scam.

And how did Madoff get away with this? Didn't anyone smell a rat? It seems that some did:

Bernard L. Madoff is alleged to have pulled off one of the biggest frauds in Wall Street history. But there were multiple red flags along the way, including a series of accusations leveled against Mr. Madoff's operation. Now some are asking why regulators and investors didn't pick up on the alleged scheme long ago.

"There's no smoking gun, but if you added it all up you wonder why people either did not get it or chose to ignore the red flags," says Jim Vos, who runs Aksia LLC, a firm that advises investors and came away worried after examining Mr. Madoff's operation.

. . .Meanwhile, a series of media stories also raised questions about Madoff's operations, including a piece entitled "Madoff Tops Charts; Skeptics Ask How" in industry publication MAR/Hedge in May, 2001, and a subsequent story in Barron's. Mr. Madoff generally brushed off reporters' questions, citing the audited results and arguing that his business was too complicated for outsiders to understand.

We might expect the reasonable man to have questioned Madoff's tactics and results. But no, many of his clients aparently knew he was manipulating things, but they thought he was doing something illegal but that might still benefit them, the entitled ones, and the investments kept pouring in. From Clusterstock:

Specifically, we're hearing that the smart money KNEW Bernie had to be cheating, because the returns he was generating were impossibly good. Many Wall Streeters suspected the wrong rigged game, though: They thought it was insider trading, not a Ponzi scheme. And here's the best part: That's why they invested with him

. . .So why did these smart and skeptical investors keep investing? They, like many Madoff investors, assumed Madoff was somehow illegally trading on information from his market-making business for their benefit. They didn't consider the possibility that he was clean on that score but running a good old-fashioned Ponzi scheme.

Sounds a bit like a Nigerian Scam in a three-piece suit, doesn't it? To refresh your memory on that, look at this discussion from Quatloos.com:

In many cases, this is really a scam-within-a-scam: The Nigerians are making you think that you are going to scam the Nigerian Government, the Central Bank of Nigeria, etc., when in fact they are going to scam you out of what they are going to charge you to get in the scam, or what portion of the scam you are going to pay to make it work.

If you pay the money up-front by wire-transfer or by mail, one of two things will happen: (1) you have simply lost your money and will never see it again; or (2) and much more likely, within a couple of days you will get a phone call or letter from your contact telling you that something has gone wrong, and that to clear it up and release the funds you will have to send just a little more money. This latter scamming will go on literally for weeks and months, until you either run out of money or figure it out.

If you actually go to Nigeria, it is the same scam. You will pay some money and wait. There will be a delay, and then a requirement that you pay additional money to clear up the delay, and then another delay and more money, and so forth and so on until (1) your money is exhausted, or (2) you leave the country, or (3) you are kidnapped or murdered for the rest of your money.

The Nigerian government is getting tired of the reputation these scams have brought, which is ironic since it is rumored that many government officials and employees actually participate in them. However, we have to agree in light of today's discussion with this sentiment:

People who fall for so-called "Nigerian scams" aren't victims at all—in fact, they're greedy and should be jailed, according to Nigerian high commissioner Sunday Olu Agbi. He said today that Nigeria has gained a bad reputation because of the scams perpetrated by a minuscule number of people, and that those who find themselves involved with the scams are equally as guilty as those running them.

"The Nigerian Government frowns very seriously on these scams... and every day tries to track down those who are involved," Olu Agbi told the Sydney Morning Herald in response to a previous article on Australians falling for Nigerian scams. "People who send their money are as guilty as those who are asking them to send the money."

If the greedy and entitled folks who received the scam letters and emails didn't think that they deserved something for nothing, or more accurately, to take something that doesn't belong to them courtesy of the scammer, these 419 scams would dry up in a week.

Physicians may be somewhat more intelligent, on average, than the overall population, but they are just as prone, if not more so, to want what isn't theirs. Take this example of a physician who abused his position for gain, trodding all over the rights and safety of his patients:

When a Congressional investigation revealed in June that Dr. Joseph Biederman, a world-renowned child psychiatrist, had earned far more money from drug makers than he had reported to his university, he said that his interests were “solely in the advancement of medical treatment through rigorous and objective study.”

But e-mail messages and internal documents from Johnson & Johnson made public in a court filing reveal that Dr. Biederman pushed the company to finance a research center at Massachusetts General Hospital, in Boston, with a goal to “move forward the commercial goals of J.& J.” The documents also show that the company prepared a draft summary of a study that Dr. Biederman, of Harvard, was said to have written.
Dr. Biederman’s work helped to fuel a fortyfold increase from 1994 to 2003 in the diagnosis of pediatric bipolar disorder and a rapid rise in the use of powerful, risky and expensive antipsychotic medicines in children.

And so we come full circle in our discussion, and return to imaging self-referral. A recent article in Imaging Economics discusses research by Jean Mitchell, PhD, professor of public policy at Georgetown, and a prominent researcher in this venue, published in the May 2008 issue of Medical Care. Dr. Mitchel looked at private insurance reimbursement for MR, CT, and PET, and found that utilization had increased significantly from 2000 to 2004, powered by physician self-referral and lease arrangements.

"Physician self-referrals are a response to financial incentive," said Mitchell. "Everyone responds to that. If you were in their shoes and getting pay cuts, which is essentially what's happened, you would try to make up that lost income. The easiest way to do it, in specialties that need imaging, is to expand the scope of practice in order to bill for the imaging. That is what's happening."

. . .The two camps of public and physician opinion that have emerged view this scenario with emotions ranging from satisfied approval to unmitigated disgust. Supporters of using self-referral in this manner point to the increased convenience to patients by offering imaging in house. Additionally, they question the presumption that self-referral is often not medically necessary. . .Members of this camp also say quite plainly: If the imaging is medically necessary, why not benefit?

Why not, indeed? I'm entitled to it, and I'm going to get it. As for necessity, I've made this argument before. We know for a fact that the self-referrers order from two to eight times the number of scans as compared to those clinicians who do not self-refer. So, either the latter are under-serving their patients, or the self-referrers are ordering scans that are not necessary. It cannot go both ways. Doctors hold a unique position of trust and power over their patients:

Patients often trust their doctors to a fault. In cases where they perhaps should ask questions, or at least have the option to make a choice, patients will often defer to their physician's expertise. If imaging is recommended, it will most likely take place. But in cases of self-referral and twisting the system, is the physician role as patient agent compromised?

The Imaging Economics article comes to a simple conclusion:

Realistically, a full ban may be the best method.

"I initially thought we need policy makers working with insurers and physicians on which types of scans would be more effective in more cases," said Vivian Ho, PhD, professor of medicine at Baylor College of Medicine and associate professor of economics at Rice University, who provided commentary on the Mitchell study in Medical Care. "But this is extremely difficult and would take a lot of time. The other alternative that should be considered is to completely ban self-referral for diagnostic imaging. It's unfortunate, but on the other hand, it's a pretty compelling argument to save a great deal of money that can hold down insurance costs."

For now, physicians and the public need to recognize that this is an issue crying out for a solution.

"Yes, there's more pressure from managed care on physicians," said Ho. "But to me that's not the way the economics should work. To force this cost upon consumers doesn't lead to efficient markets. It's unfair, and with little demonstrable benefit."

True, but that objective analysis doesn't begin to describe the problem. You have greed on the part of a small but significant number of physicians, driving them to self-refer to scanners in their offices. They are over-utilizing and ultimately tainting life-saving technology in the interests of padding their pockets, or to "recover lost revenue." But lest we forget, this technology, at least CT, uses ionizing radiation, and it is NOT without consequence to use it indiscriminantly.

We can talk all day long about closing loopholes and tightening exclusions. Blah, blah, blah. It won't work. We all know it won't work because everytime it has been tried, the greedy and entitled find ways around the solutions. HERE is what must be done, if anyone has the guts to do it. Self-referral of this sort needs to be banned and criminalized. There needs to be jail-time, not just fines, applied to the wanton disregard the self-referrers show for their patients' welfare. These folks need to be hit and hit hard. Assuming, of course, that we really do feel that they are not entitled to their ill-gotten gains.

