Did you know that about half of cardiologists' $400,000+ average income comes from self-referring patients to undergo imaging studies on scanners owned in part or in whole by the physicians themselves? This type of arrangement violates the spirit but not the letter of the Stark Law, created in 1992 to address the inevitable economic and medical inequities that result when physicians are permitted to self-refer Medicare/Medicaid patients (or circularly-refer them within a tight group of cronies). However, Stark is arcane and has many exceptions, one of the biggest being the exception for "in-office ancillary services." Some cardiologists responded by buying stress-testers and coronary CT-scanners for their practices, and commenced to printing money.
But surely all those expensive imaging studies (that you and I ultimately paid for with payroll taxes and insurance premiums) were justified and medically appropriate, right? Might there be a difference in the practice patterns between private cardiologists owning such machines, and cardiologists who don't?
Shah et al drilled down into United Healthcare's database of 17,847 people who followed up with a cardiologist more than 90 days after coronary revascularization. They chose this group because, simply put, these patients should generally not get stress tests (the American College of Cardiology recommends a 2-year hiatus on stress testing after coronary stent placement, and 5 years after CABG).
Results: How many of those patients got nuclear or echocardiographic stress tests within a month after their outpatient visits?
- 12.6% if their doctor billed for both professional and technical fees (e.g., her practice owned the scanner)
- 8.8% if the cardiologist billed only for professional fees (e.g., didn't own the scanner, but billed for interpretation of the test results)
- 5.0% if the cardiologist billed for neither (e.g., referred the patient to an imaging center that performed, interpreted, and billed for the test & interpretation)
The Centers for Medicare and Medicaid Services have long been concerned about the costs associated with self-referrals for imaging tests, and have tried to push back against the practice. In 2008 CMS tried to stop paying for coronary-CT scans unless clinical trials were done to test if they add any benefit in risk stratification & treatment of heart disease. One small professional society (The Society of Cardiovascular Computed Tomography, financially backed by large corporations who make scanners) was able to successfully lobby CMS to back off its rule.
Of course, cardiologists are not the only specialists who make income off tests they order, perform and interpret -- neurologists have done this with MRIs, and of course pulmonologists do it every day with pulmonary function tests and sleep studies.
Clinical Takeaway: The physician-owned machines are surely more convenient for the patients, and more efficient. But medicine's the one place where efficiencies like this seem to result in all of us paying more, not less. Maybe a little inefficiency wouldn't be so bad.
Shah BR et al. Association Between Physician Billing and Cardiac Stress Testing Patterns Following Coronary Revascularization. JAMA 2011;306(18):1993-2000.