Americans For Responsible Imaging

Moving Forward

2010-01-30T09:42:00.000-08:00

Scott Brown has won his Senate race, and we can all breathe a sigh of relief. The Democrats are in disarray, even "hysterical" by one report. The nation has taken a step back from the brink of an abominable health care plan. But even assuming that the bill does fade away and die, we still have much work to do. The health care system does need reform, but there is little agreement on the issues or the fixes.

I would still expect some sort of limited legislation to make it through Congress; the egos involved may not let the matter drop as has happened so many times in the past. But, we now have the blessing of a second chance, a reprieve, and possibly a window of opportunity which will allow our voices to be heard.

Many of my readers are movers and shakers in the world of Radiology, and many have access to powerful people in Washington. Now is the time to decide what we as physicians, as radiologists, and as Americans would like to see changed in our system. I think we can all agree about bringing self-referral to the forefront of the discussion.

We must take a different approach than we have before. With all due respect to those involved, the message promulgated by AMIC has not resonated well in Congress. The implication that services will be curtailed if rates are lowered did not have any effect in the discussions about DRA-2005, and likely it won't today. Since AMIC is tied to the various non-radiological societies such as the American College of Cardiology it cannot easily discuss self-referral. The "political expediency" of sitting beside the cardiologists when testifying before Congress almost destroyed our very credibility on self-referral. My suggestion as a hick from the boonies is for the ACR to separate from AMIC as quickly as possible, and do what must be done to be certain Congress truly understands what self-referral is all about. We have to clarify the issue as being anything but a turf battle, or a grab for money. We need to reestablish the message and the moral high ground it entails. And while we're at it, we need to be absolutely certain that the leadership of the ACR is truly and accurately representing us. We can have no more questions arise such as those coming out of Toledo.

Beyond this, we must help decide where the US is to go from here, since we cannot maintain the status quo forever. Do we want to push for universal care? Probably, although in reality it exists and we, the physicians pay for it by covering "self-pay" patients. Do we want a single-payor system? I don't, but some do, and we have to have the discussion. Should insurance companies be required to cover pre-existing conditions? My son has a chronic disease, and will be uninsurable once he is too old for my policy to cover him. However, others have stated here that such coverage would bankrupt the system. We all want tort reform, but how do we get a legislature full of the likes of former Senator John Edwards, litigator extraordinare, to agree?

And so on.

Again, we have been granted a reprieve, a blessing, if you will, by the fortuitous turn of events in Massachusetts. Let's have the discussions and go to Washington with ideas. We have what might be a once-in-a-lifetime opportunity. Let's not let it go to waste.

Don't Look Behind The Curtain!

2009-10-10T07:33:00.000-07:00

I've been so disgusted with the news on self-referral these days that I haven't bothered to post. But one of my partners, whom we shall call John Coolidge, authored the following piece based on a recent Wall Street Journal article. Read it and weep, especially if you are a radiologist.

While relaxing with a glass of wine after a 12 hour day of spanking and cranking out 100’s of dictations, a Wall Street Journal article was brought to my attention. In reading it, my mental state stained the deep purple merlot with a brighter war-like red.

War!.....on Specialists!....am I a specialist? I asked, trying to decide whether or not I needed to be defensive…..

I read on.

The War on Specialists
ObamaCare punishes cardiology and oncology to finance GPs.

“Whew! I am neither of those two groups.” I thought.

WSJ: “……From Senate Finance Chairman Max Baucus's health-care bill to changes the Administration is pushing in Medicare, Democrats are systematically attacking specific medical fields like cardiology and oncology. With almost no scrutiny, they're trying to engineer a "cheaper" system so that government can afford to buy health care for all—even if the price is fewer and less innovative ways of extending and improving lives.”

The government is trying to engineer a cheaper system that it can afford….”by doing what?” you might ask….

WSJ – “Take a provision in the Baucus bill that would punish any physician whose "resource use" is considered too high.”

You mean “Punish” Cardiologists and Oncologists” who over-utilize resources???

WSJ – “physicians will be punished if he orders too many tests, performs too many procedures or prescribes too many drugs—whether or not the treatments result in better patient outcomes…...internists and family physicians will see higher payments on the order of 6% to 8%. …….in part because they're underpaid.”

Fair enough, I agree. This is not sounding like specialty warfare to me, this is sounding like someone finally awoke from their slumber and had a V8 moment.

WSJ – “But this boost for GPs comes at the expense of certain specialties. The 2010 rules, which will be finalized next month, visit an 11% overall cut on cardiology and 19% on radiation oncology. They're targets only because of cost….The chunks Team Obama took out of cardiology RVUs are especially drastic. The basic tools of heart specialists—echocardiograms (stress tests) and catheterizations—are slashed by 42% and 24%, respectively.

Oh….you mean the tools cardiologists have abused for years with skyrocketing utilization, caused by economically motivated self referral? Those tools?

WSJ- “Jack Lewin, who heads the American College of Cardiology, said in an interview that the crackdown will cause "a horrible disruption" that will force many community and independent practices to close their doors, lay off staff or make senior patients wait days or weeks for tests and services.”

Translation….”HOLY SHIT! ……THEY FINALLY GOT A BEAD ON US!....QUICK, BLAME THE RADIOLOGIST!”

WSJ – “Cancer doctors get hit because the Administration believes specialists order too many MRIs and CT scans. Certain kinds of diagnostic imaging lose 24% under new assumptions that machines are in use 90% of the time, up from 50%. There isn't a radiologist in America running an MRI 10.8 hours out of 12, unless he's lining up patients on a conveyor belt.”

I can see Dr. Lewin and the ACC Clan now, rubbing their hands, praying that smoke screen will continue to work. Let’s look at that a little more closely. Cancer docs get a hit because they order too many MRI’s, and CT scans. Then they suggest it is the radiologist who is running the scanners. Oh Contraire……It is the oncologist and cardiologists who are taking the hit because THEY OWN THE SCANNERS TO WHICH THEY ARE ORDING THE TEST BE DONE! Not the radiologist! THE RADIOLOGISTS DON’T ORDER TESTS! The punishment, my esteemed colleagues of the ACC, lies where it should, with the individuals ordering the tests. Don’t try to blame the radiologist. Only around 25% of “high value imaging” is actually done in a RADIOLOGIST’S office. The rest is done in hospitals, and in the offices of the self referrer.

The final insult to my intelligence was the following comments:

WSJ – “Markets are supposed to determine the composition of the workforce, not a command medical economy run out of Washington. It is perfectly insane to support one type of doctor by punishing others on a flawed theory about cost-control…..If Democrats are going to stomp on specialists, they should at least be open about it. Then again, all Americans might take a different view of health-care "reform" if they understood that it means snuffing out the best medicine.”

Free Market you say? Not a command economy you say? Be open about it you say? Let me ask you; is the ordering and delivery of medical imaging in America a free market? Who decides which imaging center, radiologists office, or hospital outpatient imaging center a patient goes to? Is it the patient? NO! It is the command economy of the SELF REFERRER that decides. It is the command economy of the IN-NETWORK insurance contract. It is not the patient who decides. Let me state this another way. I could be the best radiologist there is. Fellowship trained, highly skilled, well published, and with the most up to date equipment and protocols, the best service, and at the lowest price, and I am still RELIANT UPON ANOTHER DOCTOR TO SEND ME THEIR PATIENT. Let’s open up the markets! Let’s make them free and transparent! Let’s make the contractual arrangements you have with your leased scanners open to public scrutiny and the light of day. Let’s allow free competition for expertise, equipment, price, and services! LET’S FREE THE MEDICAL IMAGING MARKET. LET’S DRAW BACK THE CURTAIN! …….Are you afraid Dr. Lewin?

…..To the WSJ, Are you afraid of open markets, or just of fair reporting? Be careful who you listen to in this debate, least you be listening to the fox regarding the state of the henhouse.

Bill W. And Other Confessions

2009-06-01T07:46:00.000-07:00

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 AuntMinnie.com, 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, http://www.imagingaccess.org/, 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 AuntMinnie.com, 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:

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

2008-12-13T19:06:00.000-08:00

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 insulting...to 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 FoxBusiness.com, 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 Quatloos.com:
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.

Self-Referral and the Bank Bailout

2008-09-30T19:37:00.001-07:00

The big topic of conversation everywhere these days is the $700 Billion bailout of Wall Street, which so far has yet to be approved by Congress. Whether you are for the rescue operation or not, you will still be able to see some uncanny parallels between the economic crisis and the imaging self-referral issue.

The facts of self-referral are pretty simple. Because of the In-Office Exception of Stark II, doctors who own imaging equipment placed in their offices can order scans to their hearts' content, and collect technical fees thereof. Studies have demonstrated that giving out the keys to the cash-register leads to anywhere from two to eight times the number of scans being ordered. No one seems to be disputing that at all. The excess scans are costing you and me somewhere in the neighborhood of $16 billion per year. Not much dispute on this either.

I don't claim to be an expert on the mortgage crisis, but I think the main problem is pretty clear. Loans were given to people who shouldn't have qualified for them, and a lot of folks made a lot of money by treading on the line between what was proper and what was not. Because the whole thing was perpetuated by housing prices that could not sustain their rate of growth, the house of cards quickly fell over, right on top of all of us. Rightly or wrongly, President Bush and some in Congress attempted to bail the financial institutions out of their bad behavior. As of right now, the bailout didn't pass Congress, mainly because a large number of US citizens weren't for it, and they let their representatives know this in uncertain terms. Their main objection? The bill made all of us pay for the wild speculation and manipulation of a few, and it didn't punish those responsible.

I predict that once the public gets its collective mind around the self-referral issue, something similar will occur. Right now, patients are indoctrinated into thinking that their physician's in-office scanner is their solely for the patient's convenience. They do not realize that they are being taken for a ride by an authority figure that is manipulating them for their own profit, toeing a similar fine line between what is proper and what isn't. When they eventually wake up, I think there will be a significant backlash toward their beloved clinicians.

It has been said that those who sought loans without proper credit have some culpability in the mortgage crisis. Someone making a relatively low wage (or no wage) with no credit should not be thinking of buying a home. Patients also are at least partly to blame for the self-referral problem. Americans are addicted to imaging. When they go to their doctor or to the Emergency Room, they expect to be scanned for every ache and pain, and this plays right into the hands of those who would make a profit with unnecessary imaging.

So, who will rescue the country from imaging self-referral? Once again, the only real hope is the government. While DRA-2005 didn't properly focus on the self-referrers (and the ACR and AMIC didn't bother to make this clear to Congress) its slash-and-burn philosophy did have significant effects. A recent GAO report demonstrated that imaging expenses declined 12.7% in 2007 following implementation of DRA 2005. Yes, this hurt radiologist-owned facilities, but I'll bet it hurt the self-referrers more.

As a Conservative, I chafe at the need for govermnental intervention in these issues. But I think we Conservatives are mischaracterized. It is impossible to achieve "zero-regulation," mainly because of human nature. That would yield sheer anarchy. There will always be those who look for loopholes and other ways to thwart the sytem. I don't think anyone really wanted lenders to give out loans to those who would never be able to pay for them, and we know that Pete Stark never intended for self-referrers to have PET/CT's in their offices.

It could be argued that regulations such as the Stark Laws and government programs for housing loans have created these situations, but without the regulations there would be a complete free-for-all. Sadly, only the government can provide the fix.

A "Clear Vue" to Self-Referral

2008-08-26T13:39:00.000-07:00

The self-referral mills in St. Louis were not alone in their approach to skirting the Stark Laws. According to ArkansasBusiness.com, there is another such operation in Lowell, Arkansas. In similar fashion, Fayetteville MRI, running a strip mall operation called Clearvue Medical Imaging, also depends on self-referral of its investors, and keeps it legal by avoiding Medicare and Medicaid patients.

Arkansas Business got hold of a confidential memo, which

. . . indicates that Fayetteville MRI – led by four northwest Arkansas doctors – is seeking 50 physicians to invest a total of $5,000. It anticipates annual profits that would quickly exceed $2 million from a controversial business plan that relies on self-referral.
State and federal laws forbid self-referral to imaging centers that accept Medicare and Medicaid patients, so Fayetteville MRI will not accept patients insured by those government programs, the memo said.

The article goes on to name the names of the owners and shareholders of the operation. They are actually leasing an outpatient clinic from a radiologist!
Their attorney is none too happy about being "outed":
Tim Ezell, an attorney with Friday Eldredge & Clark LLP of Little Rock and who is representing Fayetteville MRI, wasn't happy that Arkansas Business obtained a copy of the private offering memorandum. It was mailed to the newspaper by an anonymous tipster identified only as "A Concerned Doctor."
"It's really troubling to me that the contents of this offering memo are out there for public consumption because it really is supposed to be confidential," he said.

And he was very quick to point out that his little project is just within the limits of legality:

Ezell also said the business model isn't violating kickback laws.
"Those kickback laws are applicable to situations where there are ... government health care beneficiaries involved, like Medicare and Medicaid," he said. "There are no government beneficiaries involved in the Fayetteville MRI transaction."

Yup. When cornered, one of the physician-investors excused his actions: Brown, one of the investors in Fayetteville MRI, said what's driving up the health care costs are attorneys who file malpractice claims against doctors.
"We have to cover our butt on everything," Brown said. "We know we could be sued and they always are looking in retrospect what tests I do that are not needed for my clinical care."
So if he orders tests, it's to protect himself from plaintiffs' attorneys in the event of a lawsuit, he said.
"It's all to cover myself from lawyers," Brown said. "It has nothing to do with padding my pocketbook."
Oh, puhleeeese. I'll go back to an argument I made earlier. All doctors face this same pressure. We know for certain that the self-referrers order from two to eight times the number of scans of those who don't own their own equipment. So, I guess that not only are the less-well-endowed committing malpractice, but they must be more immune to lawsuits as well. Wow.

Three of the four St. Louis shops closed after receiving negative publicity. We'll see if the light of truth has the same effect in Arkansas.

If I Had A Scanner.....

2008-08-21T10:34:00.000-07:00

Midi courtesty of http://www.brownielocks.com/

With apologies to Peter, Paul, and Mary

If I had a scanner,
I’d scan her in the morning,
I’d scan her in the evening,
As long as I can.

I’d check her for tumors,
I’d check her for infection,
I’d scan her for the cash I’d get
From Medicare and Aetna
As long as I can.

If I had a PET/CT,
I’d scan her in the morning,
I’d scan her in the evening,
As long as I can.

I’d check her for tumors,
I’d check her for infection,
I’d scan her for the cash I’d get
From Medicare and Aetna
As long as I can.

If I had an MRI,
I’d scan her in the morning,
I’d scan her in the evening,
As long as I can.

I’d check her for tumors,
I’d check her for infection,
I’d scan her for the cash I’d get
From Medicare and Aetna,
As long as I can.

I don’t have a scanner,
I don’t have a PET/CT,
I don’t have an MRI, so much for my plan.

Cause the hammer of CMS
Rang the bell of warning,
And they cut off the cash I’d get
From Medicare and Aetna.
It’s all over, man.

Cause the hammer of CMS
Rang the bell of warning,
And they cut off the cash I’d get
From Medicare and Aetna.
It’s all over, man.

Changin' Times

2008-08-19T13:19:00.000-07:00

We haven't seen a total reversal of self-referral yet, but there have been some victories here and there. The Times, They Are a Changin'. Slowly but surely.

Remember the blatant self-referral clinics in St. Louis? There were four imaging centers that skirted the Stark Laws by not accepting federally-paid patients (Medicare, Medicaid, etc.) According to a follow-up article by Mary Jo Feldstein of the St. Louis Post-Dispatch, three of the four have closed down. No one knows why this happened at this point, but maybe patients got wise to what was happening to them, or just maybe someone developed a conscience. More likely, they were about to get into trouble over insurance money: Insurers are looking into whether the clinics violated a policy that requires physicians and facilities that care for some of their members to care for all of their members.
To care for "all of their members", the self-referrers would have had to take Medicare patients, too, which would disrupt their little operation. No doubt clinic #4, Cedar Plaza Imaging in south St. Louis County, is not long for this world, either.

CMS may have given us another early Christmas present. According to Diagnostic Imaging,
Following its charge to reduce costly imaging overutilization, the Centers for Medicare and Medicaid Services has announced more stringent prohibitions against self-referral practices. Final Stark rules for the Hospital Inpatient Prospective Payment System for 2009 could force providers to restructure numerous space and equipment arrangements. . .
The new provisions broaden the definition of Designated Health Services (DHS) "entities" and prohibit under-arrangements and "per-click" arrangements for space and equipment leases. . .
The final IPPS rules will become effective Oct. 1, 2009. They will be published in the Aug. 19 issue of the Federal Register.
The implications for radiologists are positive. The new rules will take further incentive away from self-referral and will make lease arrangements with imaging centers less attractive, said attorney Thomas W. Greeson, a partner in the law firm of Reed Smith LLP in Falls Church, VA,
"It will also mean that many of the arrangements where hospitals have been able to establish relationships with referring physicians based on ownership or leasing of services on a per-click basis will be less attractive and give radiologists the opportunity to be part of the technical component services that otherwise were provided under these various arrangements," Greeson told Diagnostic Imaging.
This is a pretty big step. It doesn't cure the problem, but it's a start. Sadly, the self-referrers will no doubt find ways around any new rules and regulations that CMS can deliver, but at least it's getting harder and harder to do so.

GAO Talks, AMIC Squawks

2008-07-25T11:56:00.000-07:00

The Government Accountability Office has just published a study with the lengthy title of "Rapid Spending Growth and Shift to Physician Offices Indicate Need for CMS to Consider Additional Management Practices." In brief, the GAO demonstrated what we already know, that in-office imaging is growing much faster than otherwise equivalent segments. Obviously, I'm not particularly surprised by this revelation. From Diagnostic Imaging's summary:

Medicare spending for in-office imaging services increased from $6.9 billion in 2000 to more than $14 billion in 2006.
The proportion of outpatient Medicare imaging performed in physician offices rose from 58% in 2000 to 64% in 2006.
Spending on advanced imaging, such as CT, MRI, and nuclear medicine, rose 17% per year, substantially faster than spending on less expensive ultrasound and x-ray procedures.
Cardiologists relied on medical imaging for 36% of their total Medical revenue in 2006, up from 23% in 2000.
In-office imaging spending in 2006 varied nearly eightfold from state-to-state, from $62 in Vermont to $472 in Florida. The huge difference led GAO analysts to express concern about whether Medicare payment policies have emboldened physicians to overuse imaging.

The GAO did propose some solutions, primarily:
Given the pressures of a fiscally unsustainable Medicare program, CMS has undertaken several initiatives aimed at improving its performance as a purchaser of health care services. With respect to rapidly growing imaging services, the experience of the private plans in our study suggests that the benefits of front-end management of these services exceeded their costs. We believe CMS may be able to improve its prudent purchaser efforts by adopting strategies such as prior authorization and privileging.
Basically, they want precertification. This is a good start, but I really don't think it will do the job. Possibly there will be some minor effect in the beginning, but those who make a lot of money from self-referral will be more than happy to jump through the hoops to get to the pot of gold. But at least the problem is getting some lip-service from places that count.

The report includes a response from our friends at AMIC, who are none too pleased to have their masters' gravy-trains interrupted:

AMIC representatives raised four principal concerns about the draft report. First, they stated the draft report should have focused on strategies such as accreditation (which improves quality), and adherence to clinical practice guidelines (that result in appropriate use of imaging services), rather than private sector strategies such as use of RBMs, prior-authorization, and other techniques which focus solely on controlling
costs. Specifically, AMIC representatives expressed several concerns about RBMs. They stated that the for-profit structure and lack of transparency in sharing appropriateness guidelines make RBMs incompatible with the Medicare program. They also contended that there is no evidence that RBMs improve care or add value, and RBMs involve physicians in lengthy interactions. Moreover, they stated that prior authorization had been tried and proven unfeasible for Medicare for lack of sufficient administrative resources. In the draft report, we noted plans’ increasing use of accreditation to assure quality of imaging services. With regard to prior authorization and RBMs, we are recommending that CMS consider the feasibility of these and other front-end approaches. We would also note that while HHS indicated that prior authorization might be inconsistent with the Medicare program, the department did not rule it out as a strategy that had been tried and proven unfeasible for Medicare.
Second, AMIC representatives stated that in emphasizing spending growth we had failed to recognize the benefits of imaging and its effects in reducing overall health costs by substituting for more invasive procedures or treatments. We acknowledged the benefits of imaging throughout the draft report and noted that while some of this spending growth may be appropriate, financial incentives inherent in Medicare’s payment policies for potentially inappropriate use of imaging in physicians’ offices, and their implications for a fiscally unsustainable Medicare program cannot be ignored. We are not aware of any peer-reviewed studies that conclusively show the role of imaging in reducing overall health care costs.
Third, AMIC representatives stated that by focusing only on Part B spending under the physician fee schedule, the draft report did not acknowledge growth in imaging across other sites of care such as hospitals. As we stated in the draft report, Medicare’s physician payment policies contain financial incentives for physicians to directly benefit from higher fees paid for the provision of imaging services in their offices, while receiving lower fees for interpretation of in hospitals. However, we have added additional information to the report, noting that about two-thirds of all imaging services were delivered in the hospital setting in 2006, and that spending on imaging services delivered in physician offices grew twice as fast compared to spending on services delivered in the hospital setting.
AMIC’s fourth concern was that the draft report did not discuss the fairness of the payment reductions resulting from the changes mandated in the DRA. As noted in the draft report, we will examine the effects of payment changes mandated by the DRA in a separate report.

Blah, blah, blah. It's OK to talk about limiting self-referral, as long as we don't actually do anything about it, right? Well, the GAO is talking about it, and maybe CMS will eventually do something about it. I'm not all that keen on RBM's either, but it's a start, and we need to start somewhere.

The Today Show Mentions Self-Referral

2008-07-25T07:17:00.001-07:00

A report featuring NBC Medical Reporter Dr. Nancy Snyderman was aired yesterday on the Today Show, which discussed mainly the amount of radiation one would receive from various tests. Self-referral was mentioned quite briefly in that patients were urged to ask their ordering doc if he or she has a financial interest in the scanning facililty. See the video HERE.

While the ACR has done much to bring imaging self-referral to light, they sometimes take too much credit. In a piece about the Today Show report, Dr. Thrall of the ACR said: "ACR media and public relations efforts regarding quality imaging and the effect of financial incentives on imaging quality and cost are clearly having an effect."ACR media and public relations efforts regarding quality imaging and the effect of financial incentives on imaging quality and cost are clearly having an effect." I'm sorry, but the only mention of the ACR in the piece concerns accreditation. Listen for yourself.

But, I guess any publicity on this topic is good publicity. Even if some wish to take credit where credit is not due.

Cheat Me In St. Louis

2008-07-16T11:49:00.000-07:00

Just when I think imaging self-referral can't get worse, I find something like this. As reported in the Saint Louis Post-Dispatch, a lawyer named Kirk Bowman is managing four imaging mills in the St. Louis area. The business model is very simple:

Here's how Bowman's clinics work: After being evaluated by a board of directors, physicians who want to join make an investment that varies by location, Bowman said. He declined to provide details.
To remain investors, physicians must earn 75 "participation units" throughout the quarter. An MRI counts as three participation units. A CT scan counts as two. Then, the profits are split equally among the investors, he said. Physicians can miss the target for one quarter before being asked to relinquish their ownerships.
Bowman said the referral requirements ensured everyone's contributing to the center's being a success. . .
The referral requirements are so low, 25 to 50 patients a quarter, that physicians do not feel pressured to prescribe tests unnecessarily, Bowman and Schwarze said. And, profits earned are too small to tempt physicians to risk their livelihoods for a bump in income, they said.

You might think this little Ponzi scheme violates the Stark laws, and you would be correct, except for one minor detail: The Stark law was named after its sponsor, U.S. Rep. Pete Stark, D-Calif., and was designed to protect patients and limit health care spending. It bars a physician from referring patients to a diagnostic center in which the doctor has a financial interest when the patient's care is paid for by the federal government through such programs as Medicare.
At least two dozen states have extended similar laws to cover all patients, but Missouri has not. Because the clinic Schwarze invested in declines to care for patients in federal programs, it is not covered by the Stark law.
Bowman isn't worried about the appearances:

"We assume people are honest. I don't know another way to do it," Bowman said. "I don't think a doctor is going to risk his whole career to manufacture an MRI."

Honest. Riiiiiiight. Just ask Dr. Jean Mitchell from Georgetown, who has written extensively about self-referral: "There's no other business where you can control demand and supply," Mitchell said. "This is guaranteed success. It's a cash cow."
She sees Bowman's clinics as even more questionable because they require physicians to refer a certain number of patients to maintain their investment.
"I've never seen anything so blatant as this," said Mitchell, a health economist.
Neither have I.

If you happen to be in St. Louis, and your doctor sends you to Reliable Imaging of St. Louis in West County, Lynn Haven Imaging in Hazelwood, Cedar Plaza Imaging in South County or Boone's Crossing Imaging in the Chesterfield Valley for imaging, look him or her in the eye and ask how much he or she will be making from the referral. Then consider finding another doctor.

GE Is Worried About Radiation?

2008-07-07T16:56:00.001-07:00

Fellow blogger Doctor Dalai has a recent post about SPECT/CT scanners. It seems that General Electric is trying to get him to buy a machine that doesn't do as good a job of scanning, in his opinion, but they are pushing it as the scanner with the lowest dose to the patient:

The following link is to an article regarding the possible link between multiple CTs and cancer risks, especially in children. Aiding us in our cause for our low-dose SPECT/CT Infinia Hawkeye 4 system. Maximum patient dose with the Infinia Hawkeye 4 is 2.5ma. Why more dose for Attenuation Correction and Anatomical Mapping in Nuclear Medicine environment?

I had to laugh when I read this. You might remember my post about GE promoting the sale of scanners to self-referrers from last year. GE has an entire web-page devoted to the joys of owning your own scanners, and how GE will help you get one. My favorite quote from their site is:

In-office CT also provides a highly credible and effective means of differentiating your practice from others in your market. It places you on the leading edge of patient care and may engender positive word-of-mouth that has the potential to increase your revenue opportunities significantly.

So, if you are "increasing your revenue opportunities significantly", you are scanning a lot of patients. Let's be real and admit that some significant proportion of those patients maybe didn't need to be scanned. Thus, GE is proposing irradiating patients for profit. That doesn't quite mesh with their great concern over the increased dose someone would get if scanned on another company's SPECT/CT. But I guess that doesn't matter, does it?