Fighting human nature is an uphill battle, especially when some of us were made to feel "special":

Fred Rogers, the late TV icon, told several generations of children that they were "special" just for being whoever they were. He meant well, and he was a sterling role model in many ways. But what often got lost in his self-esteem-building patter was the idea that being special comes from working hard and having high expectations for yourself.

Sadly, being "special" today means to some that they don't have to follow the rules. But they, like the rest of us, aren't all that "special" after all. Some of us are just pigs. No offense to pigs.

Self-Referral and the Bank Bailout

The big topic of conversation everywhere these days is the $700 Billion bailout of Wall Street, which so far has yet to be approved by Congress. Whether you are for the rescue operation or not, you will still be able to see some uncanny parallels between the economic crisis and the imaging self-referral issue.

The facts of self-referral are pretty simple. Because of the In-Office Exception of Stark II, doctors who own imaging equipment placed in their offices can order scans to their hearts' content, and collect technical fees thereof. Studies have demonstrated that giving out the keys to the cash-register leads to anywhere from two to eight times the number of scans being ordered. No one seems to be disputing that at all. The excess scans are costing you and me somewhere in the neighborhood of $16 billion per year. Not much dispute on this either.


I don't claim to be an expert on the mortgage crisis, but I think the main problem is pretty clear. Loans were given to people who shouldn't have qualified for them, and a lot of folks made a lot of money by treading on the line between what was proper and what was not. Because the whole thing was perpetuated by housing prices that could not sustain their rate of growth, the house of cards quickly fell over, right on top of all of us. Rightly or wrongly, President Bush and some in Congress attempted to bail the financial institutions out of their bad behavior. As of right now, the bailout didn't pass Congress, mainly because a large number of US citizens weren't for it, and they let their representatives know this in uncertain terms. Their main objection? The bill made all of us pay for the wild speculation and manipulation of a few, and it didn't punish those responsible.


I predict that once the public gets its collective mind around the self-referral issue, something similar will occur. Right now, patients are indoctrinated into thinking that their physician's in-office scanner is their solely for the patient's convenience. They do not realize that they are being taken for a ride by an authority figure that is manipulating them for their own profit, toeing a similar fine line between what is proper and what isn't. When they eventually wake up, I think there will be a significant backlash toward their beloved clinicians.


It has been said that those who sought loans without proper credit have some culpability in the mortgage crisis. Someone making a relatively low wage (or no wage) with no credit should not be thinking of buying a home. Patients also are at least partly to blame for the self-referral problem. Americans are addicted to imaging. When they go to their doctor or to the Emergency Room, they expect to be scanned for every ache and pain, and this plays right into the hands of those who would make a profit with unnecessary imaging.


So, who will rescue the country from imaging self-referral? Once again, the only real hope is the government. While DRA-2005 didn't properly focus on the self-referrers (and the ACR and AMIC didn't bother to make this clear to Congress) its slash-and-burn philosophy did have significant effects. A recent GAO report demonstrated that imaging expenses declined 12.7% in 2007 following implementation of DRA 2005. Yes, this hurt radiologist-owned facilities, but I'll bet it hurt the self-referrers more.

As a Conservative, I chafe at the need for govermnental intervention in these issues. But I think we Conservatives are mischaracterized. It is impossible to achieve "zero-regulation," mainly because of human nature. That would yield sheer anarchy. There will always be those who look for loopholes and other ways to thwart the sytem. I don't think anyone really wanted lenders to give out loans to those who would never be able to pay for them, and we know that Pete Stark never intended for self-referrers to have PET/CT's in their offices.

It could be argued that regulations such as the Stark Laws and government programs for housing loans have created these situations, but without the regulations there would be a complete free-for-all. Sadly, only the government can provide the fix.

A "Clear Vue" to Self-Referral

The self-referral mills in St. Louis were not alone in their approach to skirting the Stark Laws. According to ArkansasBusiness.com, there is another such operation in Lowell, Arkansas. In similar fashion, Fayetteville MRI, running a strip mall operation called Clearvue Medical Imaging, also depends on self-referral of its investors, and keeps it legal by avoiding Medicare and Medicaid patients.

Arkansas Business got hold of a confidential memo, which

. . . indicates that Fayetteville MRI – led by four northwest Arkansas doctors – is seeking 50 physicians to invest a total of $5,000. It anticipates annual profits that would quickly exceed $2 million from a controversial business plan that relies on self-referral.

State and federal laws forbid self-referral to imaging centers that accept Medicare and Medicaid patients, so Fayetteville MRI will not accept patients insured by those government programs, the memo said.

The article goes on to name the names of the owners and shareholders of the operation. They are actually leasing an outpatient clinic from a radiologist!
Their attorney is none too happy about being "outed":

Tim Ezell, an attorney with Friday Eldredge & Clark LLP of Little Rock and who is representing Fayetteville MRI, wasn't happy that Arkansas Business obtained a copy of the private offering memorandum. It was mailed to the newspaper by an anonymous tipster identified only as "A Concerned Doctor."

"It's really troubling to me that the contents of this offering memo are out there for public consumption because it really is supposed to be confidential," he said.

And he was very quick to point out that his little project is just within the limits of legality:

Ezell also said the business model isn't violating kickback laws.

"Those kickback laws are applicable to situations where there are ... government health care beneficiaries involved, like Medicare and Medicaid," he said. "There are no government beneficiaries involved in the Fayetteville MRI transaction."

Yup. When cornered, one of the physician-investors excused his actions:

Brown, one of the investors in Fayetteville MRI, said what's driving up the health care costs are attorneys who file malpractice claims against doctors.

"We have to cover our butt on everything," Brown said. "We know we could be sued and they always are looking in retrospect what tests I do that are not needed for my clinical care."

So if he orders tests, it's to protect himself from plaintiffs' attorneys in the event of a lawsuit, he said.

"It's all to cover myself from lawyers," Brown said. "It has nothing to do with padding my pocketbook."

Oh, puhleeeese. I'll go back to an argument I made earlier. All doctors face this same pressure. We know for certain that the self-referrers order from two to eight times the number of scans of those who don't own their own equipment. So, I guess that not only are the less-well-endowed committing malpractice, but they must be more immune to lawsuits as well. Wow.

Three of the four St. Louis shops closed after receiving negative publicity. We'll see if the light of truth has the same effect in Arkansas.

If I Had A Scanner.....

Midi courtesty of http://www.brownielocks.com/

With apologies to Peter, Paul, and Mary

If I had a scanner,
I’d scan her in the morning,
I’d scan her in the evening,
As long as I can.

I’d check her for tumors,
I’d check her for infection,
I’d scan her for the cash I’d get
From Medicare and Aetna
As long as I can.

If I had a PET/CT,
I’d scan her in the morning,
I’d scan her in the evening,
As long as I can.

I’d check her for tumors,
I’d check her for infection,
I’d scan her for the cash I’d get
From Medicare and Aetna
As long as I can.

If I had an MRI,
I’d scan her in the morning,
I’d scan her in the evening,
As long as I can.

I’d check her for tumors,
I’d check her for infection,
I’d scan her for the cash I’d get
From Medicare and Aetna,
As long as I can.

I don’t have a scanner,
I don’t have a PET/CT,
I don’t have an MRI, so much for my plan.

Cause the hammer of CMS
Rang the bell of warning,
And they cut off the cash I’d get
From Medicare and Aetna.
It’s all over, man.

Cause the hammer of CMS
Rang the bell of warning,
And they cut off the cash I’d get
From Medicare and Aetna.
It’s all over, man.

Changin' Times

We haven't seen a total reversal of self-referral yet, but there have been some victories here and there. The Times, They Are a Changin'. Slowly but surely.

