Monday, April 07, 2008

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.

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