I just love it when people bend and use the facts to their own advantage.

Self-Referral on the Wikipedia

2008-07-07T16:54:00.000-07:00

A poster named Rolf-Rad on AuntMinnie.com has created a page on the Wikipedia about self-referral. It is very well written, and possibly could serve as a focal point for further discussions. Please view it and contribute more information.

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

2008-05-28T07:34:00.000-07:00

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.

A Chat With An Internist

2008-05-27T12:48:00.000-07:00

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.

Uro-Trash

2008-05-19T06:40:00.000-07:00

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.

A Sad Commentary

2008-05-04T17:09:00.000-07:00

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!"

The Inappropriate Appropriateness Argument

2008-04-30T06:24:00.000-07:00

Dr. Ron in the last post has done away with the convenience argument, as far as I'm concerned. But don't worry, our friends the self-referrers have more justifications up their sleeves. Even Tim Trysla, head of AMIC, voiced the "Appropriateness" argument when discussing an article by Dr. Jean Mitchell:

We have reviewed the article in Health Affairs on equipment leasing and are hopeful that the author will release the underlying study data so that her peers can replicate her analysis. Since its inception, the Access to Medical Imaging Coalition (AMIC) has worked with policymakers with the goal of ensuring appropriate utilization of medical imaging services. Unfortunately, the Health Affairs article does not offer any data on the appropriateness of the imaging procedures it analyzes -- which is the key to crafting responsible and sustainable policies on access to medical imaging services.
Without having access to the author's data, it is impossible to know if the conclusions she has drawn are reflective of the facts. However, if the arrangements described in the Health Affairs article are in violation of federal or state law, those violations of the law should be prosecuted.
AMIC looks forward to continuing to work with the Congress to enact a reasonable Medicare imaging policy that preserves and strengthens beneficiary access to the right imaging procedure at the right time.

This opens up an ethical minefield, which is mostly controlled by the self-referring clinicians themselves. They are the ones who determine which patients deserve a scan and which do not. These are "their patients" after all, and who are we to second-guess their judgement? If a patient walks in with a headache, should they not be scanned to rule out a subdural? Well??? Bottom line here is that the clinicians win the appropriateness argument, since in a real sense, they set the rules for it.

But wait. This logic can be turned on its head and thrown right back at them.

We know without any real doubt that those with imaging equipment in their offices order more scans than those who don't self-refer. This is pretty much a given. Let's say that they order twice as many studies, which is really underestimating the problem, but that's OK for the moment. AND, let's assume that all of those scans are appropriate. We wouldn't want to question the judgement of our friends, now would we? With me so far? Now, we turn back to the behavior of those who DON'T have scanners in their offices. They are ordering at One-HALF the rate of their colleagues. Therefore, if the self-referrers are ordering appropriately, the non-self-referrers are jilting their patients, not utilizing the life-saving services available right down the street at their local hospital.

The truth cannot fall both ways, can it? Either the self-referrers are ordering inapproriately, most likely due to the fact that they will make a profit doing so, or the non-self-referrers are restricting their ordering inappropriately. One group is harming their patients, and I'll leave it to you to figure out which one that is.

Is something that is convenient always good for you?

2008-04-28T14:40:00.000-07:00

A reader named Ron put a comment on the last post, and it is so well-written, I thought it deserved full exposure.

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.
Since September of 2006, Harold, the test of time has not proven you wrong. I bet hundreds more cars, boats and McMansions could be added to your list. Self referrers are still laughing all the way to the bank and the amounts of imaging tests and in office machinery is increasing exponentially.
Patients are lining up like rats behind the Pied Piper in supporting these self referring schemes. Insurance companies still seem willing to throw money at these guys. And the government....

Self-Referring Physicians Order More Scans

2008-04-26T05:23:00.000-07:00

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.

The NEMA Code of Ethics

2008-04-19T17:06:00.000-07:00

NEMA, the National Electronic Manufacturers Association, is an organization of technology companies that includes most of the manufacturers of medical imaging equipment. Their "Code of Ethics" is a long document outlining the sorts of interactions their members should and should not have with health care professionals and institutions in the business of selling things to them. The underlying principle is: Members shall encourage ethical business practices and socially responsible industry conduct and shall not use any unlawful inducement in order to sell, lease, recommend, or arrange for the sale, lease, or prescription of, their products.
Most of the rest of the document talks about things they can sponsor in the realm of training and so on, and things they can't do, such as take a client to a concert or a golf game. Gifts are a no-no, and hospitality should be "modest," i.e., if they put you up in a hotel, it should be in neither the best nor the worst room available.

This is all well and good, as far as it goes. The problem lies in the fact that there is such a tremendous amount of money to be made on the sale of a scanner, for example, that sometimes the approach is bent a little. Of course, I'm thinking about the scanners sold to those who self-refer. Think about it. Is self-referral an "ethical business practice"? Is selling the 10th MRI scanner in a small town that already has nine others "socially responsible"? I don't think so, personally. I guess it all depends on your point of view, doesn't it?

And "unlawful inducements"? Every scanner manufacturer will be glad to show the self-referrer just how much he can make with their scanner. Yes, I understand that this isn't an "unlawful inducement", but it is going right up to the border of the gray zone.

I'm not quite sure where NEMA's lobbying of Congress as part of AMIC falls in their code, but it seems to have been acceptable to those in charge.

A code of ethics is great so long as it isn't reinterpreted for each particular situation. Is that happening with NEMA? I'll leave that up to you.

"The Politics of Greed"

2008-04-19T08:26:00.000-07:00

Eradicator, over on AuntMinnie.com, found an incredible article in ImagingBiz.com, written by Curtis Kauffman-Pickelle, who is "a strategic business consultant to more than 30 imaging centers and radiology practices and CEO of the Imaging Center Institute." Obviously, Mr. Kauffman-Pickelle knows his way around the outpatient imaging world. He decries the "pollution" of this sector by the "dark attraction of greed": What is difficult to control, however (and extremely difficult to train salespeople to penetrate), is the political referral that clearly falls within the category of an expected quid pro quo: I will send you my scans if you give me something in return.
Kauffman-Pickelle goes on to describe the ways in which unscrupulous operators will go around the law and regulations trying to bribe their way into a full schedule. He goes on to say, Back to the fundamental question: How do you compete with this greed?
You don’t. Greed is as old as civilization itself, and money—as a manifestation of this one of the seven deadly sins—has been changing behavior and sinking people for centuries.
What ethical and honest businesses need to do is rise above the temptation, knowing that those operating sleazy businesses are really in the minority and that they stand a very good chance of being caught and punished; they are not likely to be happy with themselves and their lives, and are not respected members of the medical community. You need to be able to look at yourself in the mirror each day and know that you are helping people, running a clean and effective operation, and inspiring your staff and teammates to achieve success through your leadership. Your ethics, values, and character will win in the long term.
This is good business as well. Never apologize for your success or for making a good living at your chosen craft. You have earned it, and our society is based on the hard work and commitment of entrepreneurs in all kinds of professions, including medical imaging. Don’t be distracted by those who seem to be getting away with illegal behavior. You really would not want to trade places with them, so leave them to their own devices.
This is of course very good advice, and an excellent analysis. I would carry it over to the problem of imaging self-referral, which is really the same sort of greed-based pursuit of money as described above.

Mr. Kauffman-Pickelle's approach makes sense for those who are of high moral and ethical fiber. Naturally, they are not going to lower themselves to borderline or overtly illegal activities to make an extra dollar. Sadly, those who do participate probably don't care. I would have to disagree with the author about the perpetrators being unhappy and not respected in the community, at least as far as physician self-referrers are concerned. They are happy as clams, wallowing in their ill-gotten gains. They feel completely immune from penalty, that they deserve every cent. Very few of their colleagues care about the source of the revenue in the least; they are only envious of the parade of Mercedes and BMWs and the other swag flaunted by those who abuse the system.

This is why the government will eventually have to step in; there isn't much self-policing going on here. The politics of greed rule.

There ARE Some Ethical Docs Out There

2008-04-15T11:49:00.000-07:00

You might think from reading this blog, as well as any other media source, that many doctors are greedy S.O.B.'s, trying to make an extra buck anywhere they can. While that might be true in some cases, there is a growing movement away from such avaricious behavior.

Gina Kolata, writing in the New York Times today, notes a trend of doctors rejecting pay from industry. It seems that several very prominent physicians have sworn off the dole from pharmaceutical companies and the like. The scientists say their decisions were private and made with mixed emotions. In at least one case, the choice resulted in significant financial sacrifice. While the investigators say they do not want to appear superior to their colleagues, they also express relief. At last, they say, when they offer a heartfelt and scientifically reasoned opinion, no one will silently put an asterisk next to their name.
They are part of a group responding to accusations of ethical conflicts inherent in these arrangements, and their decisions repudiate decades of industry influence, says Dr. Jerome P. Kassirer, a professor at the Tufts School of Medicine, who has written a book on conflicts of interest. . .
(Kassirer) attributes the change to publicity about conflicts and what can be almost a public shaming when researchers’ conflicts are published. “Finally, it’s gotten to people,” Dr. Kassirer said.
Well, if that's what it takes, maybe we need to provide a public shaming for our self-referring friends. How about taking out an ad in every newspaper in every major city (or maybe just one big one in USA Today) listing every self-referring physician that owns his/her own imaging equipment? Of course, the case has to be made in the introductory paragraphs that this is a bad thing. The convenience arguments and so forth have to be destroyed before they are even uttered. People have to be made aware of what is really happening. No doubt they will be angry when they finally understand.

The NYT article does give me hope that the self-referrers (and the radiologists that read for them) can be made to do the right thing. It would be nice if they all grasped the problem without being forced to do so, but that doesn't seem too likely. Now, who is going to take out that ad?

A Cardiologist "Gets It"

2008-04-07T09:53:00.000-07:00

You never know what you will find when you Google "Self-Referral". The list generally includes numerous discussions of Stark laws and CMS rulings.

Today, I stumbled across this very insightful piece from Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology. This would be someone pretty well respected among cardiologists, yes?

At first, Dr. DeMaria pays the usual lip-service to self-referral:

That the increase in medical imaging procedures raises the issue of self-referral should be no surprise. Several studies have demonstrated that diagnostic imaging services are rendered with greater frequency and at greater cost when performed by non-radiologists using equipment in their offices (2). In fact, data suggest that the bulk of the increased use of imaging has been attributable to physicians who self-refer (3). However, it must be recognized that the provision of diagnostic services by attending physicians has many advantages. Many non-radiologists have gained expertise with the imaging procedures in their specialty and have contributed important research findings to advance the field. These specialists can interpret the imaging tests in the context of physiologic and pathophysiologic knowledge of the organ system involved and can integrate the findings with the clinical variables present in any individual patient. The ability to perform an imaging test at the same time and in the same place as the overall evaluation is also an advantage. Thus, although the potential financial incentives of self-referral cannot be ignored, the practice of rendering diagnostic imaging by knowledgeable attending physicians has considerable rationale.

But, he then zeroes in on the problem: The issue, therefore, is how to maintain the laudable attributes of cardiology practice while guarding against the undesirable incentives of self-referral. In my opinion, at least as a first step, we must acknowledge the potential bias that self-referral can introduce into decision making. It seems foolish to me to just deny that self-referral can have any possible influence in decision-making . . . We ought to guard against providing services for which we have little experience. We invite criticism if we undertake to perform procedures for which we have had little training, scant experience, or very low volumes. We should avoid obtaining equipment for our offices for which there is little demonstrated need or advantage. Given the emerging shortage of cardiologists, there would seem to be little reason to work hard at generating business.
Well, Dr. DeMaria, the problem with your brethren isn't generating business so much as generating income. But Dr. DeMaria concludes: The recent explosion of medical imaging procedures has again focused attention on the general issue of self-referral in cardiology. Diagnostic imaging has come to play a central role in the management of cardiovascular diseases, and cardiologists have often been responsible for the development and validation of clinical applications. We take pride in the improved level of care that imaging has enabled us to deliver. However, we must remain cognizant of the potential for inappropriate usage inherent in these techniques. The nature of contemporary cardiovascular medicine makes self-referral for imaging and other procedures a natural and advantageous aspect of our practice. It would be tragic if either our application or the perceptions about our application of these procedures resulted in any impediments to their use.
This would be funny if it wasn't so prophetic. Everyone almost lost out on CCTA reimbursement, and that is mainly (although not officially) because CMS was petrified that the cardiologists would abuse it like they have been abusing most of the rest of their toys.

Maybe the solution to the self-referral problem lies in alerting those with some moral authority in the clinical camps to what is happening. But they probably know about it anyway. One lone voice gets lost in the woods, at least most of the time.

Welcome, Aunt Minnie Readers

2008-04-06T08:39:00.001-07:00

Looks like someone named eradicator found this blog, and let everyone on Aunt Minnie know about it. Thanks for the promo!

Please read through the posts and see if they make sense to you. I would really like to hear your comments and suggestions as to how we can fight against the problem of imaging self-referral.

Harold

(I'm not going to say much about who I am for obvious reasons. I'm just a guy that thinks self-referral has to stop. That's all.)

The Decline and Fall of Radiology (and How to Avoid It)and a factor the authors missed

2008-03-09T09:50:00.000-07:00

In a recent JACR, Richard B. Gunderman, MD, PhD, Andrew J. Koerber IV, BS, MS make some interesting comparisons between the decline and fall of radiology, and the historical downward spiral of the Roman Empire. They base their discussion on Edward Gibbon’s The History of the Decline and Fall of the Roman Empire.