Remember the blatant self-referral clinics in St. Louis? There were four imaging centers that skirted the Stark Laws by not accepting federally-paid patients (Medicare, Medicaid, etc.) According to a follow-up article by Mary Jo Feldstein of the St. Louis Post-Dispatch, three of the four have closed down. No one knows why this happened at this point, but maybe patients got wise to what was happening to them, or just maybe someone developed a conscience. More likely, they were about to get into trouble over insurance money:

Insurers are looking into whether the clinics violated a policy that requires physicians and facilities that care for some of their members to care for all of their members.

To care for "all of their members", the self-referrers would have had to take Medicare patients, too, which would disrupt their little operation. No doubt clinic #4, Cedar Plaza Imaging in south St. Louis County, is not long for this world, either.

CMS may have given us another early Christmas present. According to Diagnostic Imaging,

Following its charge to reduce costly imaging overutilization, the Centers for Medicare and Medicaid Services has announced more stringent prohibitions against self-referral practices. Final Stark rules for the Hospital Inpatient Prospective Payment System for 2009 could force providers to restructure numerous space and equipment arrangements. . .

The new provisions broaden the definition of Designated Health Services (DHS) "entities" and prohibit under-arrangements and "per-click" arrangements for space and equipment leases. . .

The final IPPS rules will become effective Oct. 1, 2009. They will be published in the Aug. 19 issue of the Federal Register.
The implications for radiologists are positive. The new rules will take further incentive away from self-referral and will make lease arrangements with imaging centers less attractive, said attorney Thomas W. Greeson, a partner in the law firm of Reed Smith LLP in Falls Church, VA,

"It will also mean that many of the arrangements where hospitals have been able to establish relationships with referring physicians based on ownership or leasing of services on a per-click basis will be less attractive and give radiologists the opportunity to be part of the technical component services that otherwise were provided under these various arrangements," Greeson told Diagnostic Imaging.

This is a pretty big step. It doesn't cure the problem, but it's a start. Sadly, the self-referrers will no doubt find ways around any new rules and regulations that CMS can deliver, but at least it's getting harder and harder to do so.

GAO Talks, AMIC Squawks

The Government Accountability Office has just published a study with the lengthy title of "Rapid Spending Growth and Shift to Physician Offices Indicate Need for CMS to Consider Additional Management Practices." In brief, the GAO demonstrated what we already know, that in-office imaging is growing much faster than otherwise equivalent segments. Obviously, I'm not particularly surprised by this revelation. From Diagnostic Imaging's summary:

• Medicare spending for in-office imaging services increased from $6.9 billion in 2000 to more than $14 billion in 2006.
• The proportion of outpatient Medicare imaging performed in physician offices rose from 58% in 2000 to 64% in 2006.
• Spending on advanced imaging, such as CT, MRI, and nuclear medicine, rose 17% per year, substantially faster than spending on less expensive ultrasound and x-ray procedures.
• Cardiologists relied on medical imaging for 36% of their total Medical revenue in 2006, up from 23% in 2000.
  In-office imaging spending in 2006 varied nearly eightfold from state-to-state, from $62 in Vermont to $472 in Florida. The huge difference led GAO analysts to express concern about whether Medicare payment policies have emboldened physicians to overuse imaging.

The GAO did propose some solutions, primarily:

Given the pressures of a fiscally unsustainable Medicare program, CMS has undertaken several initiatives aimed at improving its performance as a purchaser of health care services. With respect to rapidly growing imaging services, the experience of the private plans in our study suggests that the benefits of front-end management of these services exceeded their costs. We believe CMS may be able to improve its prudent purchaser efforts by adopting strategies such as prior authorization and privileging.

Basically, they want precertification. This is a good start, but I really don't think it will do the job. Possibly there will be some minor effect in the beginning, but those who make a lot of money from self-referral will be more than happy to jump through the hoops to get to the pot of gold. But at least the problem is getting some lip-service from places that count.

The report includes a response from our friends at AMIC, who are none too pleased to have their masters' gravy-trains interrupted:

AMIC representatives raised four principal concerns about the draft report. First, they stated the draft report should have focused on strategies such as accreditation (which improves quality), and adherence to clinical practice guidelines (that result in appropriate use of imaging services), rather than private sector strategies such as use of RBMs, prior-authorization, and other techniques which focus solely on controlling
costs. Specifically, AMIC representatives expressed several concerns about RBMs. They stated that the for-profit structure and lack of transparency in sharing appropriateness guidelines make RBMs incompatible with the Medicare program. They also contended that there is no evidence that RBMs improve care or add value, and RBMs involve physicians in lengthy interactions. Moreover, they stated that prior authorization had been tried and proven unfeasible for Medicare for lack of sufficient administrative resources. In the draft report, we noted plans’ increasing use of accreditation to assure quality of imaging services. With regard to prior authorization and RBMs, we are recommending that CMS consider the feasibility of these and other front-end approaches. We would also note that while HHS indicated that prior authorization might be inconsistent with the Medicare program, the department did not rule it out as a strategy that had been tried and proven unfeasible for Medicare.

Second, AMIC representatives stated that in emphasizing spending growth we had failed to recognize the benefits of imaging and its effects in reducing overall health costs by substituting for more invasive procedures or treatments. We acknowledged the benefits of imaging throughout the draft report and noted that while some of this spending growth may be appropriate, financial incentives inherent in Medicare’s payment policies for potentially inappropriate use of imaging in physicians’ offices, and their implications for a fiscally unsustainable Medicare program cannot be ignored. We are not aware of any peer-reviewed studies that conclusively show the role of imaging in reducing overall health care costs.

Third, AMIC representatives stated that by focusing only on Part B spending under the physician fee schedule, the draft report did not acknowledge growth in imaging across other sites of care such as hospitals. As we stated in the draft report, Medicare’s physician payment policies contain financial incentives for physicians to directly benefit from higher fees paid for the provision of imaging services in their offices, while receiving lower fees for interpretation of in hospitals. However, we have added additional information to the report, noting that about two-thirds of all imaging services were delivered in the hospital setting in 2006, and that spending on imaging services delivered in physician offices grew twice as fast compared to spending on services delivered in the hospital setting.

AMIC’s fourth concern was that the draft report did not discuss the fairness of the payment reductions resulting from the changes mandated in the DRA. As noted in the draft report, we will examine the effects of payment changes mandated by the DRA in a separate report.

Blah, blah, blah. It's OK to talk about limiting self-referral, as long as we don't actually do anything about it, right? Well, the GAO is talking about it, and maybe CMS will eventually do something about it. I'm not all that keen on RBM's either, but it's a start, and we need to start somewhere.

The Today Show Mentions Self-Referral

A report featuring NBC Medical Reporter Dr. Nancy Snyderman was aired yesterday on the Today Show, which discussed mainly the amount of radiation one would receive from various tests. Self-referral was mentioned quite briefly in that patients were urged to ask their ordering doc if he or she has a financial interest in the scanning facililty. See the video HERE.

While the ACR has done much to bring imaging self-referral to light, they sometimes take too much credit. In a piece about the Today Show report, Dr. Thrall of the ACR said: "ACR media and public relations efforts regarding quality imaging and the effect of financial incentives on imaging quality and cost are clearly having an effect."ACR media and public relations efforts regarding quality imaging and the effect of financial incentives on imaging quality and cost are clearly having an effect." I'm sorry, but the only mention of the ACR in the piece concerns accreditation. Listen for yourself.

But, I guess any publicity on this topic is good publicity. Even if some wish to take credit where credit is not due.

Cheat Me In St. Louis

Just when I think imaging self-referral can't get worse, I find something like this. As reported in the Saint Louis Post-Dispatch, a lawyer named Kirk Bowman is managing four imaging mills in the St. Louis area. The business model is very simple:

Here's how Bowman's clinics work: After being evaluated by a board of directors, physicians who want to join make an investment that varies by location, Bowman said. He declined to provide details.

To remain investors, physicians must earn 75 "participation units" throughout the quarter. An MRI counts as three participation units. A CT scan counts as two. Then, the profits are split equally among the investors, he said. Physicians can miss the target for one quarter before being asked to relinquish their ownerships.

