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Helene Pavlov, M.D.

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Should Your Health Be For Sale to the Highest Bidder?

Posted: 08/08/2012 9:05 pm

You have pain in your knee, or your hip or shoulder. You choose a doctor recommended by a friend or relative who accepts your insurance. You make contact for an appointment. If it is not urgent and the appointment can wait, you wait. After your physical examination, the doctor orders an imaging test, an X-ray, a CT, an ultrasound and/or an MR. At that point, one or two things can happen.

First, your doctor may have imaging equipment, an X-ray, CT, MR or US machine in his/her office. The convenience of having the imaging examination at his/her office seems right and to refuse may be considered rude. As an informed consumer, you ask questions such as: Who owns this equipment? Who will be interpreting my imaging studies? If the answer to both of these questions is the ordering doctor him/herself, then this is self-referral. As a patient, it is important to know that self-referral is when the ordering doctor profits by ordering and performing examinations. Self-referring physicians may or may not have training in ionizing radiation or MR safety and/or experience in image interpretation. The certification process for image interpretation for non-radiologists is much less stringent than that for radiologists and is extremely light with regard to limiting ionizing radiation dose and/or MR safety. Also, by finding "something," but it is inconclusive on the imaging examination such that another imaging examination or a more invasive test or surgical exploration is required, that same doctor may further benefit financially.

The non-radiologist physician who interprets their own ordered and acquired images may feel they know exactly what to look for because they examined the patient, while the radiologist has not. That may be true. However, there is also an increased possibility of a limited review of the image because of inadequate interpretive skills combined with the focus on only the suspected findings. Such a review process may not be in your best interest. While image interpretation is assisted by the physical exam, it can also bias interpretation and unrelated, although clinically significant, findings may be ignored or not "seen" since they are not being looked for. Radiologists are trained to examine and review the entire image for abnormalities, even unsuspected clinical conditions.

The second scenario is when your physician does not have imaging equipment in his/her office, and your doctor recommends a specific imaging facility. This specific site may be recommended because a) there is a financial relationship with your physician, b) your physician acknowledges an acceptable level of service at that site or c) your physician recognizes the quality of both the images acquired and the interpretation specified at that site. Ask your doctor why you should go to that specific facility for imaging.

OK. So now you have been told you need an imaging exam, and you know where to go and why. You also know that your insurance requires authorization, so you call to get approval. Your insurance company advices you to "go to Imaging Facility X." You tell them you checked it out and want to go where your doctor recommended, "Imaging Facility Z." You are then informed by your insurance company: "If you go to "Imaging Facility X, you will receive a cash payment of $100-$200." According to Kaiser Health News, Anthem Blue Cross and Blue Shield customers in New England and parts of the Midwest are being offered finance incentives to go to specific recommended imaging providers. Now you have a dilemma. Are all imaging examinations interchangeable? Is it OK for you to accept potential cut rate services when it comes to your health? Is it OK for you to accept this incentive while the "greed" of the self-referring physician or that of the insurance company is considered not acceptable? What to do?

Should your insurance company put you in this situation? Should the insurance company make it problematic to obtain authorization for a needed procedure if you do not go to their designated local provider? How is their provider chosen; is it on the basis of quality or price? Will the acquired examination be adequate or will it need to be repeated somewhere else because it's not diagnostic? If that is the case, who will pay for the second examination and for the delay and the inconvenience? Is it worth the $100-$200 cash in hand? Alternatively, how can you be assured that you will get your money's worth by going to a "more expensive" provider? How do you get the quality care you deserve?

Health care today is in a state of transition. Ultimately, good outcomes must prevail and delivery of services must be based on access to affordable quality care, not on discount shopping. Greed and financial incentives by insurance companies, hospitals, doctors or even the patient are not necessarily in the patient's best interest. Be concerned about your health. Ask appropriate questions and make decisions based on quality. Remember, it is your quality of life that is at stake and choices should be based on the greatest chance for an optimal health care outcome.

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