Rome was the greatest empire that had been seen up until its time, and some would say it still holds this distinction. I'm not going to review all of its accomplishments, but they were legion. So what happened? Gibbon noted several factors. The reason most often cited is the pressure from outside, the Huns and Goths, and other shabby folks, who ultimately destroyed the city of Rome itself. The authors of the JACR article liken this to the external problems radiology faces such as uncooperative hospitals and turf battles with other docs. But Rome probably fell more because of internal decay than any other reason, and radiology as a specialty needs to see these parallels.

Gunderman and Koerber note that Rome progressed from a republican government, where the people had a say (and were honored to participate) to despotism, where the emperors took over all power, and became increasingly corrupt. They compare this to the pursuit of revenue amongst radiologists, giving the example of outpatient imaging centers being built where they will make the most money, not where they would do the most good.

Rome, it seems, also gave too much power to mercenaries, ruining the ideal of the citizen-soldier. Mercenaries sadly may eventually ignore or even turn against their employers, because, after all, they are just hired guns (or maybe hired swords in this era.) Radiology is doing something similar by turning its decision making processes over to consultants and lobbyists. Research is increasingly in the hands of the vendors, and not the universities. Radiology isn't even a required course in most medical schools. Of course, teleradiology might be the best example of how radiologists can hand off their responsibilities, although for the most part this is at least to other radiologists!

Luxuries lured Romans' attention away from where it should have been directed, and even today, after two thousand years of pillage of the sites, you can still see that a lot of time and money was spent on frivolities. Cash became the most important thing, and previously loyal folk would sell their support to the highest bidder. Corruption became widespread, and no one trusted the government. Sadly, radiology is falling prey to the same sort of thing, Making money becomes the end-all, instead of taking care of patients. To get said money, radiologists are making bad deals with hospitals and governments.

Gunderman and Koerber conclude that radiology has to avoid making income the primary motivation. It needs to promote invention and innovation, and work for the good of the patient. There must be collaboration with other specialties.

I couldn't agree more. However, I think Gunderman and Koerber left off a very important item, which is why this belongs on this blog. That is, of course, the scourge of self-referral, and the damage it is doing to radiology and to medicine in general. They do come close to mentioning this at several points, but I think it needs to be stated more explicitly in terms of the foregoing arguments.

Self-referral in many ways relates to every one of the factors that brought down Ancient Rome. I won't even try to discuss this in terms of the clinicians who participate; they are no better than the barbarians that invaded Rome. They are invading radiology and medicine quite nicely, and radiologists are holding the gates open for them. Why is this? Reread the discussion above. The primary factor is money, of course, be it the opportunity to zero in on the reads generated by the excess ordering of scans, or even the thought to preserve interpretive income when the clinician takes his paying patients away from the hospital to be scanned on his own machine. And as with the increasing corruption of Rome, radiologists are abdicating their moral responsibility to stand up and say something about this issue, for fear of disrupting their incomes. These radiologists are themselves becoming the mercenaries, being willing to work for clinicians that most would agree are not doing the right thing. From Gunderman and Koerber's article, The word mercenary derives from the Latin merces, meaning “price,” and also the source of our words mercantile and merchandise. Mercenaries are guided by overarching concern with wealth and profit, as opposed to honor. They sell their services to the highest bidder and do what they are paid to do, often unencumbered by moral scruples. To expect loyalty or trustworthiness from a mercenary is to fail to understand what a mercenary is. They enter, exit, and reenter contractual relationships as needed to maximize their earnings. In the final analysis, they can be trusted to do but one thing: pursue their own self-interest.
Need I say more? Vēnī, vīdī, vīdere animus.....

Talk To Congress!

2008-03-05T09:42:00.000-08:00

AuntMinnie.com recently reviewed a speech given at the RBMA meeting in February, 2008 by Douglas Smith, founder and president of Barrington Lakes Group, a healthcare consulting firm in Barrington, IL. Mr. Smith made some suggestions that are right in line with what I've been saying myself. Elected officials often don't differentiate between different imaging entities -- radiologist-, corporate-, or referring physician-owned -- but focus instead on imaging's spike in the percentage of total medical services, Smith said.
"The radiology profession is not well understood in the halls of Congress," Smith said. "Many Congress people don't realize that overutilization is something that is done to radiologists, not something they do."
Policy makers have moved to clamp down on costs with legislation such as the DRA, assuming that the increased volume of imaging exams performed compensates for federal reimbursement reductions.
It doesn't, of course. But unless radiologists and administrators begin to educate governmental representatives, medical imaging will get more of the same in coming years, Smith said.
What should the radiological community do about this? The Association for Quality Imaging (AQI), the American College of Radiology (ACR), the American Society of Radiologic Technologists (ASRT), and the RBMA have been working to educate governmental representatives on the cost and practice of radiology. But more can be done, especially in light of the experience and resources of the American Hospital Association, the American College of Cardiology, and other advocacy groups. Radiology staff -- from physicians and imaging center operators to teleradiology companies, suppliers, and billing companies -- need to get active to gain a voice in Congress, Smith said.
The message I hear is that Congress (and by extension state legislatures and governors) doesn't have a clue about the imaging self-referral problem in particular, and about what it is that radiologists do in general. I'm sure the self-referrers would be glad to educate them if no one else wants to bother.

A Modest Proposal

2008-02-23T11:30:00.000-08:00

Jonathan Swift's tongue-in-cheek treatise, "A Modest Proposal" was anything but modest. I'll leave it to you to read the original, but suffice it to say that his "solution" to the problem of hunger in Ireland was entirely unacceptable to say the least.

I've been ranting for some time now about the problem of imaging self-referral, and for all the good I'm doing, I might as well be talking to myself. While CMS seems to slowly trudge toward doing the right thing, it will probably take years before they accomplish anything. In the meantime, we see self-referring docs gutting the system, almost literally "eating their young" in the process.

But what to do? CMS seems to grasp the problem. Sort of. Occasionally. Congress doesn't get it at all, and gets conflicting information in the form of the ACR alternately decrying self-referral in one session and sitting with the self-referrers in another.

But it is on the state level where I think something can be done. Look at Maryland, and West Virginia as I mentioned in an older post. They are doing something about imaging self-referral, and so far the effort has been effective, angering our self-referring pals no end.

So, here is MY modest proposal: There needs to be a delegation, a road-show, if you will, sent to visit every state legislature and every governor that will consent to see them. This group needs to include those who have studied this problem extensively, and have published about the situation in peer-reviewed journals. I won't name names, but they know who they are. The delegation should include like-minded physicians from the particular state.

I have the childish opinion that members of government want to do the right thing, and will do so if given the opportunity. I'll bet you a tall latte' that the majority of those in government, at the state and the federal level, haven't got a clue about imaging self-referral. So somebody out there with credibility needs to tell them and let them help us solve the problem.

Now, when word gets out about this, there will be a lot of lobbying from the self-referrers, and the equipment companies, too, because they will not like their golden pacifiers plucked from their mouths. They will testify with all the usual drivel about patient convenience and dead grannies. The members of the "road-show" will have to be prepared for this, as I'm sure they would be. I wouldn't be totally surprised if they received threats for coming forward; $16 billion is a lot of money to be taken away from the self-referrers, and they won't be at all happy. But it needs to be done.

Anyone want to sign on for this modest little proposal?

Here's Where We're Going...

2008-02-14T12:31:00.000-08:00

From ChinaView comes an interesting tidbit:

China to control procurement of high-cost medical devices
www.chinaview.cn 2008-02-14 16:18:03

BEIJING, Feb. 14 (Xinhua) -- The Ministry of Health has reportedly tightened controls on purchases of high-priced "Group A" medical devices, which cost more than 5 million yuan (about 710,000 U.S. dollars), saying that such equipment could contribute to rising medical expenses.
The ministry and the National Development and Reform Commission will jointly develop a procurement plan for such items as X-ray machines and PET-CT scanners, according to the Beijing News.
The ministry said that these devices involved high operating costs and complex technologies.
The ministry said that it would ask experts to evaluate the purchase of such equipment before giving approval to medical organizations.

Ha! Even the old Ex-Communists get it. Well, I'm sure no one here wants to have to deal with their system, but at least they are being proactive about the high cost of medical care. If our insurance rates and health care expenditures keep skyrocketing, you can bet Washington will institute some very similar measures. Especially if Hillary should happen to win the White House.

Certifying Your Self-Referral CT

2008-01-31T09:10:00.000-08:00

If you want to legitimatize your self-referral operation, just create a society or a commission. The ICACTL, or the "Intersocietal Commission for the Accreditation of Computed Tomography Laboratories" fills the bill. Their mission statement reads, "The ICACTL is dedicated to promoting quality computed tomography diagnostic testing in the delivery of health care by providing a peer review process of laboratory accreditation." So I guess if they bless an operation, it guarantees quality. Sure it does.

Who sponsors this thing anyway? I don't see any radiology societies in there:

American Academy of Neurology
American Academy of Otolaryngology
American Association of Physicists in Medicine
American College of Cardiology
American Society of Echocardiography
American Society of Nuclear Cardiology
Society for Cardiovascular Angiography and Interventions
Society for Vascular Surgery
Society for Cardiovascular Computed Tomography
Society of Nuclear Medicine

Acquiring this blessing is pretty cheap, only $2500 for a main site, and $1000 for each additional scanner per lab. I'm going to buy a used scanner and put it in my garage, and pay my $2500 so I can be accredited too!

Oh, guess what? There is also a sister operation, ICAMRL, the Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories. Why can't we just be honest and create the ICARMFPW, the Intersocietal Commission for the Authorization of Removal of Money From Patients' Wallets?

The Bu$ine$$ of Medicine

2008-01-30T11:25:00.000-08:00

Here are two articles about doctors profiting from their patients. In both, the doctors appear to be basing their treatment decisions on how much money they can make, rather than what is best for the patient.

The first is from the New York Times, and discusses how an artificial disk for the spine called Prodisk made it through all the testing that these things need:
In a study of nearly 240 patients with lower back pain, the doctors said that the Prodisc, an artificial spinal disk, had worked much better than conventional surgery in which patients’ vertebrae were fused.
“As a surgeon, it is gratifying to see patients recover function more quickly than after fusion and return to their normal activities more easily,” Dr. Jack E. Zigler, a well-known spine specialist and one of the study’s lead researchers, said in a 2006 news release announcing the latest results of the Prodisc clinical trial.
As it turns out, Dr. Zigler had more than a medical interest in the outcome. So did doctors at about half of the 17 research centers involved in the study. They stood to profit financially if the Prodisc succeeded, according to confidential information from a patient’s lawsuit settled last year.
The other article is from NBC News Chief Science and Health Correspondent Robert Bazell who talks about cardiologists doing much the same thing.

Some very smart doctors believe that the vast majority of the 1.6 million Americans who get these procedures in any year may never need the expensive and potentially dangerous interventions, or at the very least, they don't need them yet.
But we don’t hear much about option No. 3 because it is drowned in the tsunami of profits made with the procedures, especially angioplasty with stents.
Let me be clear, the vast majority of interventional cardiologists — the doctors who perform angioplasties — are honest and caring physicians. But I remember standing in scrubs outside a procedure room in Miami when the other doctors (who mistook me for a colleague) were bragging about how many “normals” they had done angioplasties on. That’s right, people came in complaining of shortness of breath or chest pain, so the doctors put them into the cauterization lab and examined their vessels, then told these patients they needed an angioplasty and did it knowing full well it was unnecessary.
For many doctors and hospitals, angioplasty has been the mother lode. I’ve had young interventional cardiologists brag to me of their multi-million dollar signing bonuses to change hospitals.
This specialty faces a mine field of potential conflicts because so much of it is based on self-referral.

What ever happened to Marcus Welby, M.D.?

A New Way To Profit From Imaging and Self-Referral

2008-01-17T07:55:00.001-08:00

It isn't enough that self-referrers profit from their actions; now, you have the opportunity to invest in their bad behavior and make some money yourself!

From the website, http://www.directmedicalinvesting.com/:

The demand for PET scans has grown 46% per year since 2004
Analysts project that nearly 2 million more patients will require scans this year
Growth means additional demand creating a unique investment opportunity

And

Earn a monthly distribution as a partner in a full service, state-of-the-art medical facility, equipped with the most sophisticated and effective scanning diagnostic tools available today.
Private investments are great alternative to today's stock market. This cutting-edge diagnostic technology is capable of providing a crystal-ball-like look into your medical future. These diagnostic scans are now covered by most health insurance companies and HMOs, creating an exceptionally high demand for these procedures.
The medical imaging industry is highly profitable and has been expanding vigorously for nearly 2 decades. Continuous and significant medical imaging innovations are keeping this market segment growing with few signs of saturation. Due to exceptional growth and constant technological advancements, medical imaging is highly promising for the long-term investor.

Pretty clear what they have in mind. I'm not buying, but thanks for playing. You have to love the blurb on the front page: "Invest with medical experts and GE Healthcare technology." Yup. Anything to sell another scanner.

