Here's Where We're Going...

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

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

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

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/:

1. The demand for PET scans has grown 46% per year since 2004
2. Analysts project that nearly 2 million more patients will require scans this year
3. 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

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

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

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.