JAMA: Docs who bill for cardiac stress tests more likely to order them
Bimal R. Shah, MD, MBA, of the Duke University Medical Center in Durham, N.C., and colleagues outlined the potential conflict that may exist with cardiac nuclear stress and stress echocardiography testing. Physicians who own the equipment can offer the tests in an office setting, which may be more convenient for patients and may allow for faster results. But by investing in equipment physicians also may be pressured to recoup the cost.
To test the association between ownership and billing, Shah and colleagues examined data on testing after coronary revascularization. They selected coronary revascularization because the American College of Cardiology Foundation (ACCF) appropriate use criteria (AUC) guidelines advise physicians that under most circumstances they should not test patients within two years of a percutaneous coronary intervention (PCI) procedure or five years of coronary artery bypass graft (CABG) surgery.
The researchers obtained billing data from a national health insurance carrier on 17,847 patients who between Nov. 1, 2004 and June 30, 2007, had coronary revascularization and an index cardiac outpatient visit more than 90 days following the procedure. They stratified physicians into three categories: those who billed for both technical and professional services, those who billed for professional services only or those who did not bill for either. They used logistic regression models for the analyses, adjusting for patient and physician factors.
They found that 70 percent of cardiology physicians typically billed for both technical and professional fees for nuclear stress imaging studies; 14 percent billed for professional fees only; and 16 percent did not bill for these services in their practice. Half of the cardiology practices billed for both; 19 percent billed for professional fees only; and 31 percent did not generally bill for these services. The great majority of primary care physicians did not bill for any fees for cardiac stress testing.
The overall 30-day incidence of either nuclear or echocardiography stress testing within the index cardiac-related outpatient visit after revascularization was 12.2 percent. The incidence of nuclear stress testing by physicians who billed for both technical and professional fees was 12.6 percent; by physicians who billed for professional only fees it was 8.8 percent; and for physicians who billed for neither, it was 5 percent.
“[A]lthough we found that stress testing was more common among symptomatic patients, consistent with ACCF AUC guidelines, we also noted that up to one in 10 patients who were not coded as having symptoms at their outpatient visit still underwent stress testing,” Shah et al wrote. “We found that physicians who bill for both the technical and professional fees were the most likely to conduct testing under these discretionary conditions. It is unlikely that this association is attributable to significant differences in patient risk, because it persisted when our analyses were limited to patients observed by cardiologists and to those with or without coded symptoms at the index visit.”
The authors stated that such practices may be detrimental for patients, because they expose patients to radiation and impose a possible financial burden to patients or healthcare system. “These data suggest the need for broader application of AUC to minimize the possible influence of financial incentives on the decision to perform cardiac stress testing after revascularization,” they concluded.
They added the study had limitations, including the use of only private insurance data and the lack of information that might explain the clinical decision making involved in the cardiac stress test orders. In an accompanying editorial, Brent K. Hollenbeck, MD, and Brahmajee K. Nallamothu, MD, PhD, both of the University of Michigan in Ann Arbor, Mich., agreed that understanding the physician’s intent might affect the findings.
Hollenbeck and Nallamothu wrote that exceptions to the Stark laws, which were designed to prevent financial conflicts of interest in the clinical setting, undermined the legislation’s effectiveness. They pointed out that the Centers for Medicare & Medicaid Services (CMS) has substantially reduced reimbursement for cardiac stress testing and other imaging services, which has dampened their use in Medicare patients.
“These decisions by the CMS are not only important for cardiologists, but will have significant implications for how other specialists, such as urologists and orthopedic surgeons, deliver care in the United States,” they argued. “Understanding the broader implications of these levers warrants careful consideration to avoid unintended consequences that ultimately affect patient care.”