Pi$$ed Off Urologists

2008-01-13T06:36:00.000-08:00

The American Urological Association have an "Imaging Resource Center" to justify their imaging self-referral. Here is a partial list. Pick a topic and see how they posture and pander to keep the cash flowing:

AUA Positions, Letters and Talking Points
Patient-centered Imaging in Urology—The Facts on In-office Diagnostic Tests

Response to Highmark’s Diagnostic Imaging Standards

Imaging Talking Points for AUA Members- Self-referral Talking Points for Physicians

Consensus Statement on Urologic Ultrasound Utilization

Recommendations for Urologic Office Ultrasound
Coalition for Patient-Centered Imaging (CPCI)
Comments on MedPAC’s Proposed Recommendations on Imaging Utilization: January 6, 2005

CPCI Testifies to Ways & Means Subcommittee on March 17, 2005 (press release)

I shouldn't be surprised by what's in this stuff, but some of it is pretty unbelievable. For example:

In-office imaging provides the fastest, most convenient and often the most reliable results — results that are routinely used by treating physicians in providing ongoing patient care. The use of office-based imaging allows for quicker diagnosis and prompt treatment.
The American Urological Association (AUA) is concerned about recent allegations that diagnostic imaging performed by physicians other than radiologists is “substandard” and “unnecessary” and that the growth in utilization is principally attributable to in-office testing by physicians other than radiologists. None of the allegations are true. There is no credible evidence that in-office imaging is being conducted inappropriately or is resulting in inaccurate diagnoses. . .
Nor is there any basis for the allegation that office based imaging is the primary cause of increased utilization. Many factors have influenced growth in the volume of imaging services, including improved technology; changes in the standard of care for many illnesses; expansions in coverage for new diagnostic imaging modalities; and shifts in the site of service from hospitals to other health care settings. Much of this growth is in hospitals and Independent Diagnostic Testing Facilities (IDTFs). The improvement in quality has meant that many specialties, including urology are now using imaging for therapeutic purposes rather then simply a diagnosis tool. . .
A prohibition on in-office diagnostic testing would reduce patient access to timely, convenient testing, and disrupt the important continuity of care. According to the ACR, there is currently a shortage of radiologists, and in certain parts of the country there are already long waiting periods for critical imaging studies, such as mammography. Restricting in-office testing could substantially aggravate the problem, resulting is significant delays and reduced quality of care. In addition, Medicare beneficiaries pay substantially more when imaging services are provided in hospital outpatient settings instead of physicians’ offices. According to MedPAC, in 2002 the Medicare coinsurance rate for hospital outpatient imaging services was 53 percent. Coinsurance for these services in physicians’ offices was limited to 20 percent.
While increased costs are a concern to physicians and patients alike, restricting patients’ access to timely and accurate diagnoses by their own physicians is not the answer.

Oh, boo hoo. Reminds me of the old Bart Simpson quote: “I didn’t do it. You can’t prove it. Nobody saw me.” Give me a break, guys. No evidence? There is a ton of evidence. Just Google it, and you'll see. And patients will suffer if you take their toys away. And so on and so on. Don't they see just how transparent their arguments really are?

HCFA Decries Self-Referral, Circa 1999

2007-12-22T16:49:00.000-08:00

Googling "self-referral" brings up many interesting articles. Here are some exerpts from the testimony of Kathy Buto, who was then Deputy Director, HCFA Center for Health Plans & Providers U.S. Department of Health and Human Services, before the House Ways & Means Health Subcommittee on May 13, 1999:

Chairman Thomas, Congressman Stark, distinguished Subcommittee members, thank you for inviting us to discuss limits on physician self-referrals for Medicare and Medicaid beneficiaries. These limits were enacted into law, with leadership from this Subcommittee, to prevent increased program costs and potential harm to beneficiaries from unnecessary tests and treatments. They are based on numerous studies showing that physicians made far more referrals when they had a financial interest in a testing or treatment facility. Some studies also found higher prices and lower quality with self-referrals. The American Medical Association has declared self-referral unethical in most instances. . .
Concern about the ethical risks inherent in physician self-referral dates back at least to a 1986 Institute of Medicine study. A 1989 HHS Inspector General study documented that physicians who owned or invested in independent clinical laboratories referred Medicare patients for 45 percent more laboratory services than did physicians who did not have such financial interests. In 1991, the American Medical Association Council on Ethical and Judicial Affairs concluded that physicians should not refer patients to a health care facility outside their office at which they do not directly provide services and in which they have a financial interest. And in 1992, the American Medical Association House of Delegates voted to declare self-referral unethical in most instances.

So, Stark and HCFA, now CMS, had a pretty good understanding about self-referral, even back in 1999. And there was even a reasonable approach proposed:

We have taken steps in our proposed regulations to clarify the law and create appropriate flexibility. One of the most important provisions establishes that referrals to an entity with which a physician has a compensation arrangement are generally permissible as long as the compensation is at "fair market value," furthers a legitimate business purpose, and is not tied to the volume or value of physician referrals. This exception goes a long way in simplifying the policy under the law.

They were off to a pretty good start, weren't they? But somehow things got lost in the translation, and we have the mess created by "shysters and promoters" looking for ways through the Stark I and II loophole, as Stark himself phrases it.

But, keep it simple, and even doctors will be able to understand it. How about Dr. Reicher's "No machine fee for self-dealing in medical imaging." That's pretty simple, too, and right to the point.

Why Radiologists Should Avoid Imaging Self-Referral

2007-12-21T09:47:00.000-08:00

Radiologists who read studies for self-referrers try to explain away their behavior with excuses like these:

"They will buy the scanners anyway, so we might as well read for them, and thereby not anger them and lose other business."
"The patients deserve the best reads that only we can provide."
"If we don't read for them someone else will..."

Here's the answer from an anonymous source who makes a great deal of sense:
The answer is that you can never justify doing something wrong because somebody else will if you don't. That condition is always true and always will be true, and could be used to rationalize any nefarious act. This type of logic didn't hold water at Nurenberg and still doesn't.

You can't live your life according to what other people might do. You can only control what you do and face the consequences. The consequences of refraining from unethical medical practice is that you gain self-respect. You may, in the very short term, sacrifice 10% of an income that already places you among the top of U.S. incomes and among to top medical specialists. You might slip a little in the short run. In the long run, you will do better financially by not participating.

The consequences of participating is that you lose self-respect, and must live with the constant understanding that at some point you are going to have to explain all of this to your family, friends, and community. And despite the positive very short term finanicical consequence of participating, you should realize that the long term negative consequences have already hit you and will only get worse--in that you have already suffered a 10-30% in CT, MRI, and PET reimbursement because of radiologists widespread participation in self-referral.

Think about it.

GE Promotes In-Office Imaging

2007-12-16T18:40:00.000-08:00

This little ad on GE's website really says it all. Let me quote:

Expand your practice with in-office CT

More continuity. More convenience. More ways for your practice to succeed.
There are compelling reasons to add CT imaging to your practice.
First and foremost? Enhanced patient care. The ability to identify a potential problem and then confirm or rule it out with a CT exam conducted in your own office – perhaps on the same day – improves the convenience, timeliness and continuity of care your patients receive.
In-office CT also provides a highly credible and effective means of differentiating your practice from others in your market. It places you on the leading edge of patient care and may engender positive word-of-mouth that has the potential to increase your revenue opportunities significantly.
GE’s comprehensive resources can help you get started
As you consider the decision to bring a CT scanner into your practice, the question is: how do you optimize its implementation and avoid any missteps along the way?
GE Healthcare can help. We understand medical practices and have years of experience in helping independent healthcare providers make smart equipment investments.
Moreover, GE offers the industry’s most comprehensive portfolio of resources to address your needs. We have the people and the programs in place to guide you through the critical issues surrounding CT acquisition, including:
Evaluating feasibility based on in-depth market assessment
Conducting cash flow analyses for a clear ROI picture
Selecting the right scanner for your patient volume and procedure mix
Creating customized floor plans for your installation
Setting realistic design and construction timelines
Assisting with short- and long-term staffing solutions
Offering a range of financing instruments
Providing training, maintenance and service support

With GE by your side, you can concentrate on your practice, secure in the knowledge that an experienced team of professionals is guiding your CT implementation.

Wow. Doesn't that just make you feel all warm and fuzzy inside? GE is at the side of the self-referrers, guiding them down the path of, well, you know.

I have the feeling that it was the equipment companies that started this lovely trend in the first place, way back when. I don't think most docs would have thought of putting CT's, MRI's, or PET scanners in their offices without a little help from the folks that sell them. Why not have a complete GE small appliance selection for the "patient's convenience"? Perhaps a GE-designed car-wash in the back? They ARE doing this for the patients aren't they? Well, I do have to give GE credit for being honest...about "the potential to increase your revenue opportunities significantly."

Remind me to buy Philips light bulbs next time I go to Safeway.

The Excuses for Self-Referral

2007-12-16T06:33:00.001-08:00

Those who practice imaging self-referral always have an excuse for their actions. Here are some of the most common, along with some possible rebuttals.

1. Having imaging in the office is sooooooo convenient for my patients. Just ask them and they will tell you how much they appreciate it. They don't mind that I own the equipment.

The vast majority of self-referring clinicians schedule imaging at different time than the patient's clinical appointment. Thus, the patient has to make two trips anyway. How is that more convenient? Those places that do schedule the imaging on top of a clinical appointment run in a "just in time" fashion that puts undue stress on whoever is reading the study to get the interpretation out fast, which can lead to mistakes. Does this "convenience" outweigh the danger? And what if your patient has to go to the hospital? The potentially life-saving comparison images might be locked up in your office PACS, unavailable to those trying to take care of your patient for you.

2. Clinicians have lost income over the years and deserve to get it back any way they can.

If I lose money in the stock market, am I allowed to rob a bank? How did this entitlement mentality arise?

3. Advanced imaging helps me make decisions, and so it should be considered an ancillary service just like a chest x-ray.

But why does that warrent having a $2 Million scanner in your office?

4. Yes, my December volume is really high. The patients ask me to get their scans done before the end of the year since they have already met their deductables. I'm just helping them out.

And it's so much easier to collect from the insurance companies instead of the patients themselves, isn't it?

5. How dare you accuse me of ordering extra scans! Each scan I order is justified!

Perhaps, but then why do self-referring clinicians order from 2 to 8 times as many scans as those who don't self-refer? Are the latter group of doctors not taking proper care of their patients?

6. How can you call my equipment inferior? The radiologists that read my studies don't complain!

Maybe they should complain. Sounds like they are too timid to offend their revenue source.

7. What do you mean I might be causing cancers by ordering extra scans! The radiologists didn't warn me about that! Everyone says CT is safe!

Again, maybe they should be raising some warnings. All it's going to take is one good lawyer seeing a goldmine in this issue, and a lot of heads will roll.

9. I'm not hurting anyone. I only scan people with insurance.

And you send those without insurance to the hospital, having skimmed the cream for yourself.

9. If I'm doing such a bad thing, why are there lots of radiologists and equipment companies standing in line to help me do it?

Because there are always people out there willing to exploit a loophole in the law if they see a dollar at the end of it.

10. But the law allows me to do it!

You mean the loopholes in Stark I and II. Stark never intended for you to have anything beyond an x-ray and an ultrasound machine in your office.

11. So what are you going to do about it?

That's the big question, isn't it?

Two States Fight Imaging Self-Referral

2007-12-10T18:14:00.001-08:00

Some states appear to understand the problem of self-referral, and are willing to do something about it. Let's hear it for Maryland and West Virginia, who seem to be at the forefront of the battle.

As reported in amednews.com, a Maryland court has upheld a rule banning non-radiologists from self-referring for in-office imaging.

The court battle ensued when a group of 14 medical practices challenged the board last December. The plaintiffs -- comprising orthopedic surgeons, urologists and emergency physicians -- are part of the Maryland Patient Care and Access Coalition, which was formed to advocate for the issues at stake in the case. The doctors say state authorities misread the law and several exemptions within it that allow in-office referrals for ancillary services, including imaging tests.
The court noted, however, that the statute's definition of ancillary services "specifically excludes MRI and CT scans for all doctors except radiologists" -- a delineation that "forecloses the two other exceptions."

But don't think the self-referrers will take this lying down:

Baltimore orthopedic surgeon Andrew N. Pollack, MD, said quality of care and patient convenience are improved when physicians have immediate access to the diagnostic testing.
"[Physicians] can get the information they need in evaluating the patient, whereas radiologists as third parties do not have the same background on the patient's condition," said Dr. Pollack, past president of the Maryland Orthopaedic Assn. and member of the American Academy of Orthopaedic Surgeons, which filed a friend-of-the-court brief in the case.

I thought radiologists were physicians. Here is what they have to say:

"Despite the intentions [of Maryland's self-referral law] to disarm this inherent conflict of interest, overutilization still exists, causing the cost of health to rise dramatically and exposing patients to unnecessary medical procedures," states the Maryland Radiological Society in a friend-of-the-court brief. The American College of Radiology supported the state chapter. Both groups declined to comment.
The radiologists also argue that they are better trained to interpret imaging than non-radiologists. The medical board in its opinion cited examples showing patients rarely benefit from getting tests on the same day of an appointment or at the same location as the referring physician.

