One issue that obviously needs more discussion here is about what specific initiatives the ACR is undertaking regarding financially motivated self-referral. Frankly, it has been astonishingly difficult to get this concept across to people in Congress and their staffs as well as CMS. From the point of view of many of them, it seems logical that if Dr X determines one of his/her patients needs a CT scan that he/she provides it in their office, in similar fashion to a flu shot or anything else. Many also perceive this to be a matter of patient convenience. This is the perception fostered by self-referring physicians that the ACR has been fighting for over two decades.
There are reasons now, however, to think that perhaps, just perhaps, the tide may be turning and policymakers in Washington are taking a fresh look at the role ownership may play in the prescribing of certain physician services.
One reason both Congress and their policy advisory body, MedPAC, are taking a fresh look at self-referral is that they are running out of other reasons to explain why some physician services grow exponentially faster than others. In this vein, it seems most certain that Congress, this year, will prohibit physician ownership in specialty hospitals. While we have tried for years to link the arguments of our concerns in imaging to the specialty hospital ones, it now appears some on Capitol Hill are listening. Also, MedPAC, the highly influential advisory body to Congress has now listed âownershipâ and the use of certain services as a major policy they will study. Their interest is primarily driven by their concerns about the growth of imaging services, and we have been meeting with them, closely, for several years to educate and illuminate their understanding of the complexities of this problem.
Another sea change in Washington is that the dominant political philosophy in Congress changed in the last elections and is poised for further changes in the upcoming 2008 elections. The former Republican majority believed in a market-driven health care environment and government edicts about ownership was not a popular or well-liked philosophy. The new majority Democrats are much more supportive of a government-centered, regulatory health care model. This may indeed help us in our arguments against self-referral but we need to be cognizant that in other policy decisions, we may not like this kind of control.
So, what else can we do? In the long run, there is nothing better than data, objectively developed and relentlessly applied, to turn people's outlooks around. However, it is extraordinarily difficult to develop the kind of information that is now helping turn the tide. Our primary obstacle is that no payer, Medicare or private insurer, looks at ownership as a factor in determining coverage or payment for a particular service. As a result, input data must come from insurance billing records that are controlled by corporate and government entities with their own agendas. Data analysis requires sifting through millions of patient records to group services into episodes of care that are then further analyzed to see whether the same kind of specialist who billed for the office visit also billed for the imaging study or whether the imaging study was billed by a radiologist.
The ACR has always recognized the importance of this kind of analysis and has funded research on the relationship of utilization and self-referral by Scott Gazelle M.D., Ph.D., and similar research by an internal research group lead by Dr. Jonathon Sunshine, an economist.
These activities are bearing fruit. Dr. Gazelle recently published a major study in Radiology and the ACR staff has had the opportunity to present our data to leaders at the Centers for Medicare and Medicaid Services (CMS) within the past month. The data are eye opening and clearly indicate that where referral is linked to financial incentives, the utilization of imaging skyrockets. CMS is now planning its own analysis, stimulated in part by data supplied through these ACR initiatives.
Following the passage of the DRA in 2005, a new front was added to the ACR's efforts to support the practice of radiology. We helped organize a broad based coalition of manufacturers, patient groups and other medical specialties to create the Access to Medical Imaging Coalition (AMIC) to protect the outpatient practice of radiology. For the specific issues involved, the ACR has worked well with other organizations that we have not always been close to and with the imaging device industry. A tangible good outcome of the work done by AMIC is the recent letter addressed to the Senate Finance Committee leadership signed by 30 Senators stating their opposition to further cuts related to imaging. A powerful statement and indicator that the ACR message is being heard on Capitol Hill.
James H. Thrall, M.D., FACR
Chair, RADPAC
Vice Chair, American College of Radiology Association (ACRA)
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