Saturday, December 13, 2008

America The Porcine, or, It's All Mr. Rogers' Fault

Pigs get a bad rap. They are actually rather clean, intelligent creatures, but since they lack sweat glands, they need to cool off by sitting in water, or mud.

When we say that certain people act like pigs, this is truly pigs.

I have written here for several years about self-referral, and it seems that little has really changed. Oh, yes, there is a little more publicity about it here and there, some legislators somewhere "get it" and are trying to do something about it, others fall for the "convenience" argument, and refuse to do the right thing.

There is a glimmer of hope in the otherwise dismal outlook for medicine for the next few years in that self-referral is probably going to be attacked in the process of running roughshod over the remainder of the field. A preliminary health care plan from Senator Max Baucus of Montana (that may be adopted by President-Elect Obama) notes the following in regard to self-referral:

Physician Self-Referral. Physicians, like most professionals, expect to get paid for the work that they perform. Some physicians, however, have found a way to game the system so that, in addition to getting paid, they reap additional financial benefits from the provision of certain health care services. Physicians can accomplish this by having ownership or other financial interests in equipment or facilities — such as an MRI machine or a hospital — that provide health services. When those physicians refer their patients for services from which the physician reaps the additional financial benefits — a practice known as self-referral — there is reason to be concerned about the physician’s motives. Physician self-referral is generally prohibited by Federal law when the patient is covered by Medicare or Medicaid.25 Self-referral creates conflicting incentives for physicians, because the financial incentive to increase utilization of the financially rewarding services may conflict with otherwise sound medical and professional judgment. Ultimately, this practice often results in an “increased use of services and higher payments from third party payers.”26

Congress has enacted several laws to confront this problem. In 1972, Congress enacted the Anti-Kickback Statute, which “broadly prohibits the purposeful offer, payment, or receipt of anything of value to induce the referral of patients from services reimbursable by a federal health care program.”27 Few prosecutions occurred, however, and referrals to imaging facilities or medical laboratories were not deterred.28

In 1989, Congress enacted the Ethics in Patient Referrals Act (known as Stark I), which prohibits physicians from “referring Medicare or Medicaid patients for clinical laboratory services to labs with which the physician has a financial relationship…unless the relationship fits within a specified exception.”29 In 1993, Congress enacted amendments (known as Stark II) expanding the prohibited services to “physical and laboratory therapy, radiology, radiation, home health care, hospital, outpatient prescription drugs, and many types of medical equipment and supplies.”30

The Baucus plan would scrutinize physician self-referral to ensure that physicians are not engaged in financial arrangements that place financial interests ahead of the needs of patients and the American taxpayer. Physicians deserve fair pay for providing services, but they should not be able to game the system unfairly. Increased transparency to both patients and payers in the form of disclosure of physicians’ financial interests is first step.

One example is physician ownership of hospitals. There is concern that physician ownership of hospitals leads to cherry-picking the patients who are healthiest and most able to pay, while leaving the patients who are sickest and least able to pay for community hospitals to treat, often without much compensation, if any. This cherry-picking only exacerbates the cost shifting to those Americans with insurance. This concern is heightened by the fact that the patient often is unaware of a physician’s financial interest in providing services at a hospital in which he or she has an ownership interest.

Physician-owned hospitals are often smaller and more specialized than community hospitals. They tend to focus on lucrative lines of service. Community hospitals, on the other hand, tend to provide all service lines, including emergency departments. Community hospitals find it difficult to compete with their more cash-rich physician-owned counterparts. Over time, the trend of increasing physician ownership of hospitals jeopardizes the continued viability of community hospitals.

The issue of self-referral must be reviewed in light of how health care is and will be delivered. No serious effort at reform can ignore the potential gaming that financial conflicts may create.
So, yeah, they know it's out there. And they're going to do something about it. Eventually. Likely the solution, if and when it comes, will be worse than the problem.