The Charleston, West Virginia, Gazette, from December 9, has a somewhat similar story:

West Virginia doctors won’t be putting expensive diagnostic imaging equipment in their offices anytime soon.
Gov. Joe Manchin has rejected a state Health Care Authority-approved plan to let physician offices buy and install CT scanners, saying the proposal didn’t ensure that doctors would accept low-income patients unable to pay for digital X-ray services.
“He wanted to make sure that everyone who has these operates on a level playing field,’’ said Manchin spokeswoman Lara Ramsburg. “Otherwise, you’re giving an unfair advantage to one group over the other.’’
Hospitals are required to provide CT scanning services to all patients, including those without insurance and those covered by Medicaid.
“If the governor is sending this back to the authority to look at Medicaid, the uninsured and underinsured, that’s something that will be beneficial to patients,” said Joe Letnaunchyn, president of the West Virginia Hospital Association. “This will start to address the issue of a level playing field. Hospitals are providing care 24/7 to all patients.”
. . .Hospital executives say the proposal to allow doctors to have CT scanners will siphon away business, costing them tens of millions of dollars a year. CT scanning is one of the few profitable services that hospitals provide.

Again the self-referrers bleat the same refrain:

Doctors argue that more imaging machines would save lives, allowing them to diagnose diseases earlier.

And make them more money, but I guess that doesn't sound as good to their patients and the public.

The tide is turning, folks.

Stark Not Happy With His Laws

2007-12-03T17:58:00.000-08:00

There is a pretty good interview in Forbes with Congressman Fortney Pete Stark, who wrote the Stark laws about self-referral. He is disappointed that all he did was make doctors jump through the loophole in the law to keep self-referring.

The Congressman had his doubts at the time: "I didn't think there was such a big deal. So the doctors wanted to make some extra money..." But then a study in Florida showed how much these self-referral arrangements were being abused. Some doctors would send every patient in for an X-ray at facilities they owned.
While the law's intent was good, the law banning these businesses might have done more harm than good, he says now: "It gave every shyster and promoter a loophole." A whole industry of Stark-compliant businesses was born--not unlike the sector devoted to tax avoidance. Stark had to rewrite and clarify the laws in 1995, and there's still debate about it. Currently Congress is looking into regulating the use of imaging machines in doctors' offices and fighting over banning doctor-owned specialty hospitals. "We now have to keep rewriting the laws like the tax code," Stark says.

Some of the comments urge him to keep going and fix the problems. We can all only hope he does so.

How The ACC Sees It...a matter of Spin

2007-11-16T07:13:00.000-08:00

Click Image to animate

Image credit: www.lsus.edu/sc/math/rmabry/knots/2spin2.gif

While surfing the 'Net for an scrap of information, I stumbled upon an interesting page from the American College of Cardiology. Exerpted below are two pertinent paragraphs:

West Virginia Cardiologists Continue Battle for Freedom of Imaging
Ganpat G. Thakker, M.B.B.S., F.A.C.C., President, West Virginia Chapter of the American College of Cardiology, this week carried his campaign for freedom of cardiovascular imaging to the Charleston Gazette. In a letter to the editor Dr. Thakker pointed out that the Centers for Disease Control and Prevention reported last week that West Virginia citizens have the highest rate of cardiovascular disease in the United States. Cardiologists are dismayed that the West Virginia Legislature may vote to make it more difficult for patients to obtain needed cardiovascular services from their physicians. SB 266 and HB 2652, currently before the Senate and House Judiciary Committees, would let the state decide whether a physician can purchase computed tomography (CT) equipment. Both committees are expected to vote on this legislation soon.

Maryland Cardiologists Support Amendments to Self-Referral Law
Roger Leonard, M.D., F.A.C.C., President, Maryland Chapter of the American College of Cardiology, presented a statement this week to the Maryland House of Delegates Health and Government Operations Committee supporting HB 849. That bill would amend the state's restrictive self-referral law by removing MR, CT and radiation therapy services from the in-office ancillary exception for group practices in rural areas. Orthopaedic surgery is expected to support the bill while radiology's strong opposition is anticipated. In his statement Dr. Leonard argued that both the growth of imaging technology and patient access to improved techniques were unforeseen when the General Assembly passed the Maryland Self-Referral Law in 1993. Cardiac MR and CT have now become central to the safe and effective diagnosis and treatment of heart disease.

"Cardiologists are dismayed that the West Virginia Legislature may vote to make it more difficult for patients to obtain needed cardiovascular services from their physicians." Gee, that sounds an awful lot like the arguments AMIC puts forth to convince Congress of the need to amend DRA-2005. Listen to this quote from the debate in the West Virginia Lesislature over SB 266:
Senator Evan Jenkins attempted to amend the rule again by deleting the entire section prohibiting physician to physician referral. He argued strongly that a vote against his amendment would be a vote in favor of bigger government intrusion into the private practice of medicine, negatively impact access to patient care, negatively impact patient convenience and pose higher costs to patients by restricting competition.
My, but this sounds really, really familiar, doesn't it? How can we use the same arguments, but hope to achieve different results?

"Trying to Regulate Imaging Self-Referral is Like Playing Whack-A-Mole"

2007-11-15T07:10:00.000-08:00

Dr. Bruce Hillman authored the article "Trying to Regulate Imaging Self-Referral is Like Playing Whack-A-Mole" in the August issue of the AJR. The piece actually reviews and comments on another article, "The Prevalence Of Physician Self-Referral Arrangements After Stark II: Evidence From Advanced Diagnostic Imaging" from the April 17, 2007 edition of Health Affairs, by Dr. Jean M. Mitchell, a professor of public policy at Georgetown University.

Dr. Mitchell undertakes an analysis of imaging self-referral by sifting through data from a "large insurer in California". Her conclusion:

Nearly 33 percent of providers who submitted bills for magnetic resonance imaging (MRI) scans, 22 percent of those who submitted bills for computed tomography (CT) scans, and 17 percent of those who submitted bills for positron-emission tomography (PET) scans were classified as “self-referral.” Among them, 61 percent of those who billed for MRI and 64 percent of those who billed for CT did not own the imaging equipment. Rather, they were involved in lease or payment-per-scan referral arrangements that might violate federal and state laws.

Dr. Mitchell conducts a scholarly analysis of the data to come to her conclusions, and I won't try to reproduce it here. What is quite interesting, however, is the commentary to her article published on the HealthAffairs website. None of the letters were complementary, and one from a neurologist who self-refers was outright contrary:

I believe this article takes a simplistic, one-sided look at self-referral. Our private practice group has had MRI services since 1987, and we feel that we are saving health care costs. Two primary reasons: 1. Third-party insurers pay us much less than the local hospital system; 2. In-office MRI expedites diagnosis and reduces hospitalization rates. Abuses of the system should be curbed but not in a way that monopolizes services and prevent unique practice arrangements that foster excellent patient care.

Yeah, that old patient convenience and dead-granny argument. But saving the insurance companies money? Let's use an arbitrary figure and assume the outpatient charge is HALF of what a scan might cost in the hospital. (This I believe grossly overstates the discrepancy, but go with it.) So, if our self-referring friends order from 2-8 times what they would if they had to send the patients to the groady old stinky hospital, they aren't saving anyone anything at all.

More amusing is a comment from none other than Tim Trysla, "Counsel, Access to Medical Imaging Coalition." That would be the head of AMIC, folks, our ACR-sponsored lobby to help the self-referrers maintain their profits. (OK, I'll be fair and note that AMIC was supposed to help radiologists with outpatient imaging centers, too, but when you lie down with dogs, you get up with dog-hair in your mouth as well as fleas.) Here is Mr. Trysla's eLetter:

We have reviewed the article in Health Affairs on equipment leasing and are hopeful that the author will release the underlying study data so that her peers can replicate her analysis. Since its inception, the Access to Medical Imaging Coalition (AMIC) has worked with policymakers with the goal of ensuring appropriate utilization of medical imaging services. Unfortunately, the Health Affairs article does not offer any data on the appropriateness of the imaging procedures it analyzes -- which is the key to crafting responsible and sustainable policies on access to medical imaging services.
Without having access to the author's data, it is impossible to know if the conclusions she has drawn are reflective of the facts. However, if the arrangements described in the Health Affairs article are in violation of federal or state law, those violations of the law should be prosecuted.
AMIC looks forward to continuing to work with the Congress to enact a reasonable Medicare imaging policy that preserves and strengthens beneficiary access to the right imaging procedure at the right time.

Gee, if he applied any more spin to the situation, he would have the worst case of vertigo in the room. Note the usual political tactic of trying to discredit Dr. Mitchell's data. I'm not sure what data Tim feels is missing here. Oh, yes, the appropriateness data. Well, you know, that is really the crux of the entire self-referral debate, isn't it? Every patient that makes it through the door of a specialist, say a neurologist, has some symptom related to that specialty, such as the neurological system in this example. Therefore, a head CT could be considered appropriate for every last one of them. So, why does the data (from this and other sources) show an increase in the number of scans ordered when the doc can profit from it? Are those in a non-self-referring situation neglecting their patients, or is the system being abused? I guess it is appropriate for a bank-robber to ply his trade at banks, since that is where the money is. Every scan can be justified on an individual basis, and I'm sure Tim knows that. But when you have a massive shift in ordering behavior, something is very wrong.

Dr. Hillman furthers the argument, and even notes that his own research prompted a "change in the opinion of the American Medical Association Council on Ethics and Judicial Affairs (AMA CEJA) on physician conflict of interest and self-referral arrangements":

Physicians are free to enter lawful contractual relationships, including the acquisition of ownership interests in health facilities, products, or equipment. However, when physicians refer patients to facilities in which they have an ownership interest, a potential conflict of interest exists. In general, physicians should not refer patients to a health care facility which is outside their office practice and at which they do not directly provide care or service when they have an investment interest in that facility. The requirement that the physician directly provide the care or services should be interpreted as commonly understood. The physician needs to have personal involvement with the provision of care on site.

Personal involvement by a self-referring clinician with an on-site scanner? Yeah, right. I've never seen that happen, and neither has anyone else in this venue. You would think this closes the book, but of course it does not. Stark II was supposed to keep this stuff at bay, but it didn't. Hillman notes:

The in-office exception to the Stark II regulations and state laws, on which the arrangements described by Mitchell are based, conveys the right of physicians to maintain imaging capabilities—expected at the time of the bill’s passage to be largely plain X-ray and sonography—in their office practices. While hard to rationalize even then, given the research results, the exception recognized the political reality of how difficult it would be to pass the legislation if the law did not contain this exemption.

It would have made no sense to remove X-ray and U/S from clinicians' offices, because in most cases, those clinicians are actually reading and using those studies themselves, in other words, they are directly involved. Just like the AMA suggests. But because scanners have become cheaper and easier to place in an office setting,

Equipment manufacturers have taken advantage of these trends to market high-tech imaging devices to physicians on the basis of their projected financial return.
In fact, the acquisition of high-tech imaging capabilities has become the favored approach of nonradiologists’ practices to replace lost revenue from declining reimbursement for their traditional services [6]. In pretty much all regions of the United States, physicians are becoming more entrepreneurial, even to the point of ceasing to provide poorly reimbursed traditional services in favor of higher-paying services such as imaging. Many are outsourcing interpretations to radiologists—at lower rates than they are receiving from insurers—and making a profit on the professional fees as well. Elevated technical fees for imaging are promoting this activity and facilitating the kinds of lease-by-the hour and “pay-per-click” arrangements described by Mitchell, which are in direct conflict with the AMA opinion detailed above and, as Mitchell notes, quite possibly with existing anti-self-referral legislation.

But, but, but....it's for my patients' convenience! Granny will die if she can't get scanned on my in-office money printing press, I mean CT scanner!

. . .such arrangements cannot be rationalized on the basis of quality of care, convenience, access to care, or any of the other explanations commonly offered by the apologists for self-referral. It’s about the money and, if we accept that physicians are susceptible to financial incentives, in conflict with yet another AMA CEJA opinion addressing conflict of interest:
"Under no circumstances may physicians place their own financial interests above the welfare of their patients. The primary objective of the medical profession is to render service to humanity; reward or financial gain is a subordinate consideration. For a physician to unnecessarily hospitalize a patient, prescribe a drug, or conduct diagnostic tests for the physician’s financial benefit is unethical. If a conflict develops between the physician’s financial interest and the physician’s responsibilities to the patient, the conflict must be resolved to the patient’s benefit [7].

Sadly, Hillman ends on a disheartening note:

Given Mitchell’s [1] demonstration of the susceptibility to self-referring physicians to placing their own financial interests above patients’ health interests, it’s hard to be sanguine about the prospects for further regulation improving on the situation. As a sympathetic health economist once said to me, “Finding ways around regulation is the American national past-time” (Albert Williams, PhD, The RAND Corporation, personal communication, 1985). Closing the Stark II in-office exception is a noble regulatory goal, however, we must recognize that there are limitations to what regulatory actions can accomplish. History tells us that even if a Stark III were to pass Congress, there almost surely will be adverse and unintended consequences.

Hence, the Whack-A-Mole analogy. The ugly little critter just keeps popping up somewhere else. In other words, if we staunch the financial hemorrhaging from imaging self-referral, those who are willing to suspend their morals enough to participate will find some other way to pillage the system. No doubt that is true. However, to carry the analogy a bit further, this mole needs to be whacked with a really big hammer, and really hard. There needs to be prosecution, and punishment, with fines, revocation of licenses, and even jail-time. But of course that won't happen, because the practice is so wide-spread, and there is so much money involved. We are seeing more litigation of sham leasing arrangements, as noted in this blurb from the AMA, but there is a long way to go. A very long way.

