The Self-Referral Issue David C. Levin, M.D. NCQDIS, 12/2/04.

The Self-Referral IssueThe Self-Referral Issue

David C. Levin, M.D.David C. Levin, M.D.

NCQDIS, 12/2/04NCQDIS, 12/2/04

If nonradiologists are allowed If nonradiologists are allowed to self-refer, overutilization to self-refer, overutilization

inevitably resultsinevitably results

Frequency of imaging per episode of illnessFrequency of imaging per episode of illness

Clinical presentationClinical presentationRatio of imaging frequency, self-Ratio of imaging frequency, self-

referrers/radiologist-referrersreferrers/radiologist-referrers

Chest painChest pain 1.91.9

CHFCHF 2.72.7

Difficulty urinatingDifficulty urinating 2.22.2

GI bleedingGI bleeding 1.71.7

HeadacheHeadache 4.34.3

Knee painKnee pain 7.77.7

Low back painLow back pain 3.63.6

Transient cerebral ischemiaTransient cerebral ischemia 4.74.7

URIURI 2.32.3

UTIUTI 2.42.4

*Hillman, JAMA 1992; 268: 2050*Hillman, JAMA 1992; 268: 2050

U.S. GAO Report, “Referrals to Physician-Owned Imaging U.S. GAO Report, “Referrals to Physician-Owned Imaging Facilities Warrant HCFA’s Scrutiny”, 10/94Facilities Warrant HCFA’s Scrutiny”, 10/94

• Compared rates of imaging for MDs having in-practice Compared rates of imaging for MDs having in-practice imaging equipt with rates for other MDs who referred imaging equipt with rates for other MDs who referred elsewhere.elsewhere.

• Based on Medicare claims covering 19.4 million office Based on Medicare claims covering 19.4 million office visits & 3.5 million imaging studies in FL during 1990.visits & 3.5 million imaging studies in FL during 1990.

• Ratios of imaging rates, self-referrers/outside referrers:Ratios of imaging rates, self-referrers/outside referrers:

MRIMRI 3.063.06

CTCT 1.951.95

USUS 5.135.13

Nuc Med Nuc Med 4.524.52

X-rayX-ray 2.102.10

% changes in Medicare utilization (proc/1000) & % changes in Medicare utilization (proc/1000) & RVU rates, 1993-2002, among radiologists, RVU rates, 1993-2002, among radiologists,

cardiologists, all nonradiologistscardiologists, all nonradiologists

0

20

40

60

80

100

120

140

160

proc/1000 RVU/1000

radiolall nonradcardiol

% % changechange

% Changes in RMPI Utilization Rates, 1998 % Changes in RMPI Utilization Rates, 1998 2002, 2002, Among Radiologists, Cardiologists, & Other MDsAmong Radiologists, Cardiologists, & Other MDs

0

10

20

30

40

50

60

70

80

90

overall radiol cardiol other MDs

overallradiolcardiolother MDs

% change

Did the much more rapid growth in Did the much more rapid growth in utilization of RMPI among cardiologists utilization of RMPI among cardiologists

substitute for cardiac cath or stress echo?substitute for cardiac cath or stress echo?

• From 1998 to 2002, cardiac cath utilization From 1998 to 2002, cardiac cath utilization rate rate 19.5%. 19.5%.

• Stress echo utilization rate Stress echo utilization rate 22.0%. 22.0%.

% Increases in Medicare Reimbursements % Increases in Medicare Reimbursements for MRI, 1997 for MRI, 1997 2002 2002

0

100

200

300

400

500

600

700

radiol neurol ortho otherMDs

multi total

radiolneurolorthoother MDsmultitotal

% increase% increase

Effect of Financial Incentives on Test-Ordering in Effect of Financial Incentives on Test-Ordering in an Ambulatory Care Centeran Ambulatory Care Center

• Examined lab and x-ray ordering habits of 15 MDs in a for-profit Examined lab and x-ray ordering habits of 15 MDs in a for-profit ambulatory care center in Boston. Lab & x-ray were on-site.ambulatory care center in Boston. Lab & x-ray were on-site.

• Prior to 1985, the MDs were paid a flat salary.Prior to 1985, the MDs were paid a flat salary.

• During 1985, financial incentives were introduced, which allowed During 1985, financial incentives were introduced, which allowed MDs to earn bonuses based upon revenues they generated.MDs to earn bonuses based upon revenues they generated.

• 3 winter months of 1984-85 (before) and 1985-86 (after) were 3 winter months of 1984-85 (before) and 1985-86 (after) were compared.compared.

• 11 of 15 ordered more x-rays in ’85-86; overall utilization by the 11 of 15 ordered more x-rays in ’85-86; overall utilization by the group group by 16%. by 16%.

• 13 of 15 ordered more lab tests in ’85-86; overall utilization by the 13 of 15 ordered more lab tests in ’85-86; overall utilization by the group group by 23%. by 23%.

*Hemenway, NEJM 1990; 322: 1059*Hemenway, NEJM 1990; 322: 1059

Effect of On-Site Radiology Facilities on Frequency Effect of On-Site Radiology Facilities on Frequency of Chest X-Raysof Chest X-Rays

• Assessed use of x-ray in 2 facilities operated by a single family Assessed use of x-ray in 2 facilities operated by a single family medicine dept at the Univ of Western Ontario. One had on-site medicine dept at the Univ of Western Ontario. One had on-site x-ray equipment; pts at the other were referred to an outside x-ray equipment; pts at the other were referred to an outside radiology office.radiology office.

• No financial link between the family physicians and the No financial link between the family physicians and the radiology service.radiology service.

• Pts had chest-related diagnoses.Pts had chest-related diagnoses.

• Pts seen at the facility having on-site x-ray were 2.4X as likely Pts seen at the facility having on-site x-ray were 2.4X as likely to have a chest x-ray.to have a chest x-ray.

• The family medicine residents’ hand-written impressions The family medicine residents’ hand-written impressions differed from the final radiology report in 23.5% of cases differed from the final radiology report in 23.5% of cases (usually overcalls).(usually overcalls).

*Strasser, J Family Practice 1987; 24: 619*Strasser, J Family Practice 1987; 24: 619

1)1) Levin DC & Rao VM. Turf Wars in Radiology: Levin DC & Rao VM. Turf Wars in Radiology: The Overutilization of Imaging Resulting From The Overutilization of Imaging Resulting From Self-Referral. JACR 2004; 1: 169-172….[March Self-Referral. JACR 2004; 1: 169-172….[March 2004]2004]

2) Levin DC & Rao VM. Turf Wars in Radiology: 2) Levin DC & Rao VM. Turf Wars in Radiology: The Quality of Interpretations of Imaging Studies The Quality of Interpretations of Imaging Studies by Nonradiologist Physicians – A Patient Safety by Nonradiologist Physicians – A Patient Safety Issue? JACR 2004; 1: 506-509….[July 2004]Issue? JACR 2004; 1: 506-509….[July 2004]

3) Levin DC, Rao VM, Orrison WW Jr. Turf Wars in 3) Levin DC, Rao VM, Orrison WW Jr. Turf Wars in Radiology: The Quality of Imaging Facilities Radiology: The Quality of Imaging Facilities Operated by Nonradiologist Physicians and of the Operated by Nonradiologist Physicians and of the Images They Produce. JACR 2004; 1: 649-651 …. Images They Produce. JACR 2004; 1: 649-651 …. [Sept 2004][Sept 2004]

If nonradiologists are If nonradiologists are allowed to interpret images, allowed to interpret images, they will make lots of errorsthey will make lots of errors

i.e. the quality issue on the professional sidei.e. the quality issue on the professional side

PERFORMANCE ON A STANDARDIZED SET PERFORMANCE ON A STANDARDIZED SET OF CHEST X-RAYSOF CHEST X-RAYS

• 3 panels3 panels

– 29 radiology residents29 radiology residents

– 111 board-certified radiologists111 board-certified radiologists

– 22 nonradiologists (from 7 private practice & 6 22 nonradiologists (from 7 private practice & 6 academic medical groupsacademic medical groups))

• 30 normal cases, 30 abnormals (infiltrates, 30 normal cases, 30 abnormals (infiltrates, pneumothoraces,masses, cardiac abnormalities)pneumothoraces,masses, cardiac abnormalities)

• ROC curves calculated for 5 physician categories: (1) ROC curves calculated for 5 physician categories: (1) top 20 radiologists, (2) bottom 20 radiologists, (3) all top 20 radiologists, (2) bottom 20 radiologists, (3) all board-certified radiologists, (4) radiology residents, (5) board-certified radiologists, (4) radiology residents, (5) nonradiologists.nonradiologists.

*Potchen, RADIOLOGY 2000; 217: 456*Potchen, RADIOLOGY 2000; 217: 456

Potchen, RADIOLOGY Potchen, RADIOLOGY 2000; 217: 4562000; 217: 456

Areas Under the ROC Curves (All Results Differ Areas Under the ROC Curves (All Results Differ Statistically from Each Other)Statistically from Each Other)

GROUPGROUP ##AREA UNDER ROC CURVE AREA UNDER ROC CURVE

(mean (mean ± 1 SD)± 1 SD)

All bd-cert radiolsAll bd-cert radiols 111111 0.860 0.860 ± 0.005± 0.005

Radiol residentsRadiol residents 2929 0.746 0.746 ± 0.011± 0.011

NonradiologistsNonradiologists 2222 0.657 0.657 ± 0.015± 0.015

*Potchen, RADIOLOGY 2000; 217: 456*Potchen, RADIOLOGY 2000; 217: 456

ACCURACY OF INTERPRETATION OF ACCURACY OF INTERPRETATION OF HEAD CTs IN THE ER BY EMERGENCY HEAD CTs IN THE ER BY EMERGENCY

PHYSICIANSPHYSICIANS

• 555 pts underwent head CT via the ER.555 pts underwent head CT via the ER.• Scans interpreted first by an ER MD, then by a Scans interpreted first by an ER MD, then by a

radiologist.radiologist.• Nonconcordance in 206 cases (39%).Nonconcordance in 206 cases (39%).• Potentially significant misinterpretations by Potentially significant misinterpretations by

ER MDs in 131 (24%).ER MDs in 131 (24%).• Major misses: infarcts, masses, cerebral edema, Major misses: infarcts, masses, cerebral edema,

parenchymal hemorrhage, contusions, parenchymal hemorrhage, contusions, subarachnoid hemorrhagesubarachnoid hemorrhage

*Alfaro, Ann Emerg Med 1995; 25: 169

1) Levin DC & Rao VM. Turf Wars in Radiology: 1) Levin DC & Rao VM. Turf Wars in Radiology: The Overutilization of Imaging Resulting From The Overutilization of Imaging Resulting From Self-Referral. JACR 2004; 1: 169-172….[March Self-Referral. JACR 2004; 1: 169-172….[March 2004]2004]

2) Levin DC & Rao VM. Turf Wars in Radiology: 2) Levin DC & Rao VM. Turf Wars in Radiology: The Quality of Interpretations of Imaging Studies The Quality of Interpretations of Imaging Studies by Nonradiologist Physicians – A Patient Safety by Nonradiologist Physicians – A Patient Safety Issue? JACR 2004; 1: 506-509….[July 2004]Issue? JACR 2004; 1: 506-509….[July 2004]

3) Levin DC, Rao VM, Orrison WW Jr. Turf Wars in 3) Levin DC, Rao VM, Orrison WW Jr. Turf Wars in Radiology: The Quality of Imaging Facilities Radiology: The Quality of Imaging Facilities Operated by Nonradiologist Physicians and of the Operated by Nonradiologist Physicians and of the Images They Produce. JACR 2004; 1: 649-651 …. Images They Produce. JACR 2004; 1: 649-651 …. [Sept 2004][Sept 2004]

If nonradiologists are allowed to If nonradiologists are allowed to perform imaging, the quality of perform imaging, the quality of the studies is likely to be poorthe studies is likely to be poor

i.e. the quality issue on the technical sidei.e. the quality issue on the technical side

Quality Assessment of 562 Imaging Quality Assessment of 562 Imaging Sites by a Health Plan (Single State)Sites by a Health Plan (Single State)

• Inspection by an RT – used a standard checklist.Inspection by an RT – used a standard checklist.• Findings reviewed by a multispecialty panel of 15 Findings reviewed by a multispecialty panel of 15

physicians (radiologists, orthopods, neurologists, physicians (radiologists, orthopods, neurologists, FPs, chiropractors, podiatrists).FPs, chiropractors, podiatrists).

• For a problem to be considered a deficiency, the For a problem to be considered a deficiency, the panel had to unanimously agree.panel had to unanimously agree.

• 90 of the 562 refused to participate. Carrier may 90 of the 562 refused to participate. Carrier may drop them from reimbursement.drop them from reimbursement.

• Of the remaining 472, 149 (32%) failed with 1-9 Of the remaining 472, 149 (32%) failed with 1-9 deficiencies.deficiencies.

Orrison, Radiology 2002; 225(P):550 [abst]Orrison, Radiology 2002; 225(P):550 [abst]

Failure RatesFailure Rates

# of sites# of sites FailuresFailures

ChiropractorsChiropractors 144144 69 (48%)69 (48%)

PodiatristsPodiatrists 4949 22 (45%)22 (45%)

FPs/GPsFPs/GPs 7272 31 (43%)31 (43%)

InternistsInternists 2020 8 (40%)8 (40%)

UrologistsUrologists 1414 5 (36%)5 (36%)

SurgeonsSurgeons 1212 3 (25%)3 (25%)

OrthopedistsOrthopedists 4343 7 (16%)7 (16%)

Ob/gynsOb/gyns 4141 3 (7%)3 (7%)

RadiologistsRadiologists 7777 1 (1%)1 (1%)

1) Levin DC & Rao VM. Turf Wars in Radiology: 1) Levin DC & Rao VM. Turf Wars in Radiology: The Overutilization of Imaging Resulting From The Overutilization of Imaging Resulting From Self-Referral. JACR 2004; 1: 169-172….[March Self-Referral. JACR 2004; 1: 169-172….[March 2004]2004]

2) Levin DC & Rao VM. Turf Wars in Radiology: 2) Levin DC & Rao VM. Turf Wars in Radiology: The Quality of Interpretations of Imaging Studies The Quality of Interpretations of Imaging Studies by Nonradiologist Physicians – A Patient Safety by Nonradiologist Physicians – A Patient Safety Issue? JACR 2004; 1: 506-509….[July 2004]Issue? JACR 2004; 1: 506-509….[July 2004]

3) Levin DC, Rao VM, Orrison WW Jr. Turf Wars in 3) Levin DC, Rao VM, Orrison WW Jr. Turf Wars in Radiology: The Quality of Imaging Facilities Radiology: The Quality of Imaging Facilities Operated by Nonradiologist Physicians and of the Operated by Nonradiologist Physicians and of the Images They Produce. JACR 2004; 1: 649-651 …. Images They Produce. JACR 2004; 1: 649-651 …. [Sept 2004][Sept 2004]

Imaging Utilization Skyrocketing in Boston?Imaging Utilization Skyrocketing in Boston?

• Harvard Pilgrim Health Care of MA (750,000 Harvard Pilgrim Health Care of MA (750,000 members) saw a 62% increase in use of advanced members) saw a 62% increase in use of advanced imaging studies in 2 years.imaging studies in 2 years.

• Tufts Health Plan saw a 48% increase in all imaging Tufts Health Plan saw a 48% increase in all imaging between 2000 & 2003.between 2000 & 2003.

• BCBS of MA saw a 20% increase in MRIs and a BCBS of MA saw a 20% increase in MRIs and a 25% increase in CTs from 2002 to 2003.25% increase in CTs from 2002 to 2003.

L. Kowalczyk, Boston Globe, 2/27/04L. Kowalczyk, Boston Globe, 2/27/04

““An MRI Machine For Every Doctor? Someone An MRI Machine For Every Doctor? Someone Has To Pay” – Has To Pay” – R. Abelson, N.Y. Times, 3/13/04R. Abelson, N.Y. Times, 3/13/04

• In Syracuse, NY the number of MRIs has grown by In Syracuse, NY the number of MRIs has grown by 1/3 in 3 years.1/3 in 3 years.

• In the past year alone, utilization of MRI studies In the past year alone, utilization of MRI studies by by 23%.23%.

• ““Unfortunately it’s the business community that pays Unfortunately it’s the business community that pays for these” – John Driscoll, local business leader.for these” – John Driscoll, local business leader.

• In NY, hospitals must get CONs for MRIs but private In NY, hospitals must get CONs for MRIs but private physician offices don’t have to.physician offices don’t have to.

• ““I don’t think you should limit the use of technology I don’t think you should limit the use of technology [and] competition” – Michael Vella, MD, head of a 23-[and] competition” – Michael Vella, MD, head of a 23-physician orthopedic group that installed 2 MRIs and physician orthopedic group that installed 2 MRIs and a nuclear camera in their office.a nuclear camera in their office.

““Financial Pressures Spur Physician Entrepreneurialism”Financial Pressures Spur Physician Entrepreneurialism”

• Based on 270 interviews during 2003 with senior MD & non-Based on 270 interviews during 2003 with senior MD & non-MD leaders of hospitals, health plans, physican groups.MD leaders of hospitals, health plans, physican groups.

• ““A common theme across markets was that harsh business A common theme across markets was that harsh business realities had left physicians feeling financially beleagured, realities had left physicians feeling financially beleagured, forcing them to become more business oriented.”forcing them to become more business oriented.”

• ““Investment in ancillary services (such as imaging or Investment in ancillary services (such as imaging or laboratory testing) was mentioned by the most respondents laboratory testing) was mentioned by the most respondents as a major strategy among physicians in their market.”as a major strategy among physicians in their market.”

• ““Physician strategies threaten to raise costs for public and Physician strategies threaten to raise costs for public and private payers through increased use.”private payers through increased use.”

• “…“….physician self-referral and antikickback laws regulating .physician self-referral and antikickback laws regulating potential conflicts of interest include exemptions that may potential conflicts of interest include exemptions that may deserve reexamination.”deserve reexamination.”

* Pham HH et al, Health Affairs 2004; 23: 70-81* Pham HH et al, Health Affairs 2004; 23: 70-81

MedPAC Report to the CongressMedPAC Report to the Congress3/6/033/6/03

• Assessed growth in medical services between Assessed growth in medical services between 1999-2002 w/i the Medicare program.1999-2002 w/i the Medicare program.

• Divided services into 4 categories: E&M, Divided services into 4 categories: E&M, procedures, imaging, and tests.procedures, imaging, and tests.

• Avg annual growth, 1999 Avg annual growth, 1999 2002: 2002:– E&M: 1.8%E&M: 1.8%– Procedures: 4.1%Procedures: 4.1%– Tests: 5.6% Tests: 5.6% – Imaging: 9.0%Imaging: 9.0%

Blue Cross Blue Shield Assoc. ReportBlue Cross Blue Shield Assoc. Report10/14/0310/14/03

• Dx imaging costs in the U.S. were approx $75 billion Dx imaging costs in the U.S. were approx $75 billion in 2000 and are forecast to in 2000 and are forecast to to $100 billion by 2005. to $100 billion by 2005.

• Between 1999 and 2001, growth in the various areas Between 1999 and 2001, growth in the various areas of outpt Dx imaging was as follows:of outpt Dx imaging was as follows:– X-ray 18%X-ray 18%

– USUS 23% 23%

– CTCT 45% 45%

– MRIMRI 47% 47%

A Possible Plan of Action – could be adopted by A Possible Plan of Action – could be adopted by payers (assumes no action by fed or state govts)payers (assumes no action by fed or state govts)

• Mandatory accreditation &/or site inspections of all imaging Mandatory accreditation &/or site inspections of all imaging facilities.facilities.

• Limitation of imaging privileges among nonradiologists.[see Limitation of imaging privileges among nonradiologists.[see Verrilli, Radiology 1998; 208: 385 & Moskowitz, AJR 2000; Verrilli, Radiology 1998; 208: 385 & Moskowitz, AJR 2000; 175: 9]175: 9]

• PrecertificationPrecertification-But only for those studies not referred to radiologists (and -But only for those studies not referred to radiologists (and therefore presumably self-referred).therefore presumably self-referred).

• Auditing of referring MD records to see if pt Hx matches the Auditing of referring MD records to see if pt Hx matches the indications shown on the precert requests.indications shown on the precert requests.

• Benchmarking of referring MDsBenchmarking of referring MDs• Pay less for self-referred studies by nonradiologists (or don’t Pay less for self-referred studies by nonradiologists (or don’t

pay at all).pay at all).• Institute (or reinstitute) CON laws.Institute (or reinstitute) CON laws.

* Levin DC & Rao VM, JACR 2004; 1: 806* Levin DC & Rao VM, JACR 2004; 1: 806

MedPAC Report to the Congress, “New Approaches in MedPAC Report to the Congress, “New Approaches in Medicare”, June 2004, pp 95-117: Medicare”, June 2004, pp 95-117: approaches being approaches being

considered for the problem of rapid rises in imagingconsidered for the problem of rapid rises in imaging costscosts• Preauthorization (i.e. precert)Preauthorization (i.e. precert)• Coding edits Coding edits

- Reduce payments for multiple studies- Reduce payments for multiple studies- Pointed out that 40% of CT claims included 2 or more studies at the same - Pointed out that 40% of CT claims included 2 or more studies at the same

timetime

• Profiling physicians to compare frequency of utilizationProfiling physicians to compare frequency of utilization• Beneficiary education re risks of radiation exposureBeneficiary education re risks of radiation exposure• Safety & technical standards – could include site inspections for Safety & technical standards – could include site inspections for

quality of equipment & images, and qualifications of staffquality of equipment & images, and qualifications of staff• PrivilegingPrivileging

- Payments limited to only those physicians qualified to perform imaging- Payments limited to only those physicians qualified to perform imaging

• Differential payment related to ability to meet performance Differential payment related to ability to meet performance standardsstandards

Maryland Health Occupations ArticleMaryland Health Occupations Article§§1-301 (k)(2), 19931-301 (k)(2), 1993

• Prohibits self-referral but has an exception for “in-office Prohibits self-referral but has an exception for “in-office ancillary services’, similar to the Stark law.ancillary services’, similar to the Stark law.

• But this exception specifically does But this exception specifically does not not include MRI, CT include MRI, CT or radiation therapy.or radiation therapy.

• Maryland AG comment on 1/5/04: “In our opinion, state Maryland AG comment on 1/5/04: “In our opinion, state law bars a physician in an orthopedic group practice law bars a physician in an orthopedic group practice from referring patients for tests on an MRI machine or from referring patients for tests on an MRI machine or CT scanner owned by that practice, regardless of CT scanner owned by that practice, regardless of whether the services are performed by a radiologist whether the services are performed by a radiologist employee or member of the practice or by an employee or member of the practice or by an independent radiology group. The same analysis holds independent radiology group. The same analysis holds true for any other non-radiology medical practice.”true for any other non-radiology medical practice.”

Highmark BCBS Privileging Program (8/04)Highmark BCBS Privileging Program (8/04)

• All studies must have written reports.All studies must have written reports.• QC and radiation safety programs required.QC and radiation safety programs required.• Current state inspection, calibration report, or physicist’s Current state inspection, calibration report, or physicist’s

report required.report required.• Automatic processing.Automatic processing.• Accreditation by the appropriate accrediting body (e.g. ACR, Accreditation by the appropriate accrediting body (e.g. ACR,

AIUM, ICANL, ICAVL).AIUM, ICANL, ICAVL).• Services on leased equipment are not covered Services on leased equipment are not covered unless lease is on unless lease is on

a full time basis.a full time basis.• To do MRI, CT, or fluoro, the practice must provide at least 5 To do MRI, CT, or fluoro, the practice must provide at least 5

different imaging modalities (e.g. plain films/DEXA, mammo, different imaging modalities (e.g. plain films/DEXA, mammo, US, echo, CT, MRI/MRA, fluoro, nuc med/nuc cardiac).US, echo, CT, MRI/MRA, fluoro, nuc med/nuc cardiac).

• A radiologist must be on-site during all normal business A radiologist must be on-site during all normal business hours.hours.