Bowman said the referral requirements ensured everyone's contributing to the center's being a success. . .

The referral requirements are so low, 25 to 50 patients a quarter, that physicians do not feel pressured to prescribe tests unnecessarily, Bowman and Schwarze said. And, profits earned are too small to tempt physicians to risk their livelihoods for a bump in income, they said.

You might think this little Ponzi scheme violates the Stark laws, and you would be correct, except for one minor detail:

The Stark law was named after its sponsor, U.S. Rep. Pete Stark, D-Calif., and was designed to protect patients and limit health care spending. It bars a physician from referring patients to a diagnostic center in which the doctor has a financial interest when the patient's care is paid for by the federal government through such programs as Medicare.

At least two dozen states have extended similar laws to cover all patients, but Missouri has not. Because the clinic Schwarze invested in declines to care for patients in federal programs, it is not covered by the Stark law.

Bowman isn't worried about the appearances:

"We assume people are honest. I don't know another way to do it," Bowman said. "I don't think a doctor is going to risk his whole career to manufacture an MRI."

Honest. Riiiiiiight. Just ask Dr. Jean Mitchell from Georgetown, who has written extensively about self-referral:

"There's no other business where you can control demand and supply," Mitchell said. "This is guaranteed success. It's a cash cow."

She sees Bowman's clinics as even more questionable because they require physicians to refer a certain number of patients to maintain their investment.

"I've never seen anything so blatant as this," said Mitchell, a health economist.

Neither have I.

If you happen to be in St. Louis, and your doctor sends you to Reliable Imaging of St. Louis in West County, Lynn Haven Imaging in Hazelwood, Cedar Plaza Imaging in South County or Boone's Crossing Imaging in the Chesterfield Valley for imaging, look him or her in the eye and ask how much he or she will be making from the referral. Then consider finding another doctor.

GE Is Worried About Radiation?

Fellow blogger Doctor Dalai has a recent post about SPECT/CT scanners. It seems that General Electric is trying to get him to buy a machine that doesn't do as good a job of scanning, in his opinion, but they are pushing it as the scanner with the lowest dose to the patient:

The following link is to an article regarding the possible link between multiple CTs and cancer risks, especially in children. Aiding us in our cause for our low-dose SPECT/CT Infinia Hawkeye 4 system. Maximum patient dose with the Infinia Hawkeye 4 is 2.5ma. Why more dose for Attenuation Correction and Anatomical Mapping in Nuclear Medicine environment?

I had to laugh when I read this. You might remember my post about GE promoting the sale of scanners to self-referrers from last year. GE has an entire web-page devoted to the joys of owning your own scanners, and how GE will help you get one. My favorite quote from their site is:

In-office CT also provides a highly credible and effective means of differentiating your practice from others in your market. It places you on the leading edge of patient care and may engender positive word-of-mouth that has the potential to increase your revenue opportunities significantly.

So, if you are "increasing your revenue opportunities significantly", you are scanning a lot of patients. Let's be real and admit that some significant proportion of those patients maybe didn't need to be scanned. Thus, GE is proposing irradiating patients for profit. That doesn't quite mesh with their great concern over the increased dose someone would get if scanned on another company's SPECT/CT. But I guess that doesn't matter, does it?

I just love it when people bend and use the facts to their own advantage.

Self-Referral on the Wikipedia

A poster named Rolf-Rad on AuntMinnie.com has created a page on the Wikipedia about self-referral. It is very well written, and possibly could serve as a focal point for further discussions. Please view it and contribute more information.

A Resolution from the American Misbegotten Association "Fairness" in Medical Imaging Interpretation

If you look up misbegotten, you will find that it is a more acceptable synonym for something less savory.

Resolution 208, Fairness in Medical Imaging Interpretation, is to come before the AMA's House of Delegates shortly, and it is expected to pass. It is introduced by some of our very good friends:

American Society of Neuroimaging
American Association of Neurological Surgeons
Congress of Neurological Surgeons
American Medical Group Association
American College of Cardiology
American College of Gastroenterology
American Gastroenterological Association
American Society for Gastrointestinal Endoscopy

So, what do these illustrious physicians call "fair"? Here's the text of the bill and relevant AMA policy:

Whereas, Expenditures for advanced medical imaging services, such as CT, MRI and PET, have significantly increased in this decade, raising legitimate concerns over utilization rates; and

Whereas, These concerns have led payers, state legislatures, government agencies and radiology management companies to consider eliminating reimbursement for in-office imaging and image interpretation by non-radiologists without consideration of their training and certified competence to provide these services; and

Whereas, Available data do not suggest that increased imaging costs are necessarily attributable to in-office imaging services by most medical specialties involved in medical imaging and interpretation; therefore be it

RESOLVED, That our American Medical Association encourage and support the in-office utilization, medical direction and supervision of advanced imaging services by qualified or certified physicians whose utilization of these modalities is within the scope of their specialty practice in accordance with appropriateness guidelines, practice guidelines, technical standards and accreditation standards for the imaging modalities utilized as defined by their specific medical society (New HOD Policy); and be it further

RESOLVED, That our AMA actively oppose efforts by federal and state legislators, regulatory bodies, private payers, public payers and radiology business management companies to restrict the application of advanced imaging services for the diagnosis and treatment of patients when such services are provided as defined by specialty specific appropriateness guidelines, practice guidelines and technical standards for the imaging modalities utilized. (Directive to Take Action)

Fiscal Note: Implement accordingly at estimated staff cost of $6,509.

Received: 05/07/08

RELEVANT AMA POLICY

D-385.974 Freedom of Practice in Medical Imaging
Our AMA will: (1) encourage and support collaborative specialty development and review of any appropriateness criteria, practice guidelines, technical standards, and accreditation programs, particularly as Congress, federal agencies and third party payers consider their use as a condition of payment, and to use the AMA Code of Ethics as the guiding code of ethics in the development of such policy; (2) actively oppose efforts by private payers, hospitals, Congress, state legislatures, and the Administration to impose policies designed to control utilization and costs of medical services unless those policies can be proven to achieve cost savings and improve quality while not curtailing appropriate growth and without compromising patient access or quality of care; (3) actively oppose efforts to require patients to receive imaging services at imaging centers that are mandated to require specific medical specialty supervision and support patients receiving imaging services at facilities where appropriately trained medical specialists can perform and interpret imaging services regardless of medical specialty; and (4) actively oppose any attempts by federal and state legislators, regulatory bodies, hospitals, private and government payers, and others to restrict reimbursement for imaging procedures based on physician specialty, and continue to support the reimbursement of imaging procedures being performed and interpreted by physicians based on the proper indications for the procedure and the qualifications and training of the imaging specialists in that specific imaging technique regardless of their medical specialty. (Res. 228, A-05; Reaffirmed in lieu of Res. 901, I-05; Reaffirmation A-06; Reaffirmation I-06; Reaffirmed in lieu of Res. 125, A-07)

Excuse me, but what a bunch of CRAP! It has been proven time and time again that self-referral DOES show increased utilization. Beyond that, what our friends are asking for is a complete disregard for imaging standards as set by us, the imagers. Can anyone gue$$ what the motivation might be for all of thi$? $ure, you can. And tell me, is it "fair" for a clinician to be able to generate income by ordering unnecessary tests, bypassing any restraint? I don't think so.

If this resolution passes, I will drop my membership in the AMA, and I would urge everyone in Radiology to do so. Obviously we have no voice there anyway.

A Chat With An Internist

I was reviewing a case with an internal medicine physician who happens to be a good friend of mine. We were talking about a patient that needed a CT, and I said, almost without thinking, "At least you don't have a scanner in your office."

This started a discussion of the relative merits of in-office scanning and self-referral. My friend was unaware of the statistics that we all know so well: self-referring docs order from two to eight times as many scans as those who don't self-refer, and they generate $16 Billion in extra expenditures annually.

