Monday, June 01, 2009

Bill W. And Other Confessions

I'm sorry about the long absence in posting. I've been seeing some minor developments in the self-referral battle. Possibly there will be some major changes with the new administration in Washington, although I am certain that any good done by the elimination of imaging self-referral will be overwhelmed by the damage done to the rest of medicine.

An anonymous author named "Bill W." wrote a disturbing article for, discussing the role of radiology in self-referral. It isn't pretty. Here is an excerpt:

"Buy yourselves a scanner!" we crowed. "You scan 'em, we'll read 'em." And so it was. The first operation purchased an old, used scanner, and proceeded to attempt high-level vascular imaging studies while the shiny new multidetector-row CT scanner in the hospital sat idle. But that wasn't enough for us. If we even heard so much as a rumor about an internist or orthopod installing an MRI or a CT system (or even a digital x-ray machine!), we were on the phone offering our services. After all, we reasoned, someone had to read the exams. The patient might as well get the benefit of our expertise, and we might as well make the money. Everyone wins.

Doctors can be a greedy lot, the understatement of the century. And they are not immune to feelings of entitlement: "I went to school for umpteen years and I deserve ..." Since their estimate of their value to society is undermined by cuts to their normal reimbursement -- payment for seeing patients -- they are on the prowl for the money they think should be theirs. When you toss in a wet-behind-the-ears 25-year-old MBA-educated business manager, and a dose of my partner, Doc Politic, you get a group of physicians who are ready, willing, and anxious to get into the imaging business.

Of course, the equipment vendors are only too happy to oblige. For the right price, just about anyone can lease a shiny new multislice CT scanner, and be the best on the block. But since the patients don't know the difference anyway, why not just buy an old used clunker that just barely does the job? The radiologists will still read the pictures. My group, and many like ours, never met a scanner they wouldn't read from. There's an old saying in this business: "Never tell a doc his scanner sucks."

. . .

This is an immoral, unethical situation. Patient trust is being perverted to allow the unscrupulous to indulge their greed and entitlement. Radiologists who enable this, and I'm one of them, need to stop and look at what they are doing. This is dirty money we are generating, and we need to walk away. But I can't. The draw is too great. I wish I had realized what I was doing before I started down this path.

This, my friends, tells the story in a way we don't often hear. The motivation for self-referral and the enabling thereof is clear, and it isn't particularly savory, but then greed never is.

Anil Gawande, M.D., writing in the New Yorker, reveals the reason behind the incredibly high cost of health care in McAllen, Texas. The answer? Physician greed. This particular mid-sized city has become a haven for ordering every test, every procedure, every possible way to pad the bill. Sadly, the care that is delivered isn't even optimum in some cases. But practicing medicine based on income won't lead to the best decisions.

When you look across the spectrum from Grand Junction to McAllen—and the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.
The soul of American medicine was lost long ago, the minute someone realized he could make more money by ordering another test.

Since my last post, there have been other interesting tidbits. However, I have to wallow a little bit in my disappointment with AMIC, in which the ACR proudly participates. They have a nicely-done new website, RightScan, RightTime dedicated to expressing the wonders of modern imaging technology. Of course, there is a little spin applied:

Rosemarie, 60, a mother of three children and legal assistant in Delaware, is lucky. She had a virtual colonoscopy that allowed her physician to make two life-changing discoveries: polyps inside her colon were caught early enough to prevent colon cancer and the tumor in her kidney was caught early enough to save her life.

Share your story of how a scan helped the outcome of your health.

I have yet to hear anyone speak against scanning per se, and I have yet to hear of anyone who died because DRA-2005 kept them from getting scanned. Everyone grasps that radiologists do wonderful things with CT's and PET scans and so on. I like chocolate too, and a little bit is probably quite healthy; a lot makes me fat and primes me for diabetes and other nasty stuff. The hyperbole doesn't impress those who are familiar with AMIC and what it's really out to do, which is primarily to preserve income for self-referring clinicians and the rads that read for them, as well as (to a much lesser extent) the radiologists who own outpatient imaging centers. Here's their latest battle cry:

The Access to Medical Imaging Coalition (AMIC) sounded alarm bells March 16 that federal efforts to rein in costs were affecting patient access to medical imaging and that government-sponsored studies were understating the damage caused. The coalition of physician, patient, and imaging manufacturer groups decried government-sponsored studies of the impact of the Deficit Reduction Act, which took effect two years ago.
They keep serving the same old whine. By the way, AMIC's old website,, now resolves to the new shiny RightScanRightPrice address. Wise move, AMIC, the new site is much friendlier.

I have to delve into a tangent, but it does relate to this topic. There is a very lenghthy thread on, concerning a company called Imaging Advantage, which appears to be replacing a group which has covered three Toledo hospitals for a long time. I urge you to read the entire thread for yourself, but suffice it to say, it appears (and I emphasize appears) to be some under-the-table activity designed to gyp the current group out of their position, and rehire those that have no other option at a much lower rate. There is the accusation (which is unsubstantiated) of Imaging Advantage planning to use off-shore radiologists for preliminary reads. Finally, there is a rather clear tie-in with Massachussets General Hospital radiologists. There is a question (and only a question at this point) of involvement of some big names within the ACR.

Rumor and innuendo are fodder for many blogs, although I endeavor to keep them out of this one. Still, I have to be very concerned, and very disappointed, in this situation. IF all the accusations are true, then members of the ACR are involved not only in promoting self-referral through AMIC, but they are trying to back-stab their own constituents as well. This is as unacceptable as it gets. IF this does turn out to be the case, I will immediately withdraw from the ACR (and demand my dues back, too), and I would urge all of you to do the same. IF the accusations are true.

It's rather ironic (IF true) that we have a bunch of academics, voted in by the rank and file, mostly private practice radiologists, who think themselves above the rest, and proceed to do everything they can to profit from the situation. Sounds a little bit like our current administration and Congress, doesn't it?

Pogo put it best:

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