A series of articles published in the Wall Street Journal (WSJ) during last few weeks have attacked physician “self-referral.” Whether examining a prostate cancer treatment known as IMRT (intensity modulated radiation therapy) or the use of spinal fusion surgery, the paper has suggested that physicians are placing profit over patient care. When I read the stories, I find myself questioning the quality of the research underlying the reports. Most of the articles simply compare statistics, and conclude that if one clinic is using a treatment at a higher rate than another clinic, or one physician is performing more surgeries than other, the most plausible explanation is that the first is "overusing" the service. It is, of course, equally possible that the second has failed to recognize the value of the service and is "under treating" patients. It is also possible that both are using the service appropriately, with the variation a result of differences in the patient mix. The methodology used merely notes a correlation, and then concludes that the causation is readily apparent. Such shoddy analysis is all too common, but that does not make it defensible.
Attacks on physician ownership are not new. In the 1980s, a "study" on the use of MRI prompted the passage of Stark. It claimed that physicians who owned an MRI were much more likely to order MRIs than those that did not. Once again, the analysis focused exclusively on correlation, not causation. Physicians who believe in the value of (or have a significant number patients who need) MRIs are far more likely to own a machine than those who don't. The study made no attempt to determine if the additional studies were medically appropriate. A solid analysis would have had independent reviewers blindly review scans sent to physician-owned scanners and to independent facilities, and ask the reviewer to evaluate the legitimacy of each scan. That was not done. Instead, the whole analysis focused on statistics.
One of my greatest frustrations is that physicians are singled out for self-referral criticism when nearly every single professional self-refers. Lawyers, plumbers, accountants and mechanics are all responsible for diagnosing and treating their client's problems. While it would be possible to separate the diagnosis and treatment, this separation is terribly inconvenient. Would you want your first plumber to identify the problem and then be required to use a second, unrelated plumber to fix it? I don't believe that the WSJ has suggested that stock brokers who identify the hot tips should be prevented from selling the stock because of a "conflict to interest." It is unclear to me why they believe physicians, alone among professionals, should be criticized for "self-referral." Newspapers have an interest in selling papers, but I have never heard it suggested that a muckraking reporter who uncovers a good scoop must permit another paper to print the story to avoid the conflict of interest.
As you may know, Congress has been holding hearings into the relationship between medical device companies and surgeons. In the hearings, lawmakers have clearly implied that any physician who has a consulting relationship with a device manufacturer must be tainted, having been "bought" by the manufacturer. The irony of the situation seems entirely lost on Congress. The politicians, all of whom routinely raise money, believe that they act independently, without any undue influence from the contributors, assume that physicians are unable to exercise similar uncorrupted judgment.
As physicians, you have your work cut out for you. A number of well-funded, highly organized groups are willing to attack you. Hospitals certainly want to provide you with a base from which to operate, but they would prefer you be prohibited from offering any ancillary services. Insurers would like to limit the number of services available. Insurers are acutely aware that any discussion of "rationing" is politically dangerous. But if the debate can be reframed as a dispute about self-referral, insurers can appear to be a white knight, saving patients from unnecessary services, rather than a financial organization limiting its economic outlay by making it more difficult for patients to obtain medically necessary services.
Unless physicians are willing to aggressively defend the need for in-office services, there is a real risk that these sources of patient convenience, and practice income, will become a thing of the past. I encourage you to contact the American Academy of Orthopaedic Surgeons (AAOS), Arthroscopy Association of North America (AANA), and other trade groups and see how you can help on this fight.
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