November 7, 2012
Aunt Minnie examines the recent GAO report taking a close look at self-referral for medical diagnostic imaging.
GAO attacks imaging self-referral, requests pay cut for exams
November 1, 2012 — A new report from the U.S. Government Accountability Office (GAO) takes a hard-line on physician self-referral of imaging services, detailing more than $100 million in annual unnecessary spending in CT and MRI alone. The report recommends steps to curb the practice, including a pay cut for self-referred imaging studies.
Physician self-referral of patients to imaging scanners that they purchase or lease is a hotly contested topic. The practice is allowed through a loophole in the Stark anti-self-referral act, and proponents claim it offers convenience to patients who don’t have to be referred to another facility for imaging exams.
Opponents, however, believe it leads to wasteful spending as non-radiologist physicians order imaging exams for economic rather than clinical reasons. Radiology advocates have long requested that the U.S. government address physician self-referral as part of its efforts to control wasteful healthcare spending.
The GAO report is a sign that the government may be listening. The report was commissioned due to concerns over Medicare Part B expenditures — including those for advanced imaging services — which “are expected to continue growing at an unsustainable rate,” according to the report. The GAO said it was asked to examine the prevalence of imaging self-referral and its impact on Medicare spending.
The GAO report analyzed Part B claims data from 2004 through 2010, specifically focusing on CT and MRI services. The report found that the overall incidence of self-referral grew during the period, with the number of self-referred MRI studies increasing by 80% over the study period, compared to growth of 12% for MRI scans that weren’t self-referred.
In addition, healthcare providers who began to self-refer saw imaging volume spike shortly after they began the practice. Providers who began self-referring in 2009 increased their CT and MRI referrals by 67.3% in 2010 compared to 2008, and the average number of referrals increased from 25.1 to 42.0 during those years.
In comparison, physicians who were already self-referring in 2009 saw their imaging volumes drop 3.4%, from an average of 47.0 referrals in 2008 to an average of 45.4 referrals in 2010. For providers who weren’t self-referring at all, imaging volumes fell 6.8%, from 20.6 referrals in 2008 to 19.2 in 2010. The findings suggest that the increase was not due to an overall rise among all providers, according to the GAO.
The report estimates that in 2010, healthcare providers who self-referred likely made 400,000 more referrals for advanced imaging studies than they would have if they were not self-referring, and these referrals probably cost Medicare $109 million. The referrals are particularly problematic for CT, as they are exposing patients unnecessarily to ionizing radiation.
The report makes several recommendations to help the U.S. Centers for Medicare and Medicaid Services (CMS) identify and rein in self-referred imaging studies:
- · The CMS administrator should insert a flag to identify self-referred imaging studies on Medicare Part B claims forms. Providers should be required to indicate whether the services for which they are billing are self-referred.
- · CMS should implement a payment reduction for self-referred advanced imaging studies to recognize the efficiencies that occur when the same provider refers and performs a service.
- · CMS should develop tools for ensuring the appropriateness of self-referred imaging services.
Response to the report was mixed. The Medical Imaging and Technology Alliance (MITA), which represents scanner vendors, found fault with the report, stating that two of the recommendations were “unworkable and unnecessary.” The report also failed to acknowledge that per capita imaging utilization has declined, and it failed to address patient access to imaging.
MITA believes that qualified physicians should be able to provide appropriate imaging services to their physicians regardless of their specialties — to do otherwise would limit patient access to care. MITA also noted that the U.S. Department of Health and Human Services (HHS) has agreed to examine the appropriateness issue, which MITA believes is best tackled through appropriateness criteria developed by physicians.
- New government study highlights advanced imaging self-referral abuse (pathologyblawg.com)
- GAO: Excess Self-Referrals Cost Medicare Over $100 Million for Imaging in 2010 . (zedie.wordpress.com)
- Doctors Cost Medicare $100 Million By ‘Self-Referring’ Their Patients For Profits (thinkprogress.org)
“Is utilization management only necessary because bad doctors order too many tests?” This is a common question I get when describing utilization management to people outside of the healthcare industry and the answer I give is that it is not about “bad” doctors or “good” doctors. It is about evidence-based medicine. This was especially clear to me during a recent doctor’s visit. Continue reading
Are patients beginning to “shop” for healthcare? According to the latest NPR-Thomson Reuters Health Poll released in April of this year, 16% of consumers said they had researched pricing information before receiving healthcare services, up from 11% in the 2010 poll. Although 16% isn’t a majority of consumers, a 5% increase in two years may signal an emerging pattern of patients acting more like consumers.
Why are patients acting more like consumers?
While the study does not directly address this question, there could be several answers. First, patients have access to more information than ever before. With the internet, patients can easily research diagnoses and treatments. Social networks allow consumers to instantly connect with other patients to share information. Additionally, health insurance companies, employers and healthcare service providers are giving patients access to information regarding healthcare service pricing. The NPR-Thomson Reuters poll results indicate that when the patients researched healthcare prices, 50% of respondents obtained it from their healthcare provider’s office and 49% obtained it from their insurance company. This was a considerable shift from the 2010 poll which showed 60% of respondents obtained pricing information from their healthcare provider’s office and 26% obtained the pricing information their health insurance company. Continue reading
Insurance companies are well-aware of the costs of fraud, waste and abuse. They are able to leverage the CMS guidelines for filing claims which would increase the ability to detect fraud, waste and abuse. The recent HIPAA guidelines for using the standard American National Standards Institute (ANSI) X12 transaction sets, complete with National Provider Identification number (NPI) requirements, can take a bite out of billions of dollars that are stolen from them if strongly enforced by all carriers, processors and adjudicators.
Will deletion of the molecular diagnostic ‘stacking codes’ provide the solution?
