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

Dec 14, 2015

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The Self-Referral Issue David C. Levin, M.D. NCQDIS, 12/2/04 Slide 2 If nonradiologists are allowed to self-refer, overutilization inevitably results Slide 3 Frequency of imaging per episode of illness Clinical presentation Ratio of imaging frequency, self- referrers/radiologist-referrers Chest pain 1.9 CHF2.7 Difficulty urinating 2.2 GI bleeding 1.7 Headache4.3 Knee pain 7.7 Low back pain 3.6 Transient cerebral ischemia 4.7 URI2.3 UTI2.4 *Hillman, JAMA 1992; 268: 2050 Slide 4 U.S. GAO Report, Referrals to Physician-Owned Imaging Facilities Warrant HCFAs Scrutiny, 10/94 Compared rates of imaging for MDs having in-practice imaging equipt with rates for other MDs who referred elsewhere.Compared rates of imaging for MDs having in-practice imaging equipt with rates for other MDs who referred elsewhere. Based on Medicare claims covering 19.4 million office visits & 3.5 million imaging studies in FL during 1990.Based on Medicare claims covering 19.4 million office 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: MRI3.06 CT1.95 US5.13 Nuc Med 4.52 X-ray2.10 Slide 5 % changes in Medicare utilization (proc/1000) & RVU rates, 1993-2002, among radiologists, cardiologists, all nonradiologists % change Slide 6 % Changes in RMPI Utilization Rates, 1998 2002, Among Radiologists, Cardiologists, & Other MDs % change Slide 7 Did the much more rapid growth in utilization of RMPI among cardiologists substitute for cardiac cath or stress echo? From 1998 to 2002, cardiac cath utilization rate 19.5%.From 1998 to 2002, cardiac cath utilization rate 19.5%. Stress echo utilization rate 22.0%.Stress echo utilization rate 22.0%. Slide 8 % Increases in Medicare Reimbursements for MRI, 1997 2002 % increase Slide 9 Effect of Financial Incentives on Test-Ordering in an Ambulatory Care Center 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.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. 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 MDs to earn bonuses based upon revenues they generated.During 1985, financial incentives were introduced, which allowed MDs to earn bonuses based upon revenues they generated. 3 winter months of 1984-85 (before) and 1985-86 (after) were compared.3 winter months of 1984-85 (before) and 1985-86 (after) were compared. 11 of 15 ordered more x-rays in 85-86; overall utilization by the group by 16%.11 of 15 ordered more x-rays in 85-86; overall utilization by the group by 16%. 13 of 15 ordered more lab tests in 85-86; overall utilization by the group by 23%.13 of 15 ordered more lab tests in 85-86; overall utilization by the group by 23%. *Hemenway, NEJM 1990; 322: 1059 Slide 10 Effect of On-Site Radiology Facilities on Frequency of Chest X-Rays 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 x-ray equipment; pts at the other were referred to an outside radiology office.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 x-ray equipment; pts at the other were referred to an outside radiology office. No financial link between the family physicians and the radiology service.No financial link between the family physicians and the 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 to have a chest x-ray.Pts seen at the facility having on-site x-ray were 2.4X as likely to have a chest x-ray. The family medicine residents hand-written impressions differed from the final radiology report in 23.5% of cases (usually overcalls).The family medicine residents hand-written impressions differed from the final radiology report in 23.5% of cases (usually overcalls). *Strasser, J Family Practice 1987; 24: 619 Slide 11 1)Levin DC & Rao VM. Turf Wars in Radiology: The Overutilization of Imaging Resulting From Self-Referral. JACR 2004; 1: 169-172.[March 2004] 2) Levin DC & Rao VM. Turf Wars in Radiology: The Quality of Interpretations of Imaging Studies by Nonradiologist Physicians A Patient Safety Issue? JACR 2004; 1: 506-509.