What we are fighting here is greed and entitlement, traits manifested by more and more Americans over the past few years, to the point that they are becoming normal behavior, to be ignored, or even applauded, envied, and emulated.

Elizabeth MacDonald, writing in her blog on, puts the blame of our current financial woes and subsequent bailouts at the feet of the beloved Mr. Rogers.

Mister Fred Rogers, the children’s TV star, who, beginning in 1968, started every show telling us that we were “special” just the way we were.

When we weren’t.

Blame all of those preening child-rearing experts who encouraged an excruciatingly costly culture of entitlement, a culture of narcissism, of excessive self-righteous self-indulgence, where generations grew up believing they were entitled to follow their own codes of conduct, a chronic “me first, I get what’s mine first” attitude–to the point where one survey shows one in three teenagers expect to be famous.

Better yet, blame the bailouts on everyone who forgot the most important part of the Mister Rogers’ Neighborhood show, a willful ignorance that has led to a mass dereliction of civic duty, of civic vision–Rogers’ emphasis on “neighborhood.”

Blame it on a post World War II culture of “me-ism,” of individuality over community, of “I’m special, you owe me,” a culture of anything goes in this Age of Aquarius.

And what did this mentality yield?

*Ten million borrowers, many of whom should never have borrowed what they did to begin with, could go bellyup on their mortgages when all is said and done. Monthly foreclosure filings, most of which are in suburban middle class neighborhoods, could grow to 303,000 monthly from 259,085, says RealtyTrac.

*In Bakersfield, California, a Mexican strawberry picker with an income of $14,000 and no English was lent every penny he needed to buy a house for $720,000. A nanny for a mortgage-bond trader at Deutsche Bank bought, along with her sister, five townhouses in Queens, New York after lenders got them to refinance to keep buying.–Michael Lewis, “The End of Wall Street’s Boom.”

Proving that when people are free to do as they please, they usually imitate each other.

Why not accept a loan for something you know you can't afford? Why shouldn't I live in a McMansion, too? Personal responsibility? Bah, Humbug!

Take as another example the recent revalation about Bernard Madoff. Basically, Madoff ran a huge scheme wherein he used the money coming in from new investors to pay old clients:

New potential victims emerged of Wall Street veteran Bernard Madoff's alleged giant Ponzi scheme, with international banks, hedge funds and wealthy private investors among those sorting out what could amount to tens of billions of dollars in losses.

New York Mets owner Fred Wilpon, GMAC LLC Chairman J. Ezra Merkin and former Philadelphia Eagles owner Norman Braman were among the dozens of seemingly sophisticated investors who placed money on what could prove to be history's largest financial scam.

And how did Madoff get away with this? Didn't anyone smell a rat? It seems that some did:

Bernard L. Madoff is alleged to have pulled off one of the biggest frauds in Wall Street history. But there were multiple red flags along the way, including a series of accusations leveled against Mr. Madoff's operation. Now some are asking why regulators and investors didn't pick up on the alleged scheme long ago.

"There's no smoking gun, but if you added it all up you wonder why people either did not get it or chose to ignore the red flags," says Jim Vos, who runs Aksia LLC, a firm that advises investors and came away worried after examining Mr. Madoff's operation.

. . .Meanwhile, a series of media stories also raised questions about Madoff's operations, including a piece entitled "Madoff Tops Charts; Skeptics Ask How" in industry publication MAR/Hedge in May, 2001, and a subsequent story in Barron's. Mr. Madoff generally brushed off reporters' questions, citing the audited results and arguing that his business was too complicated for outsiders to understand.

