ACC speaks to impact of Grassley self-referral bill on cardiologists

Twitter icon
Facebook icon
LinkedIn icon
e-mail icon
Google icon
Grassley hopes to crack down on physician self-referrals for imaging. Source: European Heart Journal  
Sen. Charles Grassley from Iowa, the ranking Republican on the Senate Finance Committee, introduced legislation on July 25, which would amend the Stark Law, requiring physicians to disclose their financial interest in certain imaging services provided through the in-office ancillary exception.

The bill, S. 3343, or the Medicare Imaging Disclosure Sunshine Act of 2008, also would provide patients with a list of alternative imaging providers in the area.

The American College of Cardiology (ACC) supports Senator’s Grassley’s bill, Patrick Hope, director of legislative policy at ACC told Cardiovascular Business News. “The college is supportive of all transparency, particularly in this area. We believe all providers should disclose any financial relationships—whether it be ownership or investment interests. We believe the public has a right to know,” Hope said.       

“The only mistake of this bill is that it only focuses on physicians in-office. We should look at imaging wherever it takes place,” according to Hope.

Citing the recent Government Accountability Office (GAO) report, Grassley said that Medicare spending for imaging services grew from $6.89 billion in 2000 to $14.11 billion in 2006. During the same time, the percentage spending on imaging services provided in physician offices grew from 58 percent (about $4 billion) in 2000 to 64 percent (about $9 billion) in 2006.

The GAO report also found that cardiologists’ spending on imaging services represented the largest share of in-office imaging spending of physician specialties other than radiology, growing from about $1.2 billion to about $3 billion—29 percent in 2000 compared to 35 percent in 2006.

In fact, the report specifically named cardiology as one of the rapidly growing proportion of physicians billing in-office. The proportion of cardiologists who billed for advanced in-office services nearly doubled between 2000 and 2006, rising from about 24 per 100 physicians to about 43 per 100 physicians, according to the report.

Hope noted that the GAO report, which relied heavily on the MedPac report of 2005, only took into consideration data as of 2006, noting that it did not take into consideration the Deficient Reduction Act (DRA) of 2005, which came into effect in 2007. “We’ve actually seen some data from the American Medical Association, which shows a sharp decrease in the amount of imaging performed directly related to the DRA.”

The report also relies too heavily on radiology benefit managers (RBMs), Hope said. “RBMs don’t offer transparency with how they run their business—they’re almost like a gate-keeper. We don’t think RBMs, or prior authorization, is the right way to go.” 

He said that the ACC does not believe it would be beneficial to return to a managed care model, where “people who are not healthcare professionals determine whether a test can be undertaken.”

However, Hope said that ACC does support the appropriateness criteria. “The college has led the charge in developing when is the right time to perform the test—the right time for the right patient.”

“Another fallacy in the GAO report is that the report did not examine the reduction that is taking place in the hospital—it’s moving from the hospital to the in-office. As a result, we are seeing the quality of less-invasive procedures, and the report just looked just at the data, the numbers,” Hope said. 

He added that additional studies should examine the potential cost-savings and quality outcomes as a result of these imaging procedures. “If you can do an imaging procedure and saved yourself from having to perform an invasive surgical procedure, then you’ve probably provided better quality care, but you’ve probably also saved the system a lot of money,” Hope said.

“It’s our understanding that the GAO report is just the first installation of something more to come—they’re going to try to look at the DRA as well. They were looking at old data, and the environment has completely changed since 2006,” Hope said.    

In a statement on the Senate floor, Grassley said that the “recently-enacted Medicare bill requires accreditation for providers of the technical component of advanced diagnostic imaging services such as MRI, CT scans and PET, and it establishes a demonstration project to assess appropriate physician use of these services. However…the legislation regrettably fails to address an issue that has contributed significantly to the rapid growth in Medicare spending for imaging services: physician self-referrals for imaging services in their offices and in facilities where they own or lease advanced imaging equipment.”

Self-referrals are prohibited under the 1993 Stark II regulations, with some exceptions. Stark allows physician group practices to self-refer if the group practice meets certain criteria regarding location of the imaging equipment. It also allows physicians to self-refer if the services are personally performed or supervised by a physician in that group. Finally, the self-referral prohibition does not apply to certain facilities, such as hospitals.

“The Medicare Imaging Disclosure Sunshine Act will provide another necessary tool to address the significant increase in Medicare spending for in-office imaging services by providing more transparency and shedding some light on physician referrals to facilities and medical imaging equipment they own,” Grassley concluded.

The Finance Committee holds jurisdiction over Medicare issues. If approved, the requirement would become effective Jan. 1, 2010.