Sunday, January 13, 2008

Pi$$ed Off Urologists


The American Urological Association have an "Imaging Resource Center" to justify their imaging self-referral. Here is a partial list. Pick a topic and see how they posture and pander to keep the cash flowing:


AUA Positions, Letters and Talking Points

Coalition for Patient-Centered Imaging (CPCI)

I shouldn't be surprised by what's in this stuff, but some of it is pretty unbelievable. For example:

In-office imaging provides the fastest, most convenient and often the most reliable results — results that are routinely used by treating physicians in providing ongoing patient care. The use of office-based imaging allows for quicker diagnosis and prompt treatment.
The American Urological Association (AUA) is concerned about recent allegations that diagnostic imaging performed by physicians other than radiologists is “substandard” and “unnecessary” and that the growth in utilization is principally attributable to in-office testing by physicians other than radiologists. None of the allegations are true. There is no credible evidence that in-office imaging is being conducted inappropriately or is resulting in inaccurate diagnoses. . .

Nor is there any basis for the allegation that office based imaging is the primary cause of increased utilization. Many factors have influenced growth in the volume of imaging services, including improved technology; changes in the standard of care for many illnesses; expansions in coverage for new diagnostic imaging modalities; and shifts in the site of service from hospitals to other health care settings. Much of this growth is in hospitals and Independent Diagnostic Testing Facilities (IDTFs). The improvement in quality has meant that many specialties, including urology are now using imaging for therapeutic purposes rather then simply a diagnosis tool. . .

A prohibition on in-office diagnostic testing would reduce patient access to timely, convenient testing, and disrupt the important continuity of care. According to the ACR, there is currently a shortage of radiologists, and in certain parts of the country there are already long waiting periods for critical imaging studies, such as mammography. Restricting in-office testing could substantially aggravate the problem, resulting is significant delays and reduced quality of care. In addition, Medicare beneficiaries pay substantially more when imaging services are provided in hospital outpatient settings instead of physicians’ offices. According to MedPAC, in 2002 the Medicare coinsurance rate for hospital outpatient imaging services was 53 percent. Coinsurance for these services in physicians’ offices was limited to 20 percent.

While increased costs are a concern to physicians and patients alike, restricting patients’ access to timely and accurate diagnoses by their own physicians is not the answer.

Oh, boo hoo. Reminds me of the old Bart Simpson quote: “I didn’t do it. You can’t prove it. Nobody saw me.” Give me a break, guys. No evidence? There is a ton of evidence. Just Google it, and you'll see. And patients will suffer if you take their toys away. And so on and so on. Don't they see just how transparent their arguments really are?

1 comment:

Ron A. Dawson, MD said...

AUA… The facts on In-office imaging. http://www.auanet.org/imaging/auaimgposition.pdf

I found their reasoning laughable. Here are some of the most ridiculous comments and my response, and this is from only the first listed article:

1. “Review of studies by residents.” Anyone in Radiology understands what this means. The residents order a STAT exam and call before the study is done to get the results. Very few have the ability to interpret exams or better yet see the forest through the trees. A couple weeks of “training” in radiology does not equal the four years or more of intensive training and testing radiologist obtain.

2. “In office testing is not the cause of increased utilization.” All I have to say is that in office imaging for the benefit and convenience of the patient would disappear once the profit is removed from doing this. Also, compare rates of imaging prior to and after obtaining in office imaging equipment. Once the oversight of imaging is gone (radiology) who is to say their rates of imaging is substantiated by sound clinical reasoning?

3. “Performance of imaging by a patient’s physician ensures that a physician familiar with the patient’s clinical condition and medical history performs the exam.” Now this one really stings. First, who is the patient’s “physician”? The radiologist is a physician and for 100 years has been the physician for millions of patients. In fact, the radiologist still is a physician and the physician for every patient he sees. The reason the radiologist may not be familiar with the patient’s condition and history is that it seems that clinical physicians refuse to provide this information. They are required to do this and it is in the best interest of their patients, but they refuse to do it. It leads me to believe that they no longer are able to obtain and provide this information and are relying totally on the radiologist to make diagnosis’s for them, or they are using this to substantiate their claims that radiologist do not know the history of these patients. Either way, they are not doing their patients any good by having a less qualified person (themselves) provide radiological care, in the name of scamming a buck. Also, in their list of procedures, VCUG and voiding studies are not listed in the exams they wish to perform. It seems that the low paying time consuming studies should be best left to the radiologist. I actually agree with radiologists doing this study in particular (as well as the others) for the protection of these young patients from the high radiation doses the rest of the urologist’s patients will be obtaining with in office imaging.

