Like many of the cost issues swirling around healthcare reform, physician self‒referrals is a controversial one and has some widely held opposing views.
On the one hand is support for the idea that referring patients to facilities in which the physician has a financial interest (sometimes in the same building) is easier, more cost effective and convenient for the patient. For these reasons, the argument goes, the practice of self-referral is really more "patient‒centric." Any financial incentive is relatively minor compared to the patient benefit.
The opposing argument, of course, is that any direct financial incentive will perversely influence the decision to recommend a service that's unnecessary and jeopardizes patient trust.
We'll get to the arguments in a minute, but what isn't up for debate is that the sheer number of self‒referrals is on the rise and at least in one case ‒ IMRT's ‒ on a very steep incline.
Working from a GAO report issued last summer, Bob Kocher, MD and Eli Adashi, MD added their assessment in a JAMA article released earlier this month (Physician Self‒Referral ‒ Regulation by Exception).
The four specific types of referrals that the GAO studied included IMRT (intensity‒modulated radiation therapy), Pathology (labs that analyze body tissues and fluids), Computed Tomography (CT's) and Magnetic Resonance Imaging (MRI's). The increases in referrals between 2004 and 2010 resulted in these charts.
All four categories showed an increase in the compounded annual growth rate (CAGR), but clearly the most dramatic increase on the self-referral side was IMRT services for the treatment of prostate cancer. In this category, the CAGR for self‒referrals increased by almost 30% while the CAGR for referrals with no financial incentive actually decreased (-0.8%).
This new evidence is both compelling and troubling. As much as doctors don't like to admit it ‒ economic interests sure seem to trump clinical ones when it comes to patient referrals for tests and treatments that doctors profit from. Bob Kocher, MD ‒ Partner at Venrock
Financial reasons aside, there are other reasons to end this practice as well. Here are two of the biggest.
The first is based on the idea that we don't always know what works. H. Gilbert Welch referenced this when he wrote about two of the more prevalent methods of cancer screening ‒ the PSA test for prostate cancer and mammography's for breast cancer.
How would you have felt ‒ after over a decade of following your doctor’s advice ‒ to learn that high-quality randomized trials of these standard practices had only just been completed? And that they showed that both did more harm than good? Justifiably furious, I’d say. Because these practices affected millions of Americans, they are locked in a tight competition for the greatest medical error on record. The problem goes far beyond these two. The truth is that for a large part of medical practice, we don’t know what works. But we pay for it anyway. Testing What We Think We Know ‒ H. Gilbert Welch, MD and professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice
Those last two sentences are worth repeating. "The truth is that for a large part of medical practice, we don't know what works. But we pay for it anyway."
The second argument against self‒referrals is a variation in medical mistakes called the silent misdiagnosis. Obviously a misdiagnosis can be direct and overt (affecting as many as 12 million Americans each year), but often it's more subtle and favors the clinical over the patient preference. This is referred to as a silent misdiagnosis and was summarized in this article in the U.K. for The Kings Fund (2012).
For example, doctors believe that 71 per cent of patients with breast cancer rate keeping their breast as a top priority. But what is the actual figure reported by patients? 7%. Furthermore, doctors believe that 96% of breast cancer patients considering chemotherapy rate living as long as possible a top priority. But what is the actual figure reported by patients? 59%. Patient's Preferences Matter ‒ Stop The Silent Misdiagnosis, by Al Mulley ‒ MD, Glyn Elwyn ‒ MD and Chris Trimble
Both of these reasons speak directly to the general practice of all referrals, so the issue is much larger than just a financial one ‒ often it's simply the authoritative (and wrong) clinical preference.
Doctors talk about the science of medicine to preserve their authority and the art of medicine to preserve their autonomy. Al Mulley, MD speaking at #SIIPC14 as quoted by Casey Quinlan ‒ Keeping Patients In The Dark
Before physicians can accurately refer patients for any test or course of treatment ‒ they need to know both what works and the patient preference. The economic incentive is a potential perversion, of course, but even when it clearly isn't, it doesn't trump the importance of the other two. In fact, it only highlights the importance of ending the practice of self-referrals abruptly and definitively.
There's a rich history of legislation (Stark and others) designed to address this controversial practice, but the layered exceptions through the years make it too easy to thwart and the rules have become comparable to speed laws that insist on 55MPH when there's no capacity to enforce that at any scale.
It's not just the perception (real or imaginary) of financial conflict, but for all three reasons, physician self-referrals need to stop now.