[July 2004] 3) Levin DC, Rao VM, Orrison WW Jr. Turf Wars in Radiology: The Quality of Imaging Facilities Operated by Nonradiologist Physicians and of the Images They Produce. JACR 2004; 1: 649-651 . [Sept 2004] Slide 12 If nonradiologists are allowed to interpret images, they will make lots of errors i.e. the quality issue on the professional side Slide 13 PERFORMANCE ON A STANDARDIZED SET OF CHEST X-RAYS 3 panels3 panels 29 radiology residents 111 board-certified radiologists 22 nonradiologists (from 7 private practice & 6 academic medical groups) 30 normal cases, 30 abnormals (infiltrates, pneumothoraces,masses, cardiac abnormalities)30 normal cases, 30 abnormals (infiltrates, pneumothoraces,masses, cardiac abnormalities) ROC curves calculated for 5 physician categories: (1) top 20 radiologists, (2) bottom 20 radiologists, (3) all board-certified radiologists, (4) radiology residents, (5) nonradiologists.ROC curves calculated for 5 physician categories: (1) top 20 radiologists, (2) bottom 20 radiologists, (3) all board-certified radiologists, (4) radiology residents, (5) nonradiologists. *Potchen, RADIOLOGY 2000; 217: 456 Slide 14 Potchen, RADIOLOGY 2000; 217: 456 Slide 15 Areas Under the ROC Curves (All Results Differ Statistically from Each Other) GROUP# AREA UNDER ROC CURVE (mean 1 SD) All bd-cert radiols 111 0.860 0.005 Radiol residents 29 0.746 0.011 Nonradiologists22 0.657 0.015 *Potchen, RADIOLOGY 2000; 217: 456 Slide 16 ACCURACY OF INTERPRETATION OF HEAD CTs IN THE ER BY EMERGENCY PHYSICIANS 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 radiologist.Scans interpreted first by an ER MD, then by a radiologist. Nonconcordance in 206 cases (39%).Nonconcordance in 206 cases (39%). Potentially significant misinterpretations by ER MDs in 131 (24%).Potentially significant misinterpretations by ER MDs in 131 (24%). Major misses: infarcts, masses, cerebral edema, parenchymal hemorrhage, contusions, subarachnoid hemorrhageMajor misses: infarcts, masses, cerebral edema, parenchymal hemorrhage, contusions, subarachnoid hemorrhage *Alfaro, Ann Emerg Med 1995; 25: 169 Slide 17 1) Levin DC & Rao VM. Turf Wars in Radiology: The Overutilization of Imaging Resulting From Self-Referral. JACR 2004; 1: 169-172.[March 2004] 2) Levin DC & Rao VM. Turf Wars in Radiology: The Quality of Interpretations of Imaging Studies by Nonradiologist Physicians A Patient Safety Issue? JACR 2004; 1: 506-509.[July 2004] 3) Levin DC, Rao VM, Orrison WW Jr. Turf Wars in Radiology: The Quality of Imaging Facilities Operated by Nonradiologist Physicians and of the Images They Produce. JACR 2004; 1: 649-651 . [Sept 2004] Slide 18 If nonradiologists are allowed to perform imaging, the quality of the studies is likely to be poor i.e. the quality issue on the technical side Slide 19 Quality Assessment of 562 Imaging 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 physicians (radiologists, orthopods, neurologists, FPs, chiropractors, podiatrists).Findings reviewed by a multispecialty panel of 15 physicians (radiologists, orthopods, neurologists, FPs, chiropractors, podiatrists). For a problem to be considered a deficiency, the panel had to unanimously agree.For a problem to be considered a deficiency, the panel had to unanimously agree. 90 of the 562 refused to participate. Carrier may drop them from reimbursement.90 of the 562 refused to participate. Carrier may drop them from reimbursement. Of the remaining 472, 149 (32%) failed with 1-9 deficiencies.Of the remaining 472, 149 (32%) failed with 1-9 deficiencies. Orrison, Radiology 2002; 225(P):550 [abst] Slide 20 Failure Rates # of sites Failures Chiropractors144 69 (48%) Podiatrists49 22 (45%) FPs/GPs72 31 (43%) Internists20 8 (40%) Urologists14 5 (36%) Surgeons12 3 (25%) Orthopedists43 7 (16%) Ob/gyns41 3 (7%) Radiologists77 1 (1%) Slide 21 1) Levin DC & Rao VM. Turf Wars in Radiology: The Overutilization of Imaging Resulting From Self-Referral. JACR 2004; 1: 169-172.[March 2004] 2) Levin DC & Rao VM. Turf Wars in Radiology: The Quality of Interpretations of Imaging Studies by Nonradiologist Physicians A Patient Safety Issue? JACR 2004; 1: 506-509.[July 2004] 3) Levin DC, Rao VM, Orrison WW Jr. Turf Wars in Radiology: The Quality of Imaging Facilities Operated by Nonradiologist Physicians and of the Images They Produce. JACR 2004; 1: 649-651 . [Sept 2004] Slide 22 Imaging Utilization Skyrocketing in Boston? Harvard Pilgrim Health Care of MA (750,000 members) saw a 62% increase in use of advanced imaging studies in 2 years.Harvard Pilgrim Health Care of MA (750,000 members) saw a 62% increase in use of advanced imaging studies in 2 years. Tufts Health Plan saw a 48% increase in all imaging between 2000 & 2003.Tufts Health Plan saw a 48% increase in all imaging between 2000 & 2003. BCBS of MA saw a 20% increase in MRIs and a 25% increase in CTs from 2002 to 2003.BCBS of MA saw a 20% increase in MRIs and a 25% increase in CTs from 2002 to 2003. L. Kowalczyk, Boston Globe, 2/27/04 Slide 23 An MRI Machine For Every Doctor? Someone Has To Pay R. Abelson, N.Y. Times, 3/13/04 In Syracuse, NY the number of MRIs has grown by 1/3 in 3 years.In Syracuse, NY the number of MRIs has grown by 1/3 in 3 years. In the past year alone, utilization of MRI studies by 23%.In the past year alone, utilization of MRI studies by 23%. Unfortunately its the business community that pays for these John Driscoll, local business leader.Unfortunately its the business community that pays for these John Driscoll, local business leader. In NY, hospitals must get CONs for MRIs but private physician offices dont have to.In NY, hospitals must get CONs for MRIs but private physician offices dont have to. I dont think you should limit the use of technology [and] competition Michael Vella, MD, head of a 23- physician orthopedic group that installed 2 MRIs and a nuclear camera in their office.I dont think you should limit the use of technology [and] competition Michael Vella, MD, head of a 23- physician orthopedic group that installed 2 MRIs and a nuclear camera in their office. Slide 24 Slide 25 Financial Pressures Spur Physician Entrepreneurialism Based on 270 interviews during 2003 with senior MD & non- MD leaders of hospitals, health plans, physican groups.Based on 270 interviews during 2003 with senior MD & non- MD leaders of hospitals, health plans, physican groups. A common theme across markets was that harsh business realities had left physicians feeling financially beleagured, forcing them to become more business oriented.A common theme across markets was that harsh business realities had left physicians feeling financially beleagured, forcing them to become more business oriented. Investment in ancillary services (such as imaging or laboratory testing) was mentioned by the most respondents as a major strategy among physicians in their market.Investment in ancillary services (such as imaging or laboratory testing) was mentioned by the most respondents as a major strategy among physicians in their market. Physician strategies threaten to raise costs for public and private payers through increased use.Physician strategies threaten to raise costs for public and private payers through increased use. .physician self-referral and antikickback laws regulating potential conflicts of interest include exemptions that may deserve reexamination..physician self-referral and antikickback laws regulating potential conflicts of interest include exemptions that may deserve reexamination. * Pham HH et al, Health Affairs 2004; 23: 70-81 Slide 26 MedPAC Report to the Congress 3/6/03 Assessed growth in medical services between 1999-2002 w/i the Medicare program.Assessed growth in medical services between 1999-2002 w/i the Medicare program. Divided services into 4 categories: E&M, procedures, imaging, and tests.Divided services into 4 categories: E&M, procedures, imaging, and tests. Avg annual growth, 1999 2002:Avg annual growth, 1999 2002: E&M: 1.8% Procedures: 4.1% Tests: 5.6% Imaging: 9.0% Slide 27 Blue Cross Blue Shield Assoc. Report 10/14/03 Dx imaging costs in the U.S. were approx $75 billion in 2000 and are forecast to to $100 billion by 2005.Dx imaging costs in the U.S. were approx $75 billion in 2000 and are forecast to to $100 billion by 2005. Between 1999 and 2001, growth in the various areas of outpt Dx imaging was as follows:Between 1999 and 2001, growth in the various areas of outpt Dx imaging was as follows: X-ray 18% US 23% CT 45% MRI 47% Slide 28 A Possible Plan of Action could be adopted by payers (assumes no action by fed or state govts) Mandatory accreditation &/or site inspections of all imaging facilities.Mandatory accreditation &/or site inspections of all imaging facilities. Limitation of imaging privileges among nonradiologists.