Moving Forward

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!

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

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

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

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

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.....

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.