Self Referral: Another Installment

Today’s Managing Health Care Costs Indicator is 215%

Nuclear exercise stress tests are generally not recommended as “routine followup” after coronary revascularization.   However, cardiologists who were paid either professional fees (to read such tests) or who actually owned the equipment and were paid both technical and professional fees were 1.6-2.3 times more likely to order such tests, according to an article in last week’s Journal of the American Medical Association.  The same pattern was found for stress echo tests, which are performed much less frequently.

The authors looked for patients who were 90 days out from bypass or angioplasty, and found imaging tests performed within 30 days of a cardiologist office visit. They excluded patients with an intervening cardiac event.   This was from a large database of commercial claims, and the patients were on average between 54 and 55.

The authors note that the frequency of these tests in cardiologist offices increased 215% between 1998 and 2006, 181% in other physician offices, and only 32% in radiologist offices.

The physicians ordering these tests no doubt believed they were necessary.  Self referral has again been shown to lead to higher utilization and higher costs.  It also appears to be associated with lower levels of practicing evidence-based care.

Smoked Pig

Today’s Managing Health Care Costs Indicator is $2159

Today’s New York Times features another tale from the land of variation.

  

Cardiologist Mark Midei inserted 30 cardiac stents in patients in a single day in 2008. The stent manufacturer (Abbott) purchased a $2159 barbeque dinner including a slow-smoked whole pig for the cardiologists’ home two days later.

The pig is a great headline, and a savory metaphor for the problem of overuse of high-margin procedures, some of which are invasive and have clear associated dangers.  The hospital subsequently notified 585 patients that they might have received medically unnecessary stents.  585!  This is mind-boggling.  

This story, initially reported in the Baltimore Sun, is reminiscent of the Tenet hospital in Redding, California.  That hospital built an empire providing cardiac surgery with very low complication rates – but it turned out that many of the cardiac surgery patients had normal coronary arteries. See Shannon Brownlee's excellent 2007 book Overtreated for the details.  

It’s especially interesting how this physician’s behavior was revealed.  His cardiology group had agreed to be purchased by the local hospital, but the hospital turned around and made him a separate deal and decided not to purchase the entire group. At that point, his spurned group attacked him, and a former chief executive vowed to “spend the rest of my life trying to destroy him personally and professionally.”  The hospital has paid $22 million to settle federal charges of kickbacks to Dr. Midei's former group. 

Most variation in health care is not as extreme as the allegations at St Joseph’s in Baltimore.   Most physicians who practice at the 90^th percentile of resource use don’t realize that they are using more resources than their colleagues, and few believe that they are performing unnecessary care.   We need better reporting on resource utilization and continuing effective peer review.  It’s a pity when peers are only effective at reining in rampant overutilization when they no longer inure benefit from that utilization.