Room: Phillips 307
Time: Wed 08:30 AM-10:00 AM

Physician Financial Incentives and the Use of Imaging: Investigating the Remaining Issues

Chair: Jonathan Sunshine (American College of Radiology)

Session Description

Financial self-interest (FSI) in imaging remains controversial. Its opponents point to the findings of empirical studies which repeatedly have shown that physicians with FSI in imaging order much more imaging than physicians who do not have FSI. In contrast, proponents of FSI assert that (i) the studies have multiple limitations that make their conclusions unpersuasive and (ii) FSI has a number of important advantages, and studies have not examined these.

The objective of this session is to empirically investigate these two assertions. The findings of the studies presented in this session have major implications for physician self-referral laws and payment policy.

Probably the greatest methodological weakness of existing studies is that they are cross-sectional and thus do not address possible heterogeneity of physicians’ underlying propensity to image. Proponents of imaging FSI tend to argue that physicians with FSI naturally have an imaging-intensive practice style, acquire imaging equipment for the convenience of their patients and themselves, and do no more imaging than if they did not have FSI.

The first paper, by Laurence Baker of Stanford University, addresses this issue. In regression analyses of the ordering of CT for Medicare patients, with physician fixed effects, it identifies the change in odds of imaging that results when a physician acquires FSI in CT equipment.

One of the main advantages of FSI in imaging claimed by its proponents is “one-stop service.” In other words, in one visit to a physician, a patient gets: (i) an initial evaluation, (ii) needed imaging, and (iii) initiation of definitive treatment based on (among other things) the information obtained from the imaging. Claimed advantages of one-stop service include convenience to the patient, more prompt initiation of treatment, and avoiding patients dropping out of the care process because they have to make three separate trips to providers.

The second paper, by Ariel Winter of the Medicare Prospective Payment Commission (MedPAC), analyzes how often an office visit takes place on the same day a Medicare patient has an imaging service, disaggregating the data by type of imaging and physician specialty category.

The third paper, by Mythreyi Bhargavan of the American College of Radiology (ACR), presents analyses that overcome other limitations of existing studies. Unlike previous studies, its analyses:

Control for the severity of patients’ illnesses. (Only one existing study does so.)
Have data for 2007, when the “Deficit Reduction Act” sharply cut payments for advanced imaging and, according to some, thereby eliminated imaging utilization problems.
Investigate whether, as proponents of FSI claim, physicians with FSI in one modality—say, CT—make correspondingly less use of alternative modalities—for example, MRI.

Laurence Baker is Chief of Health Services Research at Stanford and Professor of Health Research and Policy and of Economics.

Ariel Winter is a Senior Analyst at MedPAC, with interests mostly in physician-related topics.

Mythreyi Bhargavan is Director of Research at the ACR and Assistant Professor at Johns Hopkins University. An applied econometrician, her current areas of research include physician behavior and small area variation.

Session Organizer: Jonathan Sunshine (American College of Radiology)

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Presentations

1. Physician Acquisition of CT, Financial Incentives, and Use of CT Equipment in the United States

   Presenter: Laurence Baker (Stanford University)

   Discussant: Danny Hughes (American College of Radiology)

2. How frequently are imaging services provided on the same day as an office visit?

   Presenter: Ariel Winter (Medicare Payment Advisory Commission (MedPAC))

   Discussant: Jonathan Sunshine (American College of Radiology)

3. Does financial self-interest in imaging genuinely give rise to increased utilization?

   Presenter: Danny Hughes (American College of Radiology)

   Discussant: Ariel Winter (Medicare Payment Advisory Commission (MedPAC))