My friend is honest as the day is long, and quite non-judgemental. He had no harsh words for his colleagues who are dabbling in the scanning business. But he was very clear as to why he thought they were doing so. As an internist, he is very much aware of the impact of falling reimbursements. He notes that it is very difficult to keep his practice open at all these days. Thus, he sympathizes with those who are doing anything to stay afloat, including placing scanners in their offices. The temptation to order excess imaging is certainly there, but he expressed hope that this would not occur very often. Nothing was mentioned about convenience.

It has been said on numerous occasions that primary care physicians are underpaid, and that is the root cause for self-referral. I agree that our hardworking internists, pediatricians, and FP's do deserve a lot more than they receive, and the current situation is very sad and very difficult for them. However, a couple of points come to mind. First, two wrongs don't make a right. If I lose money in the stock-market, I'm not allowed to rob a bank to make up for my loss. Similarly, the lack of reimbursement for office visits and EKG's does not justify over-ordering of scans to produce additional technical revenue. Secondly, a significant pleurality, if not an actual majority, of self-referring physicians are not primary care docs, but rather are specialists, mainly cardiologists, oncologists, neurologists, orthopedic surgeons, and neurosurgeons, more or less in order of their abusive behavior as I see it. Maybe these guys have taken some hits as well, but their incomes have certainly not dropped as badly as the primaries.

It's hard to define what's "fair" in this setting. Certainly it isn't fair that my friend the internist works as hard as any physician I know, and isn't anywhere near as well-paid as he should be. But it also isn't fair for the self-referrers to exploit a loophole in the law and over-irradiate their patients in the name of some extra cash. But I guess life just isn't fair at all.

Uro-Trash

A doctor calling himself Krom on Auntminnie.com found this article from the Urology Times, "the leading news source for Urologists". The web-page is titled, "Ancillary income: What's possible, and what's legal?" Here's the opening paragraph:

In an age of declining reimbursements for traditional physician services—eyeball to eyeball with our patients or standing at the operating table—many physicians are looking for replacement sources of income to keep their small businesses healthy. This has been difficult or even impossible in the past because of government regulation or legislation (self-referral and anti-kickback statutes) concerning physician ownership of businesses ancillary to the provision of direct patient care.

The authors interviewed a urologist named Pat Hezmall, M.D. from Urology Associates of North Texas, a 48-man group that seems to be big into "ancillary income." Dr. Hezmall's justification for what follows is:

Physicians are liable for 100% of clinical outcomes, direct 85% of health care spending, but are recipients of only 15% of the health care revenues. Ownership of ancillary services provides physicians with an opportunity to directly improve clinical outcomes by controlling the operation and quality of the service, provide efficient and effective care, and offer therapeutic options within the practice. Improved outcomes result in increased patient satisfaction, increased physician satisfaction, increased payer satisfaction, and decreased liability.

"Additional income from ancillary services provides capital for investment in new technology, continuing the virtuous cycle of physician ownership and control of the entire decision-making process for our patients," Dr. Hezmall explained.

Ownership of ancillary services is not a new concept for urologists. As of 2003, 58% of U.S. urologists owned shares in lithotripsy partnerships. Urologists have long depended on in-office imaging equipment to practice their craft. Recent declines in reimbursement, especially for LHRH drugs, have generated an interest in expanding sources of ancillary income.

Dr. Hezmall then goes on to list all the low-hanging fruit just ripe for urologists to pluck: lithotripsy, imaging, clinical laboratory services, anatomic laboratory services, ambulatory surgery centers, specialty hospitals, and finally IMRT. Krom, the AuntMinnie poster, mentions this about radiation therapy under the jurisdiction of urologists:

. . . we have radiation oncology in our practice...if you think self referral is bad with imaging, a group of urologists in our area just put in an IMRT machine in their office and are radiating away! everyone gets RT whether it's indicated or not. an mri is one thing, putting someone thru a round of RT who may not of needed it is another. when our rad onc confronted one of them, they whine about declining reimbursements. this from a guy who has 2 houses and drives a car worth over 100g. again, their big argument...convenience! it's sad. but there are radonc-ho's who work for these places. the urologists can offer big big salaries and still get a huge windfall. win win except for the patient of course. when are the govt and insurance companies going to wake up? i assume theyll just do a DRA like deal and 1/2 the reibursement for IMRT. i wonder how theyll make up for the lost revenue then?...gee let me see...

AuntMinnie user "Fugue" came up with the name "Uro-Trash", obviously a pun on "Euro-trash", and I have blatantly stolen for my title.

The authors of the Urology Times article conclude:

We believe that the days of physicians wrestling with the professional perception that it is not proper to make money from the delivery of care in outpatient business ventures are over. Many physicians also fear that such business ventures carry significant legal risk because of government regulation.

However, with good advice and with physicians making good decisions about which ancillary services to add to their practices, this concept can be very enjoyable and profitable, and provide an added dimension to the private practice of medicine.

Gee, finally an honest answer. It is completely and totally about the money. At least they admit it.

A Sad Commentary

An anonymous reader from a small town in the west sent this comment:

I am a radiologist in a western community of 50k, with both a hospital and outpatient practice.

The cardiologists have a CT

The family practice group has a CT

The neurosurgeons have a CT

The oncologist has a CT, soon to be a PET CT

The neurosurgeons have a MRI

The neurologist has a MRI

The orthopedists have a MR

The family practice group has a MR

This is in addition to the imaging center 50% owned by the rads and hospital with 1 CT and 2 MRs. There are also 2 CTs in the hospital. So, a town of 50k has 7 CTs and 6 MRs. There never was an issue with waits for imaging in our community. If a doctor asked for a study today, we made sure that it got done, today. We call results when asked, and have turn around time for written reports measured in hours. There was not a quality issue, as we have great equipment. Pure and simple, it is about money, and outside consultants promising the moon.

And people complain about insurance getting more expensive.

I suspect that our imaging center will be out of business soon, as they take the cream and we get the indigent (and the mammograms). Legitimate competition I can take, but there is no way to compete against self-referral. I have my hands tied behind my back, and a heavy indigent care "ball and chain" around my feet.

What patient will look their self-referring doctor in the eye, and say "I am going across town" ? They do not want to compromise their relationship with the doctor, after waiting 6 weeks for an appointment.

Many of my partners have left town, and those remaing are burning out, taking care of the indigent population.

I'm still hoping for federal legislation with some teeth, or else, I'm out of here after the next election.

Very sad, indeed. The government is really the only option to fight this. Maybe the loopholes will be closed, eventually. Too bad the government doesn't have the cojones to actually punish the perpetrators of this scam. Can't you just see the explosion of finger-pointing? "It wasn't the docs idea, it was the business manager's idea! Put him in jail, not us!"

The Inappropriate Appropriateness Argument

Dr. Ron in the last post has done away with the convenience argument, as far as I'm concerned. But don't worry, our friends the self-referrers have more justifications up their sleeves. Even Tim Trysla, head of AMIC, voiced the "Appropriateness" argument when discussing an article by Dr. Jean Mitchell:

We have reviewed the article in Health Affairs on equipment leasing and are hopeful that the author will release the underlying study data so that her peers can replicate her analysis. Since its inception, the Access to Medical Imaging Coalition (AMIC) has worked with policymakers with the goal of ensuring appropriate utilization of medical imaging services. Unfortunately, the Health Affairs article does not offer any data on the appropriateness of the imaging procedures it analyzes -- which is the key to crafting responsible and sustainable policies on access to medical imaging services.

Without having access to the author's data, it is impossible to know if the conclusions she has drawn are reflective of the facts. However, if the arrangements described in the Health Affairs article are in violation of federal or state law, those violations of the law should be prosecuted.

AMIC looks forward to continuing to work with the Congress to enact a reasonable Medicare imaging policy that preserves and strengthens beneficiary access to the right imaging procedure at the right time.

