Saturday, April 26, 2008

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.


Ron A. Dawson, MD said...

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.

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