Saturday, April 19, 2008

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.


Anonymous said...

I agree with you right up until you say, "Is selling the 10th MRI scanner in a small town that already has nine others 'socially responsible'?" Here, you start venturing off into the Certificate of Need (CON) wilderness. I hope we can all agree that competition among those who are not able to game the system -- the way self-referrers do -- benefits everyone.

Harold said...

Competition to sell needed scanners is a good and healthy thing. But when scanners are sold entirely for the sake of making money and not serving the community at all, that's where I have to disagree. That, too, is "gaming" the system, as the manufacturers are creating a market that should not by rights exist.

Yes, CON's are supposed to solve this, but many states don't have them, and they are ineffective in many that do.

Anonymous said...

Wait a minute. Let's leave self-referrers out of this. Let's say there's a small community served by a hospital with an MR scanner, and there's a two-day backlog -- not same-day service, but not two weeks or two months. Also assume that some bureaucrat calculates that that's all the MRI equipment this community needs. Should I, a radiologist with no means to steer patients into my own scanner, be denied the right to open an outpatient imaging center to give patients a choice, such as offering night and weekend hours, free parking, equipment newer than 6 years old, or a friendly clean environment? If so, why? How am I gaming the system? How, for that matter, is the equipment manufacturer who sells me the scanner gaming the system?

Remember two things: If I fail, nobody bails me out -- not society, not the government, not the third-party payers. Second, if I succeed, I've done so by doing something the hospital was entirely capable of doing themselves but chose not to, whether through arrogance, laziness, or complacency.

Harold said...

Well, Dr. Anonymous Radiologist, in your zeal to justify your purchase of your scanner, you have overlooked my point entirely. The whole idea is that NEMA and its manufacturer members have been supersaturating markets that already have too many scanners. Forget CON's, which generally don't do crap and are totally politically contrived for the most part. I have absolutely nothing against someone doing what you describe, which is providing better service for their community. It is the enterpreneurial folks that place that 10th scanner when the other 9 run at half-capacity that chap me, not to mention the self-referrers who place the 11th that becomes the busiest of all.

Anonymous said...

Well, actually, I'm trying to sharpen your thinking, or at least your expression of it. The problem with your statement and your restatement is that you do not explicitly mention self-referrers.

1. If self-referral were not allowed, then there could be no such thing as "too many scanners in a market." If there's no way to force or steer patients to any given facility, market forces will eliminate those facilities that are providing a suboptimal service. Can we agree on that?

2. If self-referral were still not allowed, and a few existing scanning facilities felt competitive pressure from a new facility opening up, they might be tempted to use the power of the state to limit their competition by establishing CONs. The only people who benefit from CONs are the existing providers, and CONs permit them to grow complacent and lazy since they are protected from competitive forces. We seem to agree on this, correct?

3. NOW inject self-referrers into the mix, and all of a sudden some folks who were opposed to CONs on competitive market principles now find themselves supporting CONs. What they should be doing is opposing self-referrers, who are the root of the problem.

You said, "I have absolutely nothing against someone doing what you describe, which is providing better service for their community. It is the enterpreneurial folks that place that 10th scanner when the other 9 run at half-capacity that chap me...". To an established facility that has grown complacent, I am one of those entrepreneurial folks that need to be stopped from supersaturating the market.

To recap: you cannot talk about "too many scanners" without talking about self-referrers. Without the latter, there is no such thing as the former. If there's a community with no self-referral and I, another non-self-referrer, come to town to open up a new scanner, there can be no talk about supersaturating the market. The market can take care of itself, thank you very much.

Harold said...

We certainly agree that self-referrers are the real target. Beyond that, the issue of enterpreneurial operations is another topic. Obviously, you are opening such a center and you feel the need to justify yourself. Fine with me, but in the end, you probably aren't helping the overall situation, let alone yourself. Because of the self-referrers, the government is eventually going to force imaging back to the hospitals, which are easier to control. Good luck in your chocolate endeavors.

Anonymous said...

