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.