GAO Talks, AMIC Squawks

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

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

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?

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

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.