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: