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Self Referral
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The views that the author expresses in this article are strictly their own and should not be attributed to the American College of Radiology.
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Self- referral is not a new topic, but it certainly is a hot topic.
Since 1988, the ACR has recognized the dangerous potential of
financially motivated referral, in which patient care becomes more about
the dollar than about the patient. Initially, in the same year that
Congressman Pete Stark (D-Ca) introduced the Stark I Law, the ACR passed
a resolution that encouraged legislative efforts to address the issue of
overutilization and self- referral. Stark I did pass, thus prohibiting
referral of patients to facilities where the referring physician had a
financial interest. Similar law related to self referral to clinical
laboratories was passed in 1989 under the Omnibus Budget Reconciliation
Act. This led to multiple studies over the next 5 years that clearly
demonstrated a propensity for overutilization, and thus inappropriate
utilization, when a financial interest was present. An amendment was
made to the OBRA in 1993, now deemed the Stark II law, in which
referrals to diagnostic imaging centers and radiation therapy centers
were included as inappropriate referrals. However, a loophole allows
those who have imaging equipment within their own "office" an exemption
to this rule. It is because of this loophole that self- referral is
allowed to continue to drive up the cost of health care and compromise
quality and safety to the patient. In addition, Nuclear Medicine was
also not included in the language, allowing for exemption in totality
for this type of imaging.
How it affects Health Care or Affect on Health Care
What has this done to health care? It has affected health care in both
costs and quality. Healthcare costs continue to rise exponentially each
year. However, imaging costs are far surpassing the growth of the other
sectors, and costs near $100 billion annually, according to Medicaid and
US Governement Accounting Office data. Comparative analysis
shows a three - fold discrepancy in the growth of medical imaging in
relation to other medical services from 1999 to 2002, and a further
increase by 16% in 2003. While Medicare costs have increased by 30%,
imaging costs have increased by 50%. The other issue addressed in these
studies look at nonradiologists imaging costs compared to radiologists.
From 1993-1999, the RVU rate per 1000 Medicare beneficiaries showed a
7% increase for radiologists compared to a 32% increase for
nonradiologists. More recent data from 1999-2002 shows increases of 75%
for family physicians and 100% for cardiologists.
Reimbursement Cuts
To combat this increase, reimbursement cuts to physicians as well as
radiology have become options for Congress. Current legislation, in
fact, proposed cuts in contiguous body parts for CT, MR and Ultrasound
by 50% for the technical fee. Other legislation that was to be
implemented in January of 2006, would have resulted in reimbursement
cuts by Medicare by 4.4% to physicians across the board, every year for
the next 6 years, for a total reduction in payment by 26%. These types
of cuts lead to less participation in Medicare by physicians, which
further limits access to health care by those who need it most: the
elderly. The AMA, during their recent annual meeting in Dallas,
determined that such reductions would decrease physician participation
in Medicare by 36%. Recognizing the potential blow to health care, and
feeling pressure from both the ACR Government Relations and the AMA in
regards to physician reimbursement, a 1% increase in physician payment
in 2006 rather than the CMS proposed 4.4% cut was implemented by the
Senate Finance Committee. Regarding the technical component cuts, the
50% cut in technical fees originally proposed for contiguous body parts
has been deferred for one year, and the CMC has opted to cut the fees by
25% instead in 2006. The ACR will continue to oppose the 25% reduction
and the planned phase-in of 50% by 2007. The ACR had requested a 1-year
delay for further analysis. Clearly, this fight is far from over.
Unnecessary costs to the healthcare system are only part of the story.
Financial incentive translates into a profit margin for these groups
that are referring to their own imaging centers for extra income. As a
result, outdated or substandard equipment is often used, resulting in
poorer quality images. In addition, radiologists are only performing
about half of these studies. The rest are being performed by
cardiologists, surgeons, family practice doctors and others (Figure 1).
In a study by Hopper, et al, (1) significant interpretation error of 7%
were found in reports by non radiologists, compared to a 0% significant
error miss by radiologists included in the study. An additional study in
England by Vincent, et al, showed that 35% of abnormalities were missed
by emergency room physicians, and 39% of clinically significant findings
were missed. Thus not only raises the issue of quality of imaging, but
quality of interpretation becomes a serious consideration as well. In
some practices, cardiologists are obtaining scans of the chest, and then
cropping out the heart for interpretation, discarding the remaining
data. When that data contains a lung cancer, this type of selective
interpretation could cost the patient their life.
Congress will not close the loophole of in office imaging, which would
solve the problem completely. The feeling is that this would be
exclusionary, and thus, is not a viable option. Instead, based on the
MedPAC recommendations, the ACR has focused on the Designated Provider
of Diagnostic Imaging (DPMI). This would be modeled after the current
accreditation process by the ACR, and would include MR, CT and PET
modalities. This could save 5-6 billion for congress, while improving
standard of care related to imaging. These types of requirements are
already being implemented by some private insurers. For more information
on DPMI, visit www.qualityimaging.org.
The MedPAC recommendations, in addition to requiring CMS to develop
standards for physicians who interpret imaging studies and for providers
who perform diagnostic imaging services, also advise CMS to select
private organizations to administer the standards. MedPAC's
recommendations that CMS address accreditation and credentialing of
providers are new territory but a direction in which the agency has been
headed for some time. Additional recommendations are to prohibit
financial incentives for physicians that refer patients to imaging
centers, monitor the referral patterns, change coding edits for the
technical component when performed on multiple body parts, and to add
Nuclear Medicine and PET to the "designated health services" under Stark
laws. It was because of the ACR's education to the Centers for Medicare
and Medicaid Services (CMS) that diagnostic and therapeutic nuclear
medicine services are, in fact, part of radiology, that led to
incorporation of these services into the definition of "radiology and
certain other imaging services," which are already subject to physician
self-referral prohibitions. This clarification is now part of the 2006
Medicare Fee Schedule, effective January 1, 2006. Physicians, who have
entered into financial arrangements with nuclear medicine facilities
which allow for self-referral, and are now affected by this
clarification, have until January 1, 2007 to divest themselves of these
holdings.
Self Referral is a lonely battle the the ACR is fighting on behalf of
patient quality and safety. The AMA and virtually every specialty group
oppose any and all legislation that would curb their ability to profit
in the arena of imaging. While the arguments are that access to imaging
in the same center is more convenient for the patient, no data is
available to support that. In fact, the data suggest that the number of
"in-office" imaging studies that are actually being performed on the
same date as an office visit is exccedingly low; the convenience
argument is therefore tenuous at best. Clearly, the Congress rather has
begun to recognize the problem of greed driven medicine and the
resulting skyrocketing costs of health care, which threatens access for
patients and particularly for the elderly. MedPAC recommendations are a
promising start, and DPMI will serve to promote quality and standards in
imaging in the future. Legislative efforts on the state level are
variable, and will continue throughout the next year. Maryland now has
state legislation that prohibits self - referral, although a repeal of
this legislation is now being advocated by non-radiologist self - referring groups. Texas's
legislation calling for prohibition of self referral has been tabled,
but did result in a task force to examine the issue and referral
patterns. Battles are being won, but the war is far from over.
Unfortunately, the casualties that may ensue will be those patients who
experience unnecessary costly imaging or suboptimal imaging for
financial gain to their physician.
For more information, visit: www.qualityimaging.org | www.acr.org
Author:
Amy Kirby, M.D.
Secretary
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