4. They use numbers to show that imaging has increased over the past years when performed by radiologists. First, radiologists typically almost never place an order for a study. The radiologists recommend studies if necessary. The increase in volume comes from clinicians practicing CYA medicine or requesting out of ignorance. It comes from the many noctors or mid-level idiots the clinicians have hired to increase their income by being able to charge for patients they never evaluate themselves. It comes from ER physicians who typically do not understand what a history and physical is or what to do with the information in the rare event they have this. It comes from surgeons as a delay tactic to allow them to sleep through the night. In most instances, most radiologists would refuse this senseless “ordering” of exams. I use the word order as there is no longer recourse of refusal of these silly requests for unnecessary exams. Take what oversight is left away from radiologists and let imaging go to the office and then see where the numbers go.

5. “The prohibition of in-office testing would reduce patient access to timely convenient testing and disrupt the important continuity of care.” Not true at all, or rather this is a bold faced lie. Patients always received timely and convenient testing when imaging was not in the office. We built this great level of medicine in this country over the past 50 years without it. This new rallying call is based on greed and not continuity of care. Does this mean that all urologists without full diagnostic center including a MRI, CT, US, nuclear department and fluoroscopy are practicing below the standard of care and denying their patients convenience and continuity of care? Imagine the costs to society of duplicating these services in every urologist’s office. Each million dollar machine must be paid for, and the only way to do this is to image more patients more times. If urologists would spend more time doing what they were trained to do rather than trying to make money in a field they know little about other than what their blinders allow them to see, everyone would be better off.

6. The article states also, “According to the ACR, there is currently a shortage of radiologists, and in certain parts of the country there are already long waiting periods for critical imaging studies, such as mammography. Restricting in-office testing could substantially aggravate the problem, resulting in significant delays and reduced quality of care.” This appears to be proof that the urologists claiming this have been drugged. First, what does mammography (a screening exam) have to do with critical imaging? Second, is there any proof that a month or two delayed screening mammogram is either a significant delay or affects outcome in anyway? (The answer is no.) Third, if mammography was such a problem and urologists are now the imaging experts looking out for the best and most convenient care for their patients, why don’t they all put mammography machines in their offices? (In spite of this great need, I know of no urologist offering this needed service.) Fourth, what the heck does mammography have to do with urology? The question that should be asked is if the shortage of radiologists or the absence of in office imaging has ever resulted in a urology patient not being able to get the exam they need in a timely manner? The fact that this has not happened and is not an issue is the reason they have grasped at the mammography straw.
I ask, why are urologists not required to have a back-up urologist in the office to handle patients when he is operating. Those that are solo practice and do not offer this or 24 hour 7 day service are the ones that are really causing delays and quality of care issues. It really burns me up when I call the urologist and get an answering machine telling me to go the hospital if this is an emergency because the office is closed for lunch. How the heck am I supposed to know if it is an emergency? It is really inconvenient and poor quality of care for me to have to go to the ER, just because his office is “closed for lunch”. I have never heard of a hospital radiology department being closed for lunch.

7. “…restricting patients to timely and accurate diagnoses by their own physicians…” Again this is arrogant. The sentence means nothing, but suggests that accurate and timely diagnosis only comes when they do the imaging in their offices. I know of very few cases where timeliness of imaging affects outpatient medicine. We typically are only talking a day or two to get a study anywhere in the country on an outpatient basis, but certainly same say service is usually available outside the physicians office. Any emergency or diagnosis requiring less time seems best handled in the hospital anyway. Remember, radiologists are physicians in the community and see many more patients in the community than any sole urologist in any given year. I bet that the urologist’s patient was probably a patient of the radiologist way before that patient showed up to be claimed in their office.

The bottom line is that in today’s age, we should all be practicing evidence based medicine. Self referrers offer no evidence to their claims. They grasp at any straw and any rationalization to increase their wealth by harming patients with unnecessary and costly in office exams. I can match anyone’s anecdotes, but show me a peer reviewed study demonstrating any of the claims; I double dare you!

This brings up another question we used to ask in medical school. How do you keep important medical information hidden from a self referring Urologist?....

Publish it.... ;-)