" feel the need to justify yourself." Please spare me the psychoanalysis. In fact, we are not opening such a center, we have opened three such centers in the past ten years. One was in a smallish community already served by a hospital whose radiology department was the only game in town. If you wanted imaging, you had to go to them, or you had a 45 mile drive elsewhere. When we came to town, there was a hue and cry that there would be "too much imaging equipment" and "saturation of the market" and other such nonsense. The hospital played hardball, threatening its medical staff if the hospital found that those doctors were sending their patients for studies at our facility. Make no mistake -- if CONs had been in effect, the hospital would have fought the issuance of any CON to us, and they would have prevailed, given their political connections. Instead, we came to town offering state of the art equipment, board certified radiologists, and prompt scheduling and performing of the studies and issuing of reports afterwards. Now, ten years later, no one in town will claim with a straight face that the standard of care was not raised in that town when we entered the market. Even the hospital-based radiologists will admit that they were forced to upgrade their equipment, their style of practice -- everything.

So most bureaucrats would have looked at that town, questioned whether there was enough business to justify another full-service outpatient imaging center, and denied a CON claiming market saturation. So much for a bureaucrat's ability to form valid projections. Instead, we've made a healthy living for the past ten years by providing excellent service enjoyed by patients and their doctors. The hospital has not gone out of business. We have done well by doing good, and we have done so by doing something the hospital was eminently capable of doing if it hadn't been fat, dumb, and happy.

"Fine with me, but in the end, you probably aren't helping the overall situation, let alone yourself. I'm not even sure what that means. What "overall situation"? My profession is to provide high-quality care to patients when it's requested of me, and that's what I'm doing. My job isn't to limit the number of scanners in a metropolitan location, or to feel sorry if we step on the toes of existing providers who aren't addressing the needs of their patients or referring doctors. Remember: 1) I am unable to drum up business for myself other than by providing excellent care; 2) My success or failure has no economic impact on anyone but me -- no one bails me out if my facility fails; 3) Monopolies breed complacency and sloth; healthy competition improves everyone's lot. How am I not helping the overall situation? The people in that small town have had their overall situation measurably improved.

"Good luck in your chocolate endeavors." Here again, I'm not sure what that means. I assume it's snark, and if so, it negates your "Fine by me" comment.

You aren't by chance a hospital-based radiologist, are you?

Anonymous said...

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.

Ron A Dawson, MD said...

The first anonymous poster suggested that his appearance in the market improved things. I don't know who this person is and because of this, please do not take things personally if they do not fit your particular situation.

I understand self referral also hurts you. If one believes the old proverb that the enemy of my enemy is my friend, I should be on your side. It still doesn't mean I like what you do.

Again, I do not know the situation you describe in detail, but what is not studied or discussed with such ventures is whether or not you have improved outcomes. It seems that you have generated purchases of new equipment, but to what end? You have added extra costs to the system in the name of convenience (we have seen this word used over and over by the self referrers out there), but I suggest it is really for the sake of your pocketbook.

Issues of lease agreements, shifting of paying patients from the hospital, over saturation of radiologists, duplication of costly services, and promotion of unnecessary examinations etc... are never discussed. I say you bring unhealthy competition and increased costs. I say you suck money out of the small towns you say you are serving, hurting them rather than helping them. I say you promote self referral by promoting a "business plan" to be copied by others who feel that the pie you are eating is more deservedly theirs. I say say you are an opportunist going after the low hanging fruit which works well in business, but ethically not well in medicine. I say you are creating another pie piece without adding anything to the advancement of medicine.

See, you don't participate, and in the words of Ross Perot, you are the "giant sucking sound" we are hearing in medicine. You promote convenience and a McDonald's like service... during your working hours. You do not participate in call nor do you offer the less profitable but still necessary services provided by the hospital.

Oh yes, you do not self refer. You just self take. You are an added noncontributing cost. Yes, I agree that there may have been complacency and "poor service" in the system. However, people received their health care and health care costs were not skyrocketing out of control.
There was unseen value in the old system. The system was not broken until you tried to "fix" it.

People talk about delays, but it has become a smoke screen and mantra for the self serving. No one looks at the time of symptoms to the time the patient decides to get help. No one looks at how long a patient waits for an appointment. No one talks about a patient being imaged after a test of conservative therapy. No one looks at the time of follow-up appointments or time from imaging to therapy or surgery. We focus on a meaningless turn around time for a "report". My point is that even today, there are still very few radiological emergencies that require the kind of service you promote. There are very few people who need the kind of service and studies you provide. Remove the unnecessary exams, get rid of the excess and allow hospital equipment to fill and you know what? People still get taken care of and costs go down. The only difference is you are no longer a piece of the pie and patient outcome believe it or not, will not suffer.