November 8th, 2011
Financial Incentives Increase Use of Stress Tests
Larry Husten, PHD
Following coronary revascularization, patients are more likely to undergo cardiac stress testing if their physician has a financial interest in the test, according to a new study published in JAMA.
Bimal Shah and colleagues examined insurance data from 17,847 patients who underwent revascularization, dividing their physicians into three groups: those who billed for technical and professional fees, those who billed for professional fees only, and those who billed for neither.
The overall rate of nuclear or echo stress testing within 30 days was 12.2%, but there was a large difference in the testing rate across the three groups:
Nuclear stress testing:
- 12.6% for physicians who billed for both technical and professional fees
- 8.8% for those who billed for professional fees only
- 5.0% for those who billed for neither
- 2.8% for physicians who billed for both technical and professional fees
- 1.4% for those who billed for professional fees only
- 0.4% for those who billed for neither
The authors found that “up to 1 in 10 patients who were not coded as having symptoms at their outpatient visit still underwent stress testing.” They note that current guidelines “do not recommend routine use of early stress testing following coronary revascularization,” and they conclude that their results “suggest the need for broader application of AUC [appropriate use criteria] to minimize the possible influence of financial incentives on the decision to perform cardiac stress testing after revascularization.”
In an accompanying editorial, Brent Hollenbeck and Brahmajee Nallamothu place the study in the context of new trends in reimbursement from CMS and the large structural shift in cardiology toward hospital-based practices. They point out that “controversies surrounding physician self-referral and associated incentives wax and wane, and are seemingly repeated each decade.” As an alternative, they suggest that “the focus should be less about eliminating incentives altogether, and more about getting the price right in the first place.”
reimbursement for nuclear imaging has tanked, being the latest target the government has chosen to decrease provider payout. if the current level is not modified, it is about 30% of amount paid several years ago. as reflected by the data, technical fees far supercede how much you get for interpreting the results. as pointed out in the editorial, the economics preclude the viability of independent practices providing services in the office, hence the shift to hospital-based affiliation. However, I think physician self-referral in these circumstances is on a course to permanently wane as payers of all types are making more stringent and reinforcing compliance with appropriate use criteria. you just will not get paid unless you have prior approval. moreover, professional organizations are abetting this trend as it at least keeps the decreased pot of reimbursement within the family. just the family moved from a single family house to multifamily living quarters.