Yes, deletion of the ‘stacking codes’ does lead the way towards added transparency in the billing of common molecular genetic tests, but…
As the economy continues to limp along, many Americans are feeling squeezed. Unemployment and underemployment are at elevated levels. Gas prices are high. But at least healthcare is getting cheaper, right?
Well, that depends on who you ask.
According to data from the Centers for Medicare and Medicaid Services (CMS), Health Care Expenditure (HCE) growth has slowed significantly throughout the recession (2009-2011). The last three years of HCE growth have been 3.8%, 3.9%, and 3.9%. From 1980 through 2008, HCE growth bounced between 14% and 6% annually.
(CMS – National Health Expenditure Accounts)
On the other hand, HCE measured as a percentage of Gross Domestic Product (GDP) continues to gradually rise (depicted by the red line in the graph above). Aside from the debate about whether overall healthcare costs have truly slowed or not, it’s interesting to know that there has been a shift in who is bearing the brunt of healthcare expenses. From an interview with Susan Dentzer (Editor and Chief of “Health Affairs) on PBS:
“Private health insurance coverage declined almost 2 percent in the one year from 2009 to 2010. And, of course, it had declined in the prior year as well. So people were losing their jobs, losing their health care coverage, having to pay more. Those people who did have coverage have had to pay more. We know that employers have been shifting more of the costs of health care to workers.
So, now if you go to the physician or if you go to the hospital, the likelihood is that you’re going to have a higher co-insurance rate. You’re going to pay more of that bill directly yourself. So all of those things came together. And it meant truly people went to the emergency department less. People went to doctor’s offices less. People did less elective surgery in hospitals.”
While Ms. Dentzer’s comments speak directly to reduced health care expenditure attributed to unemployment, she also alludes to another factor. That factor is the emergence of the consumer directed health plan, otherwise known as a High Deductible Health Plan (HDHP).
In an article by Forbes, studies indicate that the use of HDHPs quadrupled during 2006-2011 and increased another 14% from 2010 to 2011 alone. Studies by the RAND corporation indicate that Americans who transition from traditional coverage to consumer directed plans use 14% less health care related services with no negative health outcomes.
This trend to HDHPs can be viewed as an effective tool for cutting healthcare costs and putting the choice in the consumer’s hands or it could be seen as an unnecessary burden to an employee in a tough economy.
Opinions likely vary, what is yours?
In a statement by Lewis Morris, Chief Counsel with the Office of the Inspector General within the US Department of Health and Human Services reporting before the US House Committee on Ways and Means, Subcommittee on Health, Chief Counsel Morris explains, “Health care fraud, waste and abuse schemes commonly include billing for services that were not provided or were not medically necessary, purposely billing for a higher level of service than what was provided, misreporting costs or other data to increase payments, paying kickbacks, and/or stealing providers’ or beneficiaries’ identities. The perpetrators of these schemes range from street criminals to Fortune 500 companies to physicians.” According to the National Health Care Anti-Fraud Association, $68 billion is fraudulently stolen from healthcare annually.
We are all in this together! Healthcare, that is. The current cost of healthcare is unsustainable, quality of care provided needs to improve and everyone needs to work together to effect a solution. Collaboration is the only way.
Your solution is not as comprehensive as you think if you have not engaged the applicable professional organization.
Have a product or service to improve the delivery of care?
A professional organization can help you hone your product or service and, if warranted, achieve buy-in across a relevant industry segment. In an industry that often resists change, collaborating with a professional organization in healthcare can make bringing a new product or service to market much easier.
Need to change behaviors in the market place?
Professional organizations provide the following benefits:
- They have invested in and have access to vast amounts of clinical research and meaningful data
- They have a deep understanding of clinical trends.
- They may enable you to gain access to clinical information and/or data that could allow you to fine-tune your product or service in a way that without access to such knowledge would not have been possible.
In the complex business environment of healthcare, it is difficult for any one person or one company to change an industry. The power of a professional organization’s collective voice can be paramount in developing a dialogue that leads to change.
Many American adults spend most of their waking hours at sedentary jobs where a lack of regular physical activity raises their risk for a host of medical problems, such as obesity, high blood pressure and diabetes. American employers are losing an estimated $225.8 billion a year because of healthcare expenses and health-related losses in productivity, and those numbers continue to rise. Employers face $12.7 billion in annual medical expenses due to obesity alone. The American Heart Association is working to change corporate cultures by motivating employees to start healthy habits including exercising and eating right.
The American Heart Association has recognized CareCore National as a Platinum-Level Fit-Friendly Company for helping employees eat better and move more.
Physical activity and employee wellness are important priorities at CareCore National because healthcare is our business. We understand the value of having healthy employees, and we are honored and excited to be recognized by the American Heart Association as a Platinum-Level Fit-Friendly Company. We’re committed to providing a culture of wellness for our employees at work. This will benefit our employees’ health and result in higher productivity for our entire company.
The American Heart Association’s Fit-Friendly Companies program is a catalyst for positive change through integrating employee wellness efforts into daily office routines. The program highlights companies that have made the health and well-being of employees a priority. We support healthy living for our employees and this validates our efforts.
CareCore National is making wellness a priority by offering healthier vending options on campus, wellness educational “Lunch and Learn” events, employee health screenings, Weight Watchers at Work or online via payroll deduction, and smoking cessation support at work.
By bringing healthy lifestyle education into the workplace, CareCore National has increased the participation of its employees. The impact of this type of program was described in a 2010 study in HealthAffairs entitled “Workplace Wellness Programs Can Generate Savings” by Baicker et al. They report that these programs not only improve the health of employees but also have positive returns for employers with both decreased absenteeism and decreased overall health care costs.
For more information about the American Heart Association’s Fit-Friendly Work sites program, click here.