The worst part of this whole fiasco is that the patients have become pawns in a big financial game. They trust their clinicians, which is as it should be, and they hang on every word they are told. They truly believe it when they are told that they need a scan, and that it is best if they have it right here in the office, which is after all so very convenient. I have heard patients request to have their scans done at the hospital, and be told that their doctor "would be mad" if they did so. This is a complete abuse of the power a physician has over his patient, and if my own position wasn't so precarious in all this, I would have brought the gentleman in question before the medical board.

Because of the wording of Stark II, many clinicians act as if it is their God-given right to buy a surplus East German CT and run it until the rotor melts, and that radiologists should be ever-so-grateful to read the blurry scans produced in this manner. What we are fighting is the mentality of entitlement, and that is something that seems to be drilled into four-year-olds and physicians in this country with equal vigor. I haven't a clue as to the solution. Except perhaps a bigger whacking hammer.

From the "Duh!" Department...Study finds high utilization rate on scanners owned by self-referring physicians

2007-10-16T07:28:00.000-07:00

Image courtesy of http://www.tomgpalmer.com

Diagnostic Imaging magazine online today reviewed this article from the upcoming issue of Radiology. (The link will work if only if you already have online access to the Grey Journal.)

To make a long story and article short, the team from the Institute of Technology Assessment at Massachusetts General Hospital "analyzed more than 526 million claims filed between 1999 and 2003 with an employer-based health insurance plan having about four million members." Dr. G. Scott Gazelle, lead author, took a slightly different approach than some other researchers in this field:

We chose to look at same-specialty referral instead of just self-referral because "self-referral" may represent referral to one's partners or colleagues. This broader definition may have resulted in the inclusion of some physicians with no financial or other relationship with the referring physician and may thus have reduced the magnitude of the observed increase in utilization (ie, if same-specialty–referring physicians without financial relationships did not demonstrate increased utilization of diagnostic imaging, their inclusion would have diluted the effect). Compared with Hillman (4) and Hillman et al (5), who defined self-referring physicians as individuals who charged at least once for an imaging procedure, we categorized referring physicians on the basis of their entire referral history for the condition of concern. Same-specialty referrers must have always referred patients to themselves or to others in the same specialty. Finally, our logistic regression analysis, which controlled for patient age and comorbidity, may provide a more accurate estimate of the effect of same-specialty referral on the utilization of diagnostic imaging procedures.

The bottom line, from DI's review:

The results indicate that physicians who refer their patients to themselves or to others of the same specialty for imaging use imaging 1.12 to 2.29 times more often than physicians who refer their patients to radiologists for imaging.
The study also found that patient age and comorbidity do not explain the increased frequency for self-referred imaging. After controlling the data set for patient age and comorbidity, imaging frequency was 1.196 to 3.228 times greater for the self-referred patients.

The numbers are somewhat lower than those Drs. David Levin and Bruce Hillman, and others have found over the years, perhaps due to the methodology of this particular paper.

Levin criticized the study design for focusing only on the professional component of insurance claims, a tactic he believes misses "carloads" of self-referred cases.
"The numbers in this study are impressive enough on their own, but they significantly underestimate the magnitude of the problem," Levin said. "Policymakers have to realize that if we continue to allow self-referral, costs will skyrocket."

But they already have, Dr. Levin, they already have.

A companion piece in today's DIMAG.com notes another "Duh":

Self-referring physicians are among the first casualties of reductions in Medicare technical payments from the new 2005 Deficit Reduction Act rules implemented in January. Some nonradiologists are shutting down their self-referred imaging businesses, according to Dr. Harvey L. Neiman, executive director of the American College of Radiology.
Neiman spoke Oct. 25 at the 2007 Economics of Diagnostic Imaging National Symposium in Arlington, VA. . .
Estimates on Medicare's cost-savings from the DRA cuts vary from $1.4 billion in first year to as much as $13 billion over a three-year period.

While the DRA cuts were probably not designed to limit self-referral per se, they will have that effect, at least in some cases.

I smell a schism within the ACR. Half of the ACR is rabidly trying to overturn the imaging cuts of DRA, and they don't mention self-referral in polite company so as not to offend their "friends" within AMIC. But here, we have Dr. Neiman speaking very publically about how DRA is helping to curb self-referral. Hmmmmmmmmm. Maybe if we all worked together on this, we might accomplish something. Ya think?

Three Interesting Articles

2007-09-16T07:30:00.000-07:00

The recent changes in imaging payment as proposed by CMS have brought about a lot of discussion. Today, three articles pertinent to the discussion were referenced in the "Daily Scan", a newsletter from the RSNA.

The first is excerpted from the Wall Street Journal. Author David Armstrong has often dealt with the self-dealing issue, and in today's Wall Street, he reviews Medicare's apparent targeting of the practice. He notes several projects that have been derailed by the new thinking, such as this:

In February, a group of cardiologists in Gainesville, Ga., announced they were building a diagnostic heart center in an $18 million joint venture with the local hospital. Last month, they said the project was dead. . .
. . ."A lot of people have just called a time out on these deals," says Daniel Mulholland, a Pittsburgh health-care attorney who has advised hospitals on such investments. "The party is over. . ."
The reason? Federal Medicare officials want to crack down on arrangements like the one that was planned in Gainesville, where doctors refer patients to businesses in which they have a financial stake.
In recent years, many physicians have become wealthy by investing in magnetic resonance imaging, or MRI, facilities, surgery centers and diagnostic sites -- and then sending their patients to them. A recent McKinsey & Co. study pegged doctors' profits from this practice, known as self-referral, at $8 billion a year.

His assessment of the new CMS proposals:

. . . tough new restrictions proposed by the federal Medicare authority. . .would essentially ban Medicare payments for many self-referred services. In unusually blunt language, the Centers for Medicare & Medicaid Services said the self-referral arrangements are "creating incentives for overutilization and corrupting medical decision-making."

What else is there to say? Well, a few graphs from the article tell much of the story. See any trend?

It goes with what I have been saying for a while. Imaging spending is skyrocketing, having doubled in the last several years. Of this, Armstrong notes that $8 Billion goes to self-referral, although other sources have pegged this at $16 Billion. He does note that the glaring loophole known as the in-office exception remains in place.

The second article comes from Capitol Hill, via thehill.com's Jeffrey Young. It seems that our friends at the big imaging companies are starting to worry about their bottom line, and are lobbying the White House to turn things around.

GE Health President and Chief Executive Joseph Hogan and other imaging company officials gathered at the White House Monday for an audience with presidential advisers to press their case that their industry is being asked to bear an unfair burden as Congress and the administration look to rein in Medicare spending.
Lawmakers have set their sights on imaging spending in particular based on evidence that spending doubled in the first five years of the decade.Trade groups representing the companies are engaged in a push against additional regulations and legislation that they say will threaten Medicare patients’ access to the innovative, but expensive, technology.

Sound familiar? It should. . .

“We acknowledge there’s a growth in the sector. We don’t necessarily agree you can equate that growth as bad,” said Amy Jensen Cunniffe, director of government relations for the Advanced Medical Technology Association (AdvaMed).
AdvaMed is one of three trade groups leading the charge against the imaging cuts, along with the National Electrical Manufacturers Association’s Medical Imaging and Technology Alliance division, and the Access to Medical Imaging Coalition, which includes industry, physician and patient groups.

Yes, they are working side-by-side with NEMA and AMIC. All three are still pushing the same agenda suggesting that cutting back on machine expenditures will limit patient access to sophisticated scans. I have yet to hear that DRA-2005 has harmed or significantly inconvenienced even one little old lady. Some self-dealers and enterpreneurs, maybe. And of course GE and Siemens. But not Granny.

The final article of the treo is from the AP newswires, and it may be the most ominous of the bunch. "Health care premiums rise 6.1 percent," writes Emily Fredrix.

The increasing cost of health insurance is putting coverage out of reach for many small to midsize companies and their workers, even though the rise in premiums this year was the lowest increase in eight years. Since 2001, the cost of premiums has gone up 78 percent, far outpacing a 19 percent increase in wages and 17 percent jump in inflationaccording to a survey released Tuesday by the Kaiser Family Foundation, a health care research group that annually tracks the cost of health insurance.
"There's no scientific tipping point that you can point to at which health insurance becomes unaffordable," said Drew Altman, the foundation's president and CEO. "But it does seem like we've crossed a threshold where health insurance is increasingly unaffordable for medium-sized employers, particularly smaller employers and average people this year."

We have been treating the healthcare money pool as endless, that another dollar can always be printed to cover this cost or that. I think we have just discovered the bottom of the pool, as we rush headlong toward it after a high-dive.

As an aside, I am certainly not letting the insurance companies off the hook. They have a lot of questions to answer on how we got where we are, while they add considerable wealth to their coffers. My son has a chronic disease, and recently generated a $14,000 bill for diagnostic procedures. Because our company hadn't made a "good deal" with our provider, I'm going to pay at least $4,000 of this out of pocket. I can afford it, thank Heavens, but what about someone who can't? And this is with paying a rather high premium for group coverage.

The hemorrhaging and wasting of money cannot go on, and CMS is in the lead to staunch the bleeding. I'm not going to anoint them as saints just yet, however, as their ambitions are not necessarily to keep things honest, but in the words of the Monty Python Blackmail Sketch: "No, no, sir, it's alright, we don't morally censor, we just want the money." They have observed the huge flow of cash into imaging, and they are going to tap it. Nothing personal.

I once had great respect for the equipment companies, who invest zillions of dollars to build the latest and greatest of scanners. We all benefit from this, especially our patients. But does this end necessarily justify the means of selling an excess of scanning capacity by pushing machines in venues where they really aren't required? I have to think not. But it's pretty clear that this party is about over, and the question will shortly become moot. Especially if Hillary wins, and Rush Limbaugh says there is an 80% chance of that.

The First Salvo Is Fired...Self-Dealing in Medical Imaging: Call for Action

2007-04-16T07:34:00.000-07:00

The Battle of Fort Sumter, the beginning of the Civil War

Image courtesy of http://www.civilwarhome.com

Dr. Murray Reicher is well-known in PACS circles as the founder of DR Systems and their famous Catapult technologist workstation. Dr. Reicher has made his mark on imaging.

In a guest editorial in the Journal of the American College of Radiology (JACR, the Blue Journal), Dr. Reicher takes aim squarely at self-referral:

I have great concern over the possible destruction of my profession caused by self-dealing in medical imaging. Self-dealing occurs when a referring doctor makes money, directly or indirectly, simply by referring a patient for a medical imaging procedure, especially by gaining a financial benefit from the technical component of the procedure. . .Do you care about the future of the medical imaging field? Are you appalled by doctors who refer on the basis of personal economic gain? Do you realize that this practice not only threatens your profession but impairs the health care of your community and sucks resources away from legitimate health care providers and hospitals?

Wow. Pretty powerful stuff. Dr. Reicher goes on to provide us with a battle cry of sorts:

No machine fee for self-dealing in medical imaging.

This position is written in plain language because nonphysicians must understand it. The statement means that no referrer should make money, directly or indirectly, through ownership or lease, from the technical component associated with a medical imaging examination.

Dr. Reicher goes on to explain why the practice should bother you:

As a result of these legal loopholes (Stark in-office exception, etc), this practice of referring patients to self-owned or leased imaging equipment has again become rampant. Self-dealing radically raises costs . . . and subjects patients to unnecessary procedures. Technical and professional quality is lowered when radiologists are not directly involved. . . Opponents of legislative or private restrictions on self-dealing see self-referred medical imaging as an opportunity for physicians to add an income source in their own offices. They cloud the issue with demands for more study and statistics. Statistics can show us how much self-dealing is costing us but can never prove that it’s ethical, because it isn’t.
In medical imaging, first, we had no rules against self-dealing. Then, we adopted rules with loopholes. Surprise: the greedy and unethical minority of physicians have jumped through the loopholes, and if we don’t close them, the reputation of all health care providers will suffer. The truth will come out, eventually.

Italics are mine. Basically, this is what people have been saying all along concering the DRA-2005 fight. But that situation took a markedly tangential course when non-self-referring radiology-owned operations were tainted with the same tar-brush. I cannot help but think that this was a result of the ACR's incomplete job of educating Congress about self-referral. Maybe they should have brought Dr. Reicher with them to the various hearings.

Dr. Reicher goes on to dismiss many of the arguments out there that support self-referral/self-dealing. First, he makes it clear that this is not a "turf" issue, which is how the ACR managed to lose the interest of Congress:

To most people, even doctors, the discussion of professional turf isn’t relevant, and nobody feels qualified to make turf judgments. But most people can understand that when your doctor collects a technical component or “machine fee” just for ordering an examination, your doctor has lost the ability to independently advise you with regard to the right test or the right facility.

He notes that it is indeed not a matter of radiologists protecting our turf, since they stand to make a significant amount of money by reading the self-referred scans.

Dr. Reicher then very accurately points out that self-referral is anticompetitive:

In fact, the practice of self-dealing exposes patients and payers to a monopolistic, anticompetitive practice. When orthopedic surgeons send patients to scanners they lease, neither the patients nor their referring doctors select the facility on the basis of normal competitive merit; the doctors do not ask which facility in the region has the best technology, the best professionals, the best pricing, or the best service. Instead, they send the patients to the facilities with which they have business agreements that provide them a profit’s interest in the fees. Restricting the anticompetitive practice of self-dealing in fact favors competition.

