Wednesday, May 28, 2008

A Resolution from the American Misbegotten Association
"Fairness" in Medical Imaging Interpretation

If you look up misbegotten, you will find that it is a more acceptable synonym for something less savory.

Resolution 208, Fairness in Medical Imaging Interpretation, is to come before the AMA's House of Delegates shortly, and it is expected to pass. It is introduced by some of our very good friends:

American Society of Neuroimaging
American Association of Neurological Surgeons
Congress of Neurological Surgeons
American Medical Group Association
American College of Cardiology
American College of Gastroenterology
American Gastroenterological Association
American Society for Gastrointestinal Endoscopy

So, what do these illustrious physicians call "fair"? Here's the text of the bill and relevant AMA policy:

Whereas, Expenditures for advanced medical imaging services, such as CT, MRI and PET, have significantly increased in this decade, raising legitimate concerns over utilization rates; and

Whereas, These concerns have led payers, state legislatures, government agencies and radiology management companies to consider eliminating reimbursement for in-office imaging and image interpretation by non-radiologists without consideration of their training and certified competence to provide these services; and

Whereas, Available data do not suggest that increased imaging costs are necessarily attributable to in-office imaging services by most medical specialties involved in medical imaging and interpretation; therefore be it

RESOLVED, That our American Medical Association encourage and support the in-office utilization, medical direction and supervision of advanced imaging services by qualified or certified physicians whose utilization of these modalities is within the scope of their specialty practice in accordance with appropriateness guidelines, practice guidelines, technical standards and accreditation standards for the imaging modalities utilized as defined by their specific medical society (New HOD Policy); and be it further

RESOLVED, That our AMA actively oppose efforts by federal and state legislators, regulatory bodies, private payers, public payers and radiology business management companies to restrict the application of advanced imaging services for the diagnosis and treatment of patients when such services are provided as defined by specialty specific appropriateness guidelines, practice guidelines and technical standards for the imaging modalities utilized. (Directive to Take Action)

Fiscal Note: Implement accordingly at estimated staff cost of $6,509.

Received: 05/07/08

RELEVANT AMA POLICY

D-385.974 Freedom of Practice in Medical Imaging
Our AMA will: (1) encourage and support collaborative specialty development and review of any appropriateness criteria, practice guidelines, technical standards, and accreditation programs, particularly as Congress, federal agencies and third party payers consider their use as a condition of payment, and to use the AMA Code of Ethics as the guiding code of ethics in the development of such policy; (2) actively oppose efforts by private payers, hospitals, Congress, state legislatures, and the Administration to impose policies designed to control utilization and costs of medical services unless those policies can be proven to achieve cost savings and improve quality while not curtailing appropriate growth and without compromising patient access or quality of care; (3) actively oppose efforts to require patients to receive imaging services at imaging centers that are mandated to require specific medical specialty supervision and support patients receiving imaging services at facilities where appropriately trained medical specialists can perform and interpret imaging services regardless of medical specialty; and (4) actively oppose any attempts by federal and state legislators, regulatory bodies, hospitals, private and government payers, and others to restrict reimbursement for imaging procedures based on physician specialty, and continue to support the reimbursement of imaging procedures being performed and interpreted by physicians based on the proper indications for the procedure and the qualifications and training of the imaging specialists in that specific imaging technique regardless of their medical specialty. (Res. 228, A-05; Reaffirmed in lieu of Res. 901, I-05; Reaffirmation A-06; Reaffirmation I-06; Reaffirmed in lieu of Res. 125, A-07)
Excuse me, but what a bunch of CRAP! It has been proven time and time again that self-referral DOES show increased utilization. Beyond that, what our friends are asking for is a complete disregard for imaging standards as set by us, the imagers. Can anyone gue$$ what the motivation might be for all of thi$? $ure, you can. And tell me, is it "fair" for a clinician to be able to generate income by ordering unnecessary tests, bypassing any restraint? I don't think so.

If this resolution passes, I will drop my membership in the AMA, and I would urge everyone in Radiology to do so. Obviously we have no voice there anyway.

Tuesday, May 27, 2008

A Chat With An Internist

I was reviewing a case with an internal medicine physician who happens to be a good friend of mine. We were talking about a patient that needed a CT, and I said, almost without thinking, "At least you don't have a scanner in your office."

This started a discussion of the relative merits of in-office scanning and self-referral. My friend was unaware of the statistics that we all know so well: self-referring docs order from two to eight times as many scans as those who don't self-refer, and they generate $16 Billion in extra expenditures annually.

My friend is honest as the day is long, and quite non-judgemental. He had no harsh words for his colleagues who are dabbling in the scanning business. But he was very clear as to why he thought they were doing so. As an internist, he is very much aware of the impact of falling reimbursements. He notes that it is very difficult to keep his practice open at all these days. Thus, he sympathizes with those who are doing anything to stay afloat, including placing scanners in their offices. The temptation to order excess imaging is certainly there, but he expressed hope that this would not occur very often. Nothing was mentioned about convenience.

