Two U-M physicians caution about implications of cardiac imaging study

Two University of Michigan Health System physicians are raising notes of caution about the implications of a new study that found cardiologists were more likely to refer patients for stress imaging when their practice owned imaging machines - resulting in potential overuse because of financial incentives.

In an editorial accompanying the imaging study in the Journal of the American Medical Association, urologist Brent K. Hollenbeck, M.D., M.S., and cardiologist Brahmajee K. Nallamothu, M.D., M.P.H., argue that while the research highlights the risks of in-office imaging, an overall increase in imaging use accompanies a broader shift toward outpatient care for cardiology and substantial declines in deaths from coronary disease.

"The increase may not entirely be a bad thing," says Hollenbeck, associate professor of urology at the U-M Medical School. "Office-based imaging offers a number of potential advantages that may improve patient care and satisfaction. There is an opportunity for earlier diagnosis by a physician who is directly involved in a patient's care. And, for specialty care, a one-stop approach can provide enhanced patient access to therapeutic and diagnostic services along with cost-saving efficiencies for the provider."

These potential benefits apply not just for cardiology, but urology, orthopedic surgery and other specialty practices, he adds.

Hollenbeck and Nallamothu also note that some of the issues raised by the study authors have already been addressed by recent reforms. The Centers for Medicare & Medicaid Services substantially reduced reimbursement for several in-office imaging services, including cardiac stress testing. Since these changes, the rise in use by Medicare patients has dropped significantly (though this was after the period of time considered in the study).

Existing regulations governing physician self-referral and associated financial benefits, known as the Stark laws, include many exceptions because of the nuances involved in clinical care, the U-M authors point out.

"Moving forward in the current era of healthcare reform, we should focus more on getting the right price for reimbursement of these services, rather than on the hope that we can eliminate incentives altogether," says Nallamothu, an interventional cardiologist at the U-M Cardiovascular Center. "Most physicians involved in providing patient care understand the limits of regulation, but it's not clear that policymakers always do."