This opens up an ethical minefield, which is mostly controlled by the self-referring clinicians themselves. They are the ones who determine which patients deserve a scan and which do not. These are "their patients" after all, and who are we to second-guess their judgement? If a patient walks in with a headache, should they not be scanned to rule out a subdural? Well??? Bottom line here is that the clinicians win the appropriateness argument, since in a real sense, they set the rules for it.

But wait. This logic can be turned on its head and thrown right back at them.

We know without any real doubt that those with imaging equipment in their offices order more scans than those who don't self-refer. This is pretty much a given. Let's say that they order twice as many studies, which is really underestimating the problem, but that's OK for the moment. AND, let's assume that all of those scans are appropriate. We wouldn't want to question the judgement of our friends, now would we? With me so far? Now, we turn back to the behavior of those who DON'T have scanners in their offices. They are ordering at One-HALF the rate of their colleagues. Therefore, if the self-referrers are ordering appropriately, the non-self-referrers are jilting their patients, not utilizing the life-saving services available right down the street at their local hospital.

The truth cannot fall both ways, can it? Either the self-referrers are ordering inapproriately, most likely due to the fact that they will make a profit doing so, or the non-self-referrers are restricting their ordering inappropriately. One group is harming their patients, and I'll leave it to you to figure out which one that is.

Is something that is convenient always good for you?

A reader named Ron put a comment on the last post, and it is so well-written, I thought it deserved full exposure.

Is something that is convenient always good for you?

Imaging studies are used to confirm a diagnosis and these studies should only be done after a full evaluation by a physician, never before. I find it inconceivable that any physician office could provide an in office imaging service immediately after the physician evaluation without wait. I’m willing to say that there will be either a considerable wait, or a reschedule to come back at a later time to the self referring physician’s office for the exam. If no wait for the exam, I'm sure there will be a wait for the results.

If this was all about convenience, then the same self referring doctors that offer in office imaging would also offer immediate no wait walk-in service 24/7. That would be most convenient for me. It would also be very convenient for me as Dr. Harold states above, to also have available child care and a full hot breakfast or a meal in general available for me when I arrive. In fact, it would be even more convenient for me if the doctor could meet me at my place of work at 5PM when I finish and provide my exam for me there. It would be convenient for him to also bring his mobile scanning equipment with him, just in case I may really need an imaging study. If I needed a specialist from Sloan Kettering, it would be convenient to bring them to his office also.

If this was all about convenience then why did all of the self referring physicians offering in office mammography stop offering the service? For what it matters, my question is why do the same self referring physicians that offer in office imaging not provide the one test that would be of most convenience to women, a mammogram, also in their offices?

Really, how inconvenient is it to make an appointment for a Radiology exam at your local hospital or Radiologist’s outpatient center? Most have after hours and weekend appointments and some could even see you the same day. If you go to your family practice doctor and they feel you need an orthopedic specialist, you make an appointment with the Orthopod and see him wherever his office is when you are scheduled. Why does the self referring family doctor not have an in house orthopedic doctor there for your convenience? What is the difference in convenience to the patient where in town they make an appointment to be seen by a Radiologist; the self referring doctor’s office (no Radiologist) or the local hospital?

Personally, I think it would be worth any inconvenience to be seen where the specialist Radiologist is present, overseeing the center and exams. Where does convenience play a factor when it comes to getting the best medical care by the best trained physicians? You wouldn’t go to the OBGYN to get your brain surgery? Why would you go to a cardiologist to get your Cat Scan of your liver? When you need an imaging study, anything from an Xray to an Ultrasound to an MRI, you want to be evaluated by the specialist, the Radiologist. You want a radiologist who is in town and known to your medical community, not some unknown name half way across the world somewhere reading scans on the cheap for the self referring doctor.

It seems that those with in office equipment have it only for their best paying patients. Those are the ones that seem to need to be less inconvenienced than the rest of us. If you have good insurance, then you are scanned by these self referrers. If you have Medicare, Medicaid, or Tricare (those in society that really cannot afford the inconvenience of the travel expenses etc.) it would be more convenient for you to be seen elsewhere. For the self referring doctor it appears it is convenient for these folks with “bad” insurance to go elsewhere. For patients without good insurance, their convenience is not at issue here.

A physician has a sworn duty to see that his patients get the best possible care irrespective of their insurance. A doctor who is not a trained radiologist who performs radiology exams is doing a disservice to patients in the name of enriching their own bank accounts. Better yet, patients have the right, and the responsibility to themselves to be seen by the best available physician for the job. In the case of imaging, it is the Radiologist. A patient should not feel obligated to help fill the coffers of a self referring doctor, by having their imaging done at his office or the center he gets a kickback from just because that is what he tells them to do.

Patients must always ask their doctor if he has a financial stake in services he offers or performs outside of his professional capacity. (Can you imagine the outcry that would come from surgeons giving money to their referring doctors for sending them patients to do unnecessary surgery on?) If a doctor has a financial stake in doing or sending you for any imaging study then you cannot trust that this study is necessary, that the study is the best study for you, or that it will be performed and interpreted under the direction of a board certified radiologist.

A self referring doctor is not interested in convenience, but rather lining his pockets at the expense of patients and the US health system. Self referring doctors are one of the main causes of increased health care costs. A self referring doctor’s patients will have more unnecessary exams, more poor quality exams, and more poor quality exam interpretations then the patients of other doctors who do not self refer. Patients being seen at the hospital or at a center where there are radiologists will always get better and more cost effective care than at a self referring doctor’s office. At worse, unnecessary exams provided by self referring doctors could lead to serious problems including increased unnecessary radiation exposure, increased unnecessary risk of contrast reactions that could lead to NFS, kidney failure and death. Self referral also has a way of leading towards additional unnecessary studies, unnecessary biopsies and unnecessary surgeries.

Self referring doctors typically have little oversight of their work. Typically their equipment is substandard and most times the people performing the exams are not certified technologists. There is no peer review or accountability for their findings from your exam. Most times, the actual images from the studies and reports are not shared with other physicians. If only the self referrer sees the study and the results and not a board certified radiologist, then who is to know what was missed and if the findings are correct. For patients, are you finding that you are getting additional imaging for the same problems because the self referring doctor got it wrong the first time or because he has a financial interest in you getting more exams?

There is nothing like the convenience of paying out a $5000 deductible and getting unnecessary exams just to make some self referring doctor rich.

Since September of 2006, Harold, the test of time has not proven you wrong. I bet hundreds more cars, boats and McMansions could be added to your list. Self referrers are still laughing all the way to the bank and the amounts of imaging tests and in office machinery is increasing exponentially.

Patients are lining up like rats behind the Pied Piper in supporting these self referring schemes. Insurance companies still seem willing to throw money at these guys. And the government....

Self-Referring Physicians Order More Scans

Jean M. Mitchell, PhD, a professor of public policy at Georgetown University, has written extensively about self-referral, and I have discussed one of her earlier articles in a previous message. Dr. Mitchell has published another article in the journal Medical Care, titled, "Utilization Trends for Advanced Imaging Procedures: Evidence From Individuals With Private Insurance Coverage in California." Apparently mining further information from the data utilized in the earlier article, she concludes:

"Use of highly reimbursed advanced imaging, a major driver of higher health care costs, should be based on clear clinical practice guidelines to ensure appropriate use."

This conclusion seems to be pointed at Tim Trysla's criticism of her earlier article, wherein the AMIC leader questioned her results because she didn't address "the appropriateness of the imaging procedures it analyzes -- which is the key to crafting responsible and sustainable policies on access to medical imaging services."

Since I'm too cheap to pay for the article itself, I'm working from reviews and from the abstract. The results cited by Dr. Mitchell note that PET utilization has increased 400%, while MRI and CT have increased over 50% between 2000 and 2004. But wait, this refers to outpatient imaging! The changes for imaging within hospitals were "small". And for what it's worth, rates were much higher in Southern California than in Northern California.

From a review of the article in the US News and World Report, "The bulk of the increase was seen in patients with private insurance that provided the physician with a fee for service reimbursement."