It has been said on numerous occasions that primary care physicians are underpaid, and that is the root cause for self-referral. I agree that our hardworking internists, pediatricians, and FP's do deserve a lot more than they receive, and the current situation is very sad and very difficult for them. However, a couple of points come to mind. First, two wrongs don't make a right. If I lose money in the stock-market, I'm not allowed to rob a bank to make up for my loss. Similarly, the lack of reimbursement for office visits and EKG's does not justify over-ordering of scans to produce additional technical revenue. Secondly, a significant pleurality, if not an actual majority, of self-referring physicians are not primary care docs, but rather are specialists, mainly cardiologists, oncologists, neurologists, orthopedic surgeons, and neurosurgeons, more or less in order of their abusive behavior as I see it. Maybe these guys have taken some hits as well, but their incomes have certainly not dropped as badly as the primaries.

It's hard to define what's "fair" in this setting. Certainly it isn't fair that my friend the internist works as hard as any physician I know, and isn't anywhere near as well-paid as he should be. But it also isn't fair for the self-referrers to exploit a loophole in the law and over-irradiate their patients in the name of some extra cash. But I guess life just isn't fair at all.

Monday, May 19, 2008

Uro-Trash

A doctor calling himself Krom on Auntminnie.com found this article from the Urology Times, "the leading news source for Urologists". The web-page is titled, "Ancillary income: What's possible, and what's legal?" Here's the opening paragraph:
In an age of declining reimbursements for traditional physician services—eyeball to eyeball with our patients or standing at the operating table—many physicians are looking for replacement sources of income to keep their small businesses healthy. This has been difficult or even impossible in the past because of government regulation or legislation (self-referral and anti-kickback statutes) concerning physician ownership of businesses ancillary to the provision of direct patient care.
The authors interviewed a urologist named Pat Hezmall, M.D. from Urology Associates of North Texas, a 48-man group that seems to be big into "ancillary income." Dr. Hezmall's justification for what follows is:

Physicians are liable for 100% of clinical outcomes, direct 85% of health care spending, but are recipients of only 15% of the health care revenues. Ownership of ancillary services provides physicians with an opportunity to directly improve clinical outcomes by controlling the operation and quality of the service, provide efficient and effective care, and offer therapeutic options within the practice. Improved outcomes result in increased patient satisfaction, increased physician satisfaction, increased payer satisfaction, and decreased liability.

"Additional income from ancillary services provides capital for investment in new technology, continuing the virtuous cycle of physician ownership and control of the entire decision-making process for our patients," Dr. Hezmall explained.

Ownership of ancillary services is not a new concept for urologists. As of 2003, 58% of U.S. urologists owned shares in lithotripsy partnerships. Urologists have long depended on in-office imaging equipment to practice their craft. Recent declines in reimbursement, especially for LHRH drugs, have generated an interest in expanding sources of ancillary income.

Dr. Hezmall then goes on to list all the low-hanging fruit just ripe for urologists to pluck: lithotripsy, imaging, clinical laboratory services, anatomic laboratory services, ambulatory surgery centers, specialty hospitals, and finally IMRT. Krom, the AuntMinnie poster, mentions this about radiation therapy under the jurisdiction of urologists:
. . . we have radiation oncology in our practice...if you think self referral is bad with imaging, a group of urologists in our area just put in an IMRT machine in their office and are radiating away! everyone gets RT whether it's indicated or not. an mri is one thing, putting someone thru a round of RT who may not of needed it is another. when our rad onc confronted one of them, they whine about declining reimbursements. this from a guy who has 2 houses and drives a car worth over 100g. again, their big argument...convenience! it's sad. but there are radonc-ho's who work for these places. the urologists can offer big big salaries and still get a huge windfall. win win except for the patient of course. when are the govt and insurance companies going to wake up? i assume theyll just do a DRA like deal and 1/2 the reibursement for IMRT. i wonder how theyll make up for the lost revenue then?...gee let me see...
AuntMinnie user "Fugue" came up with the name "Uro-Trash", obviously a pun on "Euro-trash", and I have blatantly stolen for my title.

The authors of the Urology Times article conclude:

We believe that the days of physicians wrestling with the professional perception that it is not proper to make money from the delivery of care in outpatient business ventures are over. Many physicians also fear that such business ventures carry significant legal risk because of government regulation.

However, with good advice and with physicians making good decisions about which ancillary services to add to their practices, this concept can be very enjoyable and profitable, and provide an added dimension to the private practice of medicine.

Gee, finally an honest answer. It is completely and totally about the money. At least they admit it.

Sunday, May 04, 2008

A Sad Commentary

An anonymous reader from a small town in the west sent this comment:

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.

Very sad, indeed. The government is really the only option to fight this. Maybe the loopholes will be closed, eventually. Too bad the government doesn't have the cojones to actually punish the perpetrators of this scam. Can't you just see the explosion of finger-pointing? "It wasn't the docs idea, it was the business manager's idea! Put him in jail, not us!"