Thursday editorial: Profit/patient relationship
You drop your car off for routine service. The mechanic has bad news. He needs to replace a part you’ve never heard of. It’s going to be expensive, he says.
Is this for real, you ask yourself, or is he just trying to sell me something?
You visit your doctor for routine care. There’s a problem, she says. You don’t entirely understand what’s wrong, but she wants to send you for tests at an “imaging center.” She may or may not mention that she is a part owner of that center.
Do you ask yourself the same questions you asked about the mechanic?
Tectonic shifts are underway in how health care is paid for, how it’s delivered and how much it costs. Even more fundamental financial pressures are forcing subtle changes in the doctor-patient relationship.
Post-Dispatch business writer Mary Jo Feldstein sketched out one of them last week: the rise of doctor-owned imaging centers stocked with expensive MRI machines and CT scanners.
In nearly half the states in the nation, including Illinois, it’s illegal for doctors to make referrals to outside imaging centers in which they have a stake. Medicare doesn’t allow it, either, although loopholes in its rules have made the practice increasingly common. But in Missouri, it’s perfectly legal.
Doctors who own such centers — there are perhaps two dozen in the St. Louis area, each of them a partnership involving dozens of doctors — say they provide MRIs and CT scans that are quicker, of higher quality and more convenient for patients. They scoff at the idea that the relatively modest payments they receive would motivate them to order unnecessary tests.
But the U.S. Government Accountability Office reported that doctors with a financial stake in imaging equipment are 50 percent more likely to refer patients for MRIs and 30 percent more likely to suggest CT scans than doctors who don’t have a piece of the action.
Medicare spent slightly less than $7 billion on diagnostic imaging in 2000. By 2006, the tab had leaped to $14.1 billion.
A GAO analysis found that increased Medicare spending was linked to the growth in the number of physicians with their own imaging equipment. It also found that doctors with their own equipment were deriving a larger percentage of their total income from payments for the scans. That’s because insurance companies have worked aggressively to hold down what they pay doctors for office visits and routine care.
More than just money is at stake. Researchers from Harvard University wrote last year that as many as one-third of all CT scans performed each year are unnecessary.
Since each CT scan delivers as much radiation as hundreds of X-rays, the researchers estimated that as many as 3 million additional cancer cases could be caused by unnecessary CT scans over the next two or three decades.
Whatever else it represents, health care is big business. Billions of dollars are spent in the St. Louis region each year on doctors, hospitals and prescription drugs.
Before there were doctor-owned imaging and surgical centers, hospitals built and controlled free-standing facilities to provide those services.
As not-for-profit hospitals came to operate like big businesses, doctors found themselves increasingly strained by paperwork requirements, squeezed by insurance company reimbursement rates and frustrated by what they perceived as their loss of influence of the practice of medicine. Many regarded investing in imaging and surgical centers as a way to regain control of their medical practices.
It’s hard to fault them. But it’s happening at a time when more and more responsibility — for educating themselves about health, shopping around for services and paying for their own care — is already being placed on patients. They’re not happy about those changes.
What it comes down to is that doctors want their share of the economic spoils. Knowing that, patients may start regarding them with the same skepticism they have toward big insurance companies and hospitals.
Any way you cut it, that’s a net loss for doctors.
Christian Gooden/Post-Dispatch photo
The fact that patients are skeptical about the benefits of treatment is no net loss for physicians. If a physician cannot succinctly describe the benefit of the blood test, imaging exam or treatment proposed, they are not worth their salt and the patient should probably be looking for a new physician. I see no reason this is a loss for physicians or patients.
The difference between the car mechanic and the physician is that the physician is required to tell you the benefits and risks of any treatment. It is the duty of patients to hold the physician accountable. If they hire a third party to do so (i.e. an insurance company or patient advocate) that is fine too.
For the record, my most informed (and satisfied) patients are those who ask: “What is the benefit and what are the risks of treatment?” I always let them know the risks and benefits, I let them know if I recommend the treatment based on the evidence of those risks and benefits and then the patient decides if they prefer to receive the treatment. It is my opinion that that is how any doctor should inform and treat their patient.
I fail to see what the PD editorial board has against such a method. Will you please let us know? If this is the method used, I also fail to see any conflict of interest between in a physician owning imaging devices (I don’t own any myself but know plenty of physicians who do).