Well, this doesn't really surprise anyone, does it? We all know what self-referral in this setting is, and what it does, although it is always nice to have the data to back up our impressions.

Commentary about the article from Vivian Ho, PhD, professor of medicine at Baylor College of Medicine, and associate professor of economics at neighboring Rice University, furthers the argument. The review is itself reviewed on the Baylor website. Dr. Ho (DON'T go there) reiterates,

"Increases in utilization rates were substantially higher for scans performed by self-referring physicians than for images that originated from a referral to a radiologist or hospital."

"Physicians seem to choose the self referral option, meaning they do the imaging in their own office, because they are reimbursed by private insurance companies," Ho said. "The other option would be to refer the patient to a radiologist or an outside diagnostic center."

Ho cites other studies of a trend toward manufacturing and marketing cheaper, lower quality imaging instruments. However, the level of reimbursement, regardless of the cost or quality of the equipment used, remains the same.

She writes, "The current reimbursement system lacks incentives to provide high quality imaging in a cost effective manner."

Dr. Ho also addresses the problem of leasing:

"This (leasing) creates revenue for both parties involved," Ho said. "But it also raises a lot of questions such as would it have mattered if another test had been done, one that didn't receive a reimbursement?"

So what to do?

"Unfortunately, the legal system, the method of reimbursing physicians, and our lack of tools to monitor appropriateness of testing have led to significant increases in diagnostic imaging, which likely provide little health benefit to patients."

The solution should involve policy makers, insurers, physicians and health service researchers.

"Only then can we insure that advanced imaging technologies yield a benefit, rather than become a burden to the health care system," said Ho.

I certainly agree with that. But I have to end on a slight sour note. Dr. Ho cautions:

"Doing away with the reimbursements will only penalize those physicians who are actually providing imaging in-office as a convenience to their patients," Ho said.

Now, I have to wonder just what percentage of clinicians actually fall into this category. Probably all of them if they were asked. But really, this argument is getting lamer by the minute. If the docs were so terribly concerned about their patients' convenience, they certainly wouldn't stop at providing services that maybe 5-10% of their patients actually use. Gee, what would I like to see at my doc's office? What about an in-office pharmacy? I'll bet more patients walk out with prescriptions for drugs than a slip to get a CT. How about valet parking? How about a car-wash and dry-cleaning service? The list goes on. The "convenience" excuse is nothing more than rationalization for taking advantage of the loopholes in the system. Period. And someone tell me how sending patients to a scanner leased from some other self-referrer is more convenient. It isn't.

The only answer to the situation is to make absolutely sure that our state and federal governments understand the depth and breadth of the situation, and insist that something be done. Until then, the self-referrers will continue to go about their merry, convenient way.

The NEMA Code of Ethics

NEMA, the National Electronic Manufacturers Association, is an organization of technology companies that includes most of the manufacturers of medical imaging equipment. Their "Code of Ethics" is a long document outlining the sorts of interactions their members should and should not have with health care professionals and institutions in the business of selling things to them. The underlying principle is:

Members shall encourage ethical business practices and socially responsible industry conduct and shall not use any unlawful inducement in order to sell, lease, recommend, or arrange for the sale, lease, or prescription of, their products.

Most of the rest of the document talks about things they can sponsor in the realm of training and so on, and things they can't do, such as take a client to a concert or a golf game. Gifts are a no-no, and hospitality should be "modest," i.e., if they put you up in a hotel, it should be in neither the best nor the worst room available.

This is all well and good, as far as it goes. The problem lies in the fact that there is such a tremendous amount of money to be made on the sale of a scanner, for example, that sometimes the approach is bent a little. Of course, I'm thinking about the scanners sold to those who self-refer. Think about it. Is self-referral an "ethical business practice"? Is selling the 10th MRI scanner in a small town that already has nine others "socially responsible"? I don't think so, personally. I guess it all depends on your point of view, doesn't it?

And "unlawful inducements"? Every scanner manufacturer will be glad to show the self-referrer just how much he can make with their scanner. Yes, I understand that this isn't an "unlawful inducement", but it is going right up to the border of the gray zone.

I'm not quite sure where NEMA's lobbying of Congress as part of AMIC falls in their code, but it seems to have been acceptable to those in charge.

A code of ethics is great so long as it isn't reinterpreted for each particular situation. Is that happening with NEMA? I'll leave that up to you.

"The Politics of Greed"

Eradicator, over on AuntMinnie.com, found an incredible article in ImagingBiz.com, written by Curtis Kauffman-Pickelle, who is "a strategic business consultant to more than 30 imaging centers and radiology practices and CEO of the Imaging Center Institute." Obviously, Mr. Kauffman-Pickelle knows his way around the outpatient imaging world. He decries the "pollution" of this sector by the "dark attraction of greed":

What is difficult to control, however (and extremely difficult to train salespeople to penetrate), is the political referral that clearly falls within the category of an expected quid pro quo: I will send you my scans if you give me something in return.

Kauffman-Pickelle goes on to describe the ways in which unscrupulous operators will go around the law and regulations trying to bribe their way into a full schedule. He goes on to say,

Back to the fundamental question: How do you compete with this greed?

You don’t. Greed is as old as civilization itself, and money—as a manifestation of this one of the seven deadly sins—has been changing behavior and sinking people for centuries.

What ethical and honest businesses need to do is rise above the temptation, knowing that those operating sleazy businesses are really in the minority and that they stand a very good chance of being caught and punished; they are not likely to be happy with themselves and their lives, and are not respected members of the medical community. You need to be able to look at yourself in the mirror each day and know that you are helping people, running a clean and effective operation, and inspiring your staff and teammates to achieve success through your leadership. Your ethics, values, and character will win in the long term.

This is good business as well. Never apologize for your success or for making a good living at your chosen craft. You have earned it, and our society is based on the hard work and commitment of entrepreneurs in all kinds of professions, including medical imaging. Don’t be distracted by those who seem to be getting away with illegal behavior. You really would not want to trade places with them, so leave them to their own devices.

This is of course very good advice, and an excellent analysis. I would carry it over to the problem of imaging self-referral, which is really the same sort of greed-based pursuit of money as described above.

Mr. Kauffman-Pickelle's approach makes sense for those who are of high moral and ethical fiber. Naturally, they are not going to lower themselves to borderline or overtly illegal activities to make an extra dollar. Sadly, those who do participate probably don't care. I would have to disagree with the author about the perpetrators being unhappy and not respected in the community, at least as far as physician self-referrers are concerned. They are happy as clams, wallowing in their ill-gotten gains. They feel completely immune from penalty, that they deserve every cent. Very few of their colleagues care about the source of the revenue in the least; they are only envious of the parade of Mercedes and BMWs and the other swag flaunted by those who abuse the system.

This is why the government will eventually have to step in; there isn't much self-policing going on here. The politics of greed rule.

There ARE Some Ethical Docs Out There

You might think from reading this blog, as well as any other media source, that many doctors are greedy S.O.B.'s, trying to make an extra buck anywhere they can. While that might be true in some cases, there is a growing movement away from such avaricious behavior.

Gina Kolata, writing in the New York Times today, notes a trend of doctors rejecting pay from industry. It seems that several very prominent physicians have sworn off the dole from pharmaceutical companies and the like.

The scientists say their decisions were private and made with mixed emotions. In at least one case, the choice resulted in significant financial sacrifice. While the investigators say they do not want to appear superior to their colleagues, they also express relief. At last, they say, when they offer a heartfelt and scientifically reasoned opinion, no one will silently put an asterisk next to their name.

They are part of a group responding to accusations of ethical conflicts inherent in these arrangements, and their decisions repudiate decades of industry influence, says Dr. Jerome P. Kassirer, a professor at the Tufts School of Medicine, who has written a book on conflicts of interest. . .

(Kassirer) attributes the change to publicity about conflicts and what can be almost a public shaming when researchers’ conflicts are published. “Finally, it’s gotten to people,” Dr. Kassirer said.