So, what do we do about this lovely situation? Dr. Reicher gives us several approaches. He advocates asking the ACR to help fight this battle. Personally, I still harbor grave doubts about their ability, and even their willingness to do so after they have "hooked-up" (love the kids' phraseology) with every outfit that promotes self-referral under the guise of AMIC. What else can we do? Talk to vendors, and tell them:

. . .that if they support self-dealing, they don’t support you, and you won’t support them. Referring doctors who have purchased medical imaging equipment for their offices to self-deal in medical imaging via the “in-office” Stark safe-harbor clause have sales representatives from equipment vendors whispering in their ears, supported with beautiful color collateral materials and spreadsheets. If you want vendors to stop this behavior, you must show them that biting the radiology hand that feeds them is bad business.

Sadly, I don't think there would be any vendors left to deal with if we cut off those who pushed this agenda. Still, it doesn't hurt to make them squirm a little.

Perhaps the most effective approach is that of educating the payers, and somehow forcing physicians to disclose their financial conflicts of interest. How about this for a consent form?

Attention All Patients: We make money whenever we refer you for MRI (or PET, or CT) to the following facilities: _____. As a result, you cannot trust us to impartially consider when we send you to these facilities if the tests are really needed, if there are tests better suited for your problem, if there is a more qualified facility or imaging specialist in the area, or if competing facilities offer better pricing. Because we make money by referring you to the facilities we own or lease, you should consider the need for a second opinion from an independent provider before undergoing the test. We are required to provide you with a list of competing facilities in this community that may offer safer, more accurate, or less expensive medical imaging. They are _____.

I'm not holding my breath waiting to see that one out in public. There is a huge problem with this facet of the situation. Patients trust their doctors implicitly and explicitly. This is certainly a good thing, especially for those of us who grew up watching Marcus Welby, M.D. Is it right to point out to the patients that their trust in some cases is misplaced? Are we interfering in the doctor-patient relationship, one which I once thought sacred (before getting out into the real medical world) when we point out that their beloved doc just might be taking advantage of their trust and ignorance? I honestly don't know. On those rare occasions when I have broached the subject, I mainly get the response, "Oh, I trust my doctor. If he/she says I need a scan, I'll do it anywhere he/she suggests. It's so convenient to have the scan done in his/her office!" Maybe a little brainwashing, maybe a little hostage mentality. Either way, there is probably more of an uphill educational struggle on this front than you might think.

Perhaps the hardest pill for many radiologists to swallow is the fact that they are collaborators in this practice. The self-dealers ask them to read their scans, and they are happy to do so. After all, they reason, if they don't, someone else will. They might as well keep the otherwise lost revenue, and provide the patients the best of care. Right? Dr. Reicher answers:

I owe it to my community to behave in a trustworthy manner. Businesses that maintain the respect of their customers are the most successful in the long run. The “secret” of self-dealing is ultimately going to be widely understood by the public. If you are a collaborator, you are going to be seriously embarrassed at the least, and potentially personally liable.

Gulp. Not much I can say to that, is there?

There have been several objective articles before this, discussing the costs of self-referral. However, I have never before seen such a passionately-written article on the topic, one which calls a spade a spade, in this case blatantly declaring self-referral unethical. All I can say is, "BRAVO!" The problem is, sadly, I don't think too many folks are listening just yet. But, maybe that will change, and I hope that happens before Hillary uses this sort of information to justify destroying the American Health Care system.

Rife Machines, Travel Scams, Self-Referral, and Imaging Kickbacks

2007-01-16T07:43:00.000-08:00

I just came back from a whirlwind visit to one of my relatives stricken with cancer. I am happy to report that she is doing well, with a clean PET/CT scan after 9 months of chemotherapy. Now, here's the bad news. My relative and her husband proudly announced that they had purchased a "Rife Machine," and this was the reason she had done so well. I'll let you Google the term to find out the details of this particular alternative medicine scam, but suffice it to say, it is supposed to zap the bacteria that "cause" cancer by sending a radio wave tuned to the exact "frequency" of the bacterium through the body. If you do take the time to Google, you will notice that the sites promoting this scam outnumber those exposing it by about 100 to 1. The Internet and human nature at their finest. Here is a good article debunking the outrageous claims. Check out this one as well. Anyway, in response I said, mostly under my breath, "It probably won't hurt you, and that's the best I can say for it." My relative then turned to me angrily and said, "I suppose you think it needs years of testing? You've been brainwashed by the medical establishment!" At that point, I changed the subject, knowing that I would not win this argument. I don't think I'm the one who was brainwashed at all.

There is a flaw in human nature that allows us to suspend rationality, to believe in whatever it is we want to believe at the moment. Sadly, there are people (I use the term loosely) with deficiencies of another sort that exploit the window of opportunity afforded by these lapses. This practice is not limited to health-care. My sick relative's husband, in the discomfort that followed the above exchange, went on to describe his latest money-making discovery, YTB Travel. To make a long story short, this is a multi-level marketing operation, like Amway, which sells travel-agencies. Well, to be more accurate, it sells websites that use the Travelocity engine to book travel. But the kicker is that each individual sucker, I mean client, can sell the program himself to other suckers, I mean clients, and the business they generate yields a commission for everyone in the chain above. Which means that the guys who are at the top of this pyramid scheme make big bucks, and the newly-joined make nothing. Oh, by the way, initiation into this little club is $500, and there is a $49 monthly fee. So, for $1100 the first year, you get a portal to Travelocity with your name on it. Whoopie. I went to half-a-dozen random YTB sites, and they are all absolutely identical. I even wrote to their owners, and received only one response, saying how good YTB was to him, and basically assuming that I would join up under his banner. You see, in the end, this is indeed nothing more than the same old pyramid operation with Dot.Com dressing. I'm anticipating a number of hateful emails from YTP devotees, but don't just take my word for it. Check this report from the BBB. A pyramid operation it is, folks. There's one born every minute, as old P.T. Barnum used to say.

Doctors are certainly not immune to any of these scams, and I am ashamed to say that there are real M.D.'s out there selling Rife machines, and probably owning YTB scam sites as well. Somehow, docs have become, well, indoctrinated with the idea that they know everything, that they can be experts at everything, and perhaps most unfortunately, that society owes them everything. You have read about self-referral, and that is a sad illustration of how far physicians will go to preserve the income some feel they deserve. One theory about imaging self-referral by clinicians is that since regulation and so forth have cut into their incomes, they are justified in "branching out" into other fields beyond their area of expertise to recover this income that was "theirs". One of these clinicians, Alan Boyar, M.D., admits as such in this AuntMinnie.com posting:

I was compelled to add these services because unlike radiology, office procedures are reimbursed significantly below cost and it is not possible to keep a private office open in So Cal with current rates. Before I closed, I'm in New Mexico now, I figured I really needed $85 an office visit to stay open and insurance was paying $48, EKG complete is only $28 dollars whereas my derm colleges are getting $60 to freeze a wart! My CA practice had turned into an expensive hobby and the AMA and societies didn't negotiate better rates for us.

I'm sure that's all true, and it is a very sad state of affairs indeed. Now, in Alan's case, he isn't forcing anyone to the best of my knowledge to have their hair depilated or their wart removed, or to be scanned in his Electron Beam CT emporium. But the basis of the downfall of medicine is contained in his statement. What I'm doing doesn't pay well anymore, so I'm going to start doing things beyond my scope of practice to bolster my income. I'll wager that Alan has no intention of going back and doing a Derm residency. Or a Radiology residency for that matter. He just wants the money to compensate him for his losses in primary care. Noble thought.

As noted above, docs are not immune to the cessation of rational thought when it comes to making money. I love to cite the "scanner lease" arrangements that have become so popular. These are loosely camouflaged kickback arrangements, and they are considered by most to be just at the borderline of legality. Basically, I own a scanner, and you "lease" time on it for a set fee, then turn around and bill for the scan at a higher rate than the leasing cost. Thus you make money on every scan you order. I had an internist describe this very scenario with great glee, thinking he had discovered something new and wonderful. When I told him what he was really doing, he turned white as a sheet, and asked me, "Why didn't they tell me that?" Why, indeed...

Regulators, legislators, insurers, and everyone else who is sick and tired of the financial hemorrage are all starting to wake up to what is happening, and the results are not going to be pretty. There is currently a case in Illinois where a leasing scheme is under litigation for violating the kickback statutes:

The MRIs were performed at the radiology centers, though the financial arrangement made it appear that the doctors were in charge of the equipment and billed the services as their own, the suit said. The attorney general's office alleged that the centers concocted "sham 'lease' agreements" to benefit the doctors, who then referred patients to the centers, sometimes for unnecessary tests."Illinois has a clear policy against kickbacks, and making payments to doctors for referral of patients is illegal, no matter how those payments are disguised," Atty. Gen. Lisa Madigan said in a statement. "Our investigation revealed evidence showing that this practice occurs among doctors and radiology centers in Illinois. This is an illegal practice that must stop."

I truly anticipate more and more litigation and ultimately prosecution of this sort of thing. And this will extend to self-referral as well. We put our trust in our physicians, and that should not require a suspension of rationality. But some docs stretch this trust, if not violate it completely, by ordering tests that serve little purpose beyond padding their wallets. I guess I'm from the Marcus Welby school where doctors were good people who made housecalls, didn't testify against each other, and didn't worry about fees. Sadly, ol' Doc Welby is long gone, and his sidekick (James Brolin) is married to Barbra Streisand and is deeply involved in liberal causes.

I don't know how to return us back to the day when docs could be trusted to do the right thing, and not the lucrative thing. Some on AuntMinnie have seriously proposed that the government prop up the primary care docs so they aren't tempted to dabble in imaging and hair-removal. Personally, I think the government and insurers need to examine the increased revenue produced by self-referral mills, stop the bleeding, and retroactively penalize those gluttons who ruined the system. As for faith, one of the Rife-machine articles sums it up well:

Much of the frequency medicine practised today descends from Royal Rife, who did his research in the early 1930s. Rife identified the virus that caused all cancers (!), which he named “BX”. As this was before the invention of the electron microscope, Rife invented an optical microscope with a claimed magnification of 17,000x. A perusal of the web sites of Olympus, Nikon and Zeiss shows that the best theoretical magnification claimed today is about 1,400x, although practically it is about 1,250x. (Zeiss use an appropriate slogan to promote their microscopes: “Limited only by the laws of physics”.) The secrets of Rife’s microscope are lost, presumably suppressed by orthodox optical companies, but his method of curing cancer lives on.
Rife’s 1931 demonstration of the microscope involved creating a non-filterable form of the typhoid bacillus, which appeared as small moving turquoise dots in a static background. Scientists looked through Rife’s microscope and also saw these blue dots. Some astronomers once looked through Lowell’s telescope and saw canals on Mars; some scientists once saw evidence of the refraction of N-rays in Blondlot’s laboratory; some scientists were once convinced that deuterium could fuse at room temperature within the crystal matrix of palladium. All of them were mistaken. The difference between the last three delusions and Rife is that almost nobody believes them any more. The other difference is that a belief in Mars canals or cold fusion cannot kill anyone. A belief in a false cure for cancer can.

Ordering unnecessary scans probably won't kill anyone either, although the radiation exposure could add up eventually. But American Medicine is tarnished by the practice. In the self-referral scam, docs are the culprits; in the leasing scam, docs are the victims as well. But the patients are never at the top of the pyramid, and that is where they should be, lest we forget. My relatives with the Rife machine have made me very aware that a good segment of the population doesn't trust physicians or conventional medicine. They think they are a cabal organized for their own self-preservation, and the patient be damned, that organized medicine is the pyramid operation, designed to separate them from their money. They think the doctors would let a relative die rather than lose money on a simple "cure". With the behavior I'm seeing out there, I'm not sure I can blame them for their misbelief.

Americans For Responsible Imaging

2006-09-24T16:51:00.000-07:00

Have you had a CAT scan in your doctor's office? How about an MRI or a PET? Did your doctor talk you out of going to the hospital for your test? Have you had multiple scans in your doctor's office?

Some doctors who own imaging equipment in their offices are abusing the American Healthcare system, extracting up to $16 Billion per year in unnecessary scanning revenue. Studies show that doctors who profit from scaning in their offices order from two to eight times as many exams as they would otherwise. This practice is hurting all of us by sending healthcare costs and insurance premiums spiraling out of control.

You can make a difference. Insist on having your study done in a hospital or an independent imaging center, where no one profits from self-referral. It's your life, your body, and your money.

Intel's Barrett blames broken health care system for U.S. job exodus

2006-09-22T09:22:00.000-07:00

You don't think the American Healthcare system is in trouble? Read this from the chairman of Intel. It isn't very pretty. Here is some of what he said:

"Every job that can be moved out of the United States will be moved out ... because of health care costs,'' which averaged more than $6,000 per person in 2004, Barrett said..."The (health care) system is out of control, it's unstable, it's basically bankrupt, it gets worse each year and all we do is tinker around the edges when what we need are major fixes,'' Barrett said, adding that health care costs make it increasingly difficult for U.S. companies to compete with rivals abroad.

Barrett was more interested in seeing computerized stuff in hospitals than in stopping unnecessary scanning, but the problem is still obvious. Something has to be done before we lose the greatest healthcare system in the world!

A Good Article

2006-09-21T20:37:00.000-07:00

Here is a very good article on the subject of self-referral:

http://www.imagingeconomics.com/issues/articles/2004-11_01.asp

All you have to do is "Google" the words "imaging" and "self-referral" and you will find many more!