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Use of Stress Imaging After Revascularization Highly Dependent on Billing Method
Hollenbeck BK. JAMA. 2011;2028-2030.
Shah BR. JAMA. 2011;306:1993-2000.
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Patients who were billed for technical fees, professional fees or both were more likely to undergo nuclear stress testing and stress echocardiography testing after revascularization compared with patients who were not billed, researchers reported in a recent study.
Bimal R. Shah, MD, MBA, of the Duke Clinical Research Institute and Duke University Medical Center, Dunham, N.C., and colleagues used data from a national health insurance carrier that included 17,847 patients who had PCI (n=13,127) or CABG (n=4,270) and an index cardiac outpatient visit more than 90 days after the procedure. Researchers classified physicians by whether they billed for technical and professional fees, professional fees only or neither.
According to results, the cumulative incidence of nuclear stress testing was 12.6% (95% CI, 12-13.2) for those who billed for technical and professional fees, 8.8% (95% CI, 7.5-10.2) for those who billed for professional fees only and 5% (95% CI, 4.4-5.7) for those who billed for neither; the incidence with stress echocardiography was 2.8% (95% CI, 2.5-3.2) among physicians who billed for technical and professional fees, 1.4% (95% CI, 1-1.9) among those who billed for professional fees only and 0.4% (95% CI, 0.3-0.6) for those who billed for neither.
Overall, cardiologists were more likely to conduct stress tests than primary care physicians.
“The study by Shah et al highlights the principal risk of in-office imaging,” Brent K. Hollenbeck, MD, MS, and Brahmajee K. Nallamothu, MD, MPH, both at the University of Michigan, Ann Harbor, Mich., wrote in an accompanying editorial. “By examining this phenomenon in a clinical context generally considered to be ‘inappropriate’ — namely, routine cardiac stress imaging after coronary revascularization — the investigators have demonstrated the persistence of financial conflicts of interest as a driver of utilization. The truism ‘if you provide a service, you’re more likely to provide a service’ apparently has not changed over the years.”
Disclosure: Drs. Hollenbeck and Nallamothu report no relevant financial disclosures.
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The study by Shah et al highlights what has been a well-known and critical problem for American health care economics. It can be summarized that the practice of medicine is at odds with the business of medicine. It is human nature, especially in regard to one’s own business, that when confronted with two choices, one would select the option that will be revenue positive. Moreover, if you own the revenue-generating testing services, and self-refer, it is nearly impossible not to make the testing decisions in your favor. The data supporting this contention are well illustrated in this study. The same analysis is certainly applicable for many similar testing modalities in medicine. Specifically, in cardiology, if the decision to treat or not to treat depends in part on whether the treating physician will benefit by the treatment, objective decisions are challenged if not ignored. One need only review the growing concern over physicians who have implanted stents unnecessarily in violation of many standards of practice and good judgment. Stent placement should be performed for appropriate clinical indications, not solely based on minimal angiographic abnormalities with an opportunity to bill.
Careful consideration of appropriate use of testing and procedures requires a strong hand to control reimbursement for appropriate procedures but not for capricious use. The motivating power of reimbursement may be brought to bear by involvement of our professional societies, insurance payers and large health care plans.
– Morton J. Kern, MD
Cardiology Today
Intervention Editorial Board member
Disclosure: Dr. Kern has
consulted for St. Jude Medical, makers of fraction flow reserve pressure wires,
and Volcano Therapeutics.