Well, if that's what it takes, maybe we need to provide a public shaming for our self-referring friends. How about taking out an ad in every newspaper in every major city (or maybe just one big one in USA Today) listing every self-referring physician that owns his/her own imaging equipment? Of course, the case has to be made in the introductory paragraphs that this is a bad thing. The convenience arguments and so forth have to be destroyed before they are even uttered. People have to be made aware of what is really happening. No doubt they will be angry when they finally understand.

The NYT article does give me hope that the self-referrers (and the radiologists that read for them) can be made to do the right thing. It would be nice if they all grasped the problem without being forced to do so, but that doesn't seem too likely. Now, who is going to take out that ad?

A Cardiologist "Gets It"

You never know what you will find when you Google "Self-Referral". The list generally includes numerous discussions of Stark laws and CMS rulings.

Today, I stumbled across this very insightful piece from Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology. This would be someone pretty well respected among cardiologists, yes?

At first, Dr. DeMaria pays the usual lip-service to self-referral:

That the increase in medical imaging procedures raises the issue of self-referral should be no surprise. Several studies have demonstrated that diagnostic imaging services are rendered with greater frequency and at greater cost when performed by non-radiologists using equipment in their offices (2). In fact, data suggest that the bulk of the increased use of imaging has been attributable to physicians who self-refer (3). However, it must be recognized that the provision of diagnostic services by attending physicians has many advantages. Many non-radiologists have gained expertise with the imaging procedures in their specialty and have contributed important research findings to advance the field. These specialists can interpret the imaging tests in the context of physiologic and pathophysiologic knowledge of the organ system involved and can integrate the findings with the clinical variables present in any individual patient. The ability to perform an imaging test at the same time and in the same place as the overall evaluation is also an advantage. Thus, although the potential financial incentives of self-referral cannot be ignored, the practice of rendering diagnostic imaging by knowledgeable attending physicians has considerable rationale.

But, he then zeroes in on the problem:

The issue, therefore, is how to maintain the laudable attributes of cardiology practice while guarding against the undesirable incentives of self-referral. In my opinion, at least as a first step, we must acknowledge the potential bias that self-referral can introduce into decision making. It seems foolish to me to just deny that self-referral can have any possible influence in decision-making . . . We ought to guard against providing services for which we have little experience. We invite criticism if we undertake to perform procedures for which we have had little training, scant experience, or very low volumes. We should avoid obtaining equipment for our offices for which there is little demonstrated need or advantage. Given the emerging shortage of cardiologists, there would seem to be little reason to work hard at generating business.

Well, Dr. DeMaria, the problem with your brethren isn't generating business so much as generating income. But Dr. DeMaria concludes:

The recent explosion of medical imaging procedures has again focused attention on the general issue of self-referral in cardiology. Diagnostic imaging has come to play a central role in the management of cardiovascular diseases, and cardiologists have often been responsible for the development and validation of clinical applications. We take pride in the improved level of care that imaging has enabled us to deliver. However, we must remain cognizant of the potential for inappropriate usage inherent in these techniques. The nature of contemporary cardiovascular medicine makes self-referral for imaging and other procedures a natural and advantageous aspect of our practice. It would be tragic if either our application or the perceptions about our application of these procedures resulted in any impediments to their use.

This would be funny if it wasn't so prophetic. Everyone almost lost out on CCTA reimbursement, and that is mainly (although not officially) because CMS was petrified that the cardiologists would abuse it like they have been abusing most of the rest of their toys.

Maybe the solution to the self-referral problem lies in alerting those with some moral authority in the clinical camps to what is happening. But they probably know about it anyway. One lone voice gets lost in the woods, at least most of the time.

Welcome, Aunt Minnie Readers

Looks like someone named eradicator found this blog, and let everyone on Aunt Minnie know about it. Thanks for the promo!

Please read through the posts and see if they make sense to you. I would really like to hear your comments and suggestions as to how we can fight against the problem of imaging self-referral.

Harold

(I'm not going to say much about who I am for obvious reasons. I'm just a guy that thinks self-referral has to stop. That's all.)

The Decline and Fall of Radiology (and How to Avoid It)and a factor the authors missed

In a recent JACR, Richard B. Gunderman, MD, PhD, Andrew J. Koerber IV, BS, MS make some interesting comparisons between the decline and fall of radiology, and the historical downward spiral of the Roman Empire. They base their discussion on Edward Gibbon’s The History of the Decline and Fall of the Roman Empire.

Rome was the greatest empire that had been seen up until its time, and some would say it still holds this distinction. I'm not going to review all of its accomplishments, but they were legion. So what happened? Gibbon noted several factors. The reason most often cited is the pressure from outside, the Huns and Goths, and other shabby folks, who ultimately destroyed the city of Rome itself. The authors of the JACR article liken this to the external problems radiology faces such as uncooperative hospitals and turf battles with other docs. But Rome probably fell more because of internal decay than any other reason, and radiology as a specialty needs to see these parallels.

Gunderman and Koerber note that Rome progressed from a republican government, where the people had a say (and were honored to participate) to despotism, where the emperors took over all power, and became increasingly corrupt. They compare this to the pursuit of revenue amongst radiologists, giving the example of outpatient imaging centers being built where they will make the most money, not where they would do the most good.

Rome, it seems, also gave too much power to mercenaries, ruining the ideal of the citizen-soldier. Mercenaries sadly may eventually ignore or even turn against their employers, because, after all, they are just hired guns (or maybe hired swords in this era.) Radiology is doing something similar by turning its decision making processes over to consultants and lobbyists. Research is increasingly in the hands of the vendors, and not the universities. Radiology isn't even a required course in most medical schools. Of course, teleradiology might be the best example of how radiologists can hand off their responsibilities, although for the most part this is at least to other radiologists!

Luxuries lured Romans' attention away from where it should have been directed, and even today, after two thousand years of pillage of the sites, you can still see that a lot of time and money was spent on frivolities. Cash became the most important thing, and previously loyal folk would sell their support to the highest bidder. Corruption became widespread, and no one trusted the government. Sadly, radiology is falling prey to the same sort of thing, Making money becomes the end-all, instead of taking care of patients. To get said money, radiologists are making bad deals with hospitals and governments.

Gunderman and Koerber conclude that radiology has to avoid making income the primary motivation. It needs to promote invention and innovation, and work for the good of the patient. There must be collaboration with other specialties.

I couldn't agree more. However, I think Gunderman and Koerber left off a very important item, which is why this belongs on this blog. That is, of course, the scourge of self-referral, and the damage it is doing to radiology and to medicine in general. They do come close to mentioning this at several points, but I think it needs to be stated more explicitly in terms of the foregoing arguments.

Self-referral in many ways relates to every one of the factors that brought down Ancient Rome. I won't even try to discuss this in terms of the clinicians who participate; they are no better than the barbarians that invaded Rome. They are invading radiology and medicine quite nicely, and radiologists are holding the gates open for them. Why is this? Reread the discussion above. The primary factor is money, of course, be it the opportunity to zero in on the reads generated by the excess ordering of scans, or even the thought to preserve interpretive income when the clinician takes his paying patients away from the hospital to be scanned on his own machine. And as with the increasing corruption of Rome, radiologists are abdicating their moral responsibility to stand up and say something about this issue, for fear of disrupting their incomes. These radiologists are themselves becoming the mercenaries, being willing to work for clinicians that most would agree are not doing the right thing. From Gunderman and Koerber's article,

The word mercenary derives from the Latin merces, meaning “price,” and also the source of our words mercantile and merchandise. Mercenaries are guided by overarching concern with wealth and profit, as opposed to honor. They sell their services to the highest bidder and do what they are paid to do, often unencumbered by moral scruples. To expect loyalty or trustworthiness from a mercenary is to fail to understand what a mercenary is. They enter, exit, and reenter contractual relationships as needed to maximize their earnings. In the final analysis, they can be trusted to do but one thing: pursue their own self-interest.

Need I say more? Vēnī, vīdī, vīdere animus.....