We might expect the reasonable man to have questioned Madoff's tactics and results. But no, many of his clients aparently knew he was manipulating things, but they thought he was doing something illegal but that might still benefit them, the entitled ones, and the investments kept pouring in. From Clusterstock:

Specifically, we're hearing that the smart money KNEW Bernie had to be cheating, because the returns he was generating were impossibly good. Many Wall Streeters suspected the wrong rigged game, though: They thought it was insider trading, not a Ponzi scheme. And here's the best part: That's why they invested with him

. . .So why did these smart and skeptical investors keep investing? They, like many Madoff investors, assumed Madoff was somehow illegally trading on information from his market-making business for their benefit. They didn't consider the possibility that he was clean on that score but running a good old-fashioned Ponzi scheme.

Sounds a bit like a Nigerian Scam in a three-piece suit, doesn't it? To refresh your memory on that, look at this discussion from

In many cases, this is really a scam-within-a-scam: The Nigerians are making you think that you are going to scam the Nigerian Government, the Central Bank of Nigeria, etc., when in fact they are going to scam you out of what they are going to charge you to get in the scam, or what portion of the scam you are going to pay to make it work.

If you pay the money up-front by wire-transfer or by mail, one of two things will happen: (1) you have simply lost your money and will never see it again; or (2) and much more likely, within a couple of days you will get a phone call or letter from your contact telling you that something has gone wrong, and that to clear it up and release the funds you will have to send just a little more money. This latter scamming will go on literally for weeks and months, until you either run out of money or figure it out.

If you actually go to Nigeria, it is the same scam. You will pay some money and wait. There will be a delay, and then a requirement that you pay additional money to clear up the delay, and then another delay and more money, and so forth and so on until (1) your money is exhausted, or (2) you leave the country, or (3) you are kidnapped or murdered for the rest of your money.

The Nigerian government is getting tired of the reputation these scams have brought, which is ironic since it is rumored that many government officials and employees actually participate in them. However, we have to agree in light of today's discussion with this sentiment:

People who fall for so-called "Nigerian scams" aren't victims at all—in fact, they're greedy and should be jailed, according to Nigerian high commissioner Sunday Olu Agbi. He said today that Nigeria has gained a bad reputation because of the scams perpetrated by a minuscule number of people, and that those who find themselves involved with the scams are equally as guilty as those running them.

"The Nigerian Government frowns very seriously on these scams... and every day tries to track down those who are involved," Olu Agbi told the Sydney Morning Herald in response to a previous article on Australians falling for Nigerian scams. "People who send their money are as guilty as those who are asking them to send the money."

If the greedy and entitled folks who received the scam letters and emails didn't think that they deserved something for nothing, or more accurately, to take something that doesn't belong to them courtesy of the scammer, these 419 scams would dry up in a week.

Physicians may be somewhat more intelligent, on average, than the overall population, but they are just as prone, if not more so, to want what isn't theirs. Take this example of a physician who abused his position for gain, trodding all over the rights and safety of his patients:

When a Congressional investigation revealed in June that Dr. Joseph Biederman, a world-renowned child psychiatrist, had earned far more money from drug makers than he had reported to his university, he said that his interests were “solely in the advancement of medical treatment through rigorous and objective study.”

But e-mail messages and internal documents from Johnson & Johnson made public in a court filing reveal that Dr. Biederman pushed the company to finance a research center at Massachusetts General Hospital, in Boston, with a goal to “move forward the commercial goals of J.& J.” The documents also show that the company prepared a draft summary of a study that Dr. Biederman, of Harvard, was said to have written.
Dr. Biederman’s work helped to fuel a fortyfold increase from 1994 to 2003 in the diagnosis of pediatric bipolar disorder and a rapid rise in the use of powerful, risky and expensive antipsychotic medicines in children.

And so we come full circle in our discussion, and return to imaging self-referral. A recent article in Imaging Economics discusses research by Jean Mitchell, PhD, professor of public policy at Georgetown, and a prominent researcher in this venue, published in the May 2008 issue of Medical Care. Dr. Mitchel looked at private insurance reimbursement for MR, CT, and PET, and found that utilization had increased significantly from 2000 to 2004, powered by physician self-referral and lease arrangements.