[see Verrilli, Radiology 1998; 208: 385 & Moskowitz, AJR 2000; 175: 9]Limitation of imaging privileges among nonradiologists.[see Verrilli, Radiology 1998; 208: 385 & Moskowitz, AJR 2000; 175: 9] PrecertificationPrecertification -But only for those studies not referred to radiologists (and therefore presumably self-referred). Auditing of referring MD records to see if pt Hx matches the indications shown on the precert requests.Auditing of referring MD records to see if pt Hx matches the indications shown on the precert requests. Benchmarking of referring MDsBenchmarking of referring MDs Pay less for self-referred studies by nonradiologists (or dont pay at all).Pay less for self-referred studies by nonradiologists (or dont pay at all). Institute (or reinstitute) CON laws.Institute (or reinstitute) CON laws. * Levin DC & Rao VM, JACR 2004; 1: 806 Slide 29 MedPAC Report to the Congress, New Approaches in Medicare, June 2004, pp 95-117: approaches being considered for the problem of rapid rises in imaging costs Preauthorization (i.e. precert)Preauthorization (i.e. precert) Coding editsCoding edits - Reduce payments for multiple studies - Pointed out that 40% of CT claims included 2 or more studies at the same time 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 quality of equipment & images, and qualifications of staffSafety & technical standards could include site inspections for quality of equipment & images, and qualifications of staff PrivilegingPrivileging - Payments limited to only those physicians qualified to perform imaging Differential payment related to ability to meet performance standardsDifferential payment related to ability to meet performance standards Slide 30 Maryland Health Occupations Article 1-301 (k)(2), 1993 Prohibits self-referral but has an exception for in-office ancillary services, similar to the Stark law.Prohibits self-referral but has an exception for in-office ancillary services, similar to the Stark law. But this exception specifically does not include MRI, CT or radiation therapy.But this exception specifically does not include MRI, CT or radiation therapy. Maryland AG comment on 1/5/04: In our opinion, state law bars a physician in an orthopedic group practice from referring patients for tests on an MRI machine or CT scanner owned by that practice, regardless of whether the services are performed by a radiologist employee or member of the practice or by an independent radiology group. The same analysis holds true for any other non-radiology medical practice.Maryland AG comment on 1/5/04: In our opinion, state law bars a physician in an orthopedic group practice from referring patients for tests on an MRI machine or CT scanner owned by that practice, regardless of whether the services are performed by a radiologist employee or member of the practice or by an independent radiology group. The same analysis holds true for any other non-radiology medical practice. Slide 31 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 physicists report required.Current state inspection, calibration report, or physicists report required. Automatic processing.Automatic processing. Accreditation by the appropriate accrediting body (e.g. ACR, AIUM, ICANL, ICAVL).Accreditation by the appropriate accrediting body (e.g. ACR, AIUM, ICANL, ICAVL). Services on leased equipment are not covered unless lease is on a full time basis.Services on leased equipment are not covered unless lease is on a full time basis. To do MRI, CT, or fluoro, the practice must provide at least 5 different imaging modalities (e.g. plain films/DEXA, mammo, US, echo, CT, MRI/MRA, fluoro, nuc med/nuc cardiac).To do MRI, CT, or fluoro, the practice must provide at least 5 different imaging modalities (e.g. plain films/DEXA, mammo, US, echo, CT, MRI/MRA, fluoro, nuc med/nuc cardiac). A radiologist must be on-site during all normal business hours.A radiologist must be on-site during all normal business hours.

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