"Physician self-referrals are a response to financial incentive," said Mitchell. "Everyone responds to that. If you were in their shoes and getting pay cuts, which is essentially what's happened, you would try to make up that lost income. The easiest way to do it, in specialties that need imaging, is to expand the scope of practice in order to bill for the imaging. That is what's happening."

. . .The two camps of public and physician opinion that have emerged view this scenario with emotions ranging from satisfied approval to unmitigated disgust. Supporters of using self-referral in this manner point to the increased convenience to patients by offering imaging in house. Additionally, they question the presumption that self-referral is often not medically necessary. . .Members of this camp also say quite plainly: If the imaging is medically necessary, why not benefit?

Why not, indeed? I'm entitled to it, and I'm going to get it. As for necessity, I've made this argument before. We know for a fact that the self-referrers order from two to eight times the number of scans as compared to those clinicians who do not self-refer. So, either the latter are under-serving their patients, or the self-referrers are ordering scans that are not necessary. It cannot go both ways. Doctors hold a unique position of trust and power over their patients:

Patients often trust their doctors to a fault. In cases where they perhaps should ask questions, or at least have the option to make a choice, patients will often defer to their physician's expertise. If imaging is recommended, it will most likely take place. But in cases of self-referral and twisting the system, is the physician role as patient agent compromised?

The Imaging Economics article comes to a simple conclusion:

Realistically, a full ban may be the best method.

"I initially thought we need policy makers working with insurers and physicians on which types of scans would be more effective in more cases," said Vivian Ho, PhD, professor of medicine at Baylor College of Medicine and associate professor of economics at Rice University, who provided commentary on the Mitchell study in Medical Care. "But this is extremely difficult and would take a lot of time. The other alternative that should be considered is to completely ban self-referral for diagnostic imaging. It's unfortunate, but on the other hand, it's a pretty compelling argument to save a great deal of money that can hold down insurance costs."

For now, physicians and the public need to recognize that this is an issue crying out for a solution.

"Yes, there's more pressure from managed care on physicians," said Ho. "But to me that's not the way the economics should work. To force this cost upon consumers doesn't lead to efficient markets. It's unfair, and with little demonstrable benefit."

True, but that objective analysis doesn't begin to describe the problem. You have greed on the part of a small but significant number of physicians, driving them to self-refer to scanners in their offices. They are over-utilizing and ultimately tainting life-saving technology in the interests of padding their pockets, or to "recover lost revenue." But lest we forget, this technology, at least CT, uses ionizing radiation, and it is NOT without consequence to use it indiscriminantly.

We can talk all day long about closing loopholes and tightening exclusions. Blah, blah, blah. It won't work. We all know it won't work because everytime it has been tried, the greedy and entitled find ways around the solutions. HERE is what must be done, if anyone has the guts to do it. Self-referral of this sort needs to be banned and criminalized. There needs to be jail-time, not just fines, applied to the wanton disregard the self-referrers show for their patients' welfare. These folks need to be hit and hit hard. Assuming, of course, that we really do feel that they are not entitled to their ill-gotten gains.

Fighting human nature is an uphill battle, especially when some of us were made to feel "special":

Fred Rogers, the late TV icon, told several generations of children that they were "special" just for being whoever they were. He meant well, and he was a sterling role model in many ways. But what often got lost in his self-esteem-building patter was the idea that being special comes from working hard and having high expectations for yourself.

Sadly, being "special" today means to some that they don't have to follow the rules. But they, like the rest of us, aren't all that "special" after all. Some of us are just pigs. No offense to pigs.

1 comment:

Anonymous said...

Love your blog

Keep up the great work.

Although shorter blog posts that occur more frequently will probably increase your reader base.

This post, for instance, could have been split up into 5 posts that you would post throughout a week.

The fresher your blog the more it is updated the more readers you will get.

Keep up the great work. Love the blog. (I am a radiologist so I am biased! lol_)