I read an article the other day. It was another discussion on physician utilization. Utilization has to do with efficient use of medical tests and facilities by the physician. Over utilization by certain physicians has been tied to excess use of federal funds for patient care, such as medicare.
In the article entitled, “Self-employed urologists order more imaging” by Lynn Peeples, she discusses Dr Hollingsworth study published in the Journal of Urology. Dr Hollingsworth analyzed over 37 million visits to Urology offices using data from the National Ambulatory Medicare Survey conducted between 2006 to 2008. He found that one in five visits to a urologist ended in an imaging test being done. Urologists that were self-employed ordered more imaging tests than urologists that were employed differently, such as by hospitals. Of note, four or five urologists are self-employed. The most common tests performed were ultrasounds for enlarged prostate, kidney stones, or because of blood in the urine.
One of the suggestions for this increase in imaging ordered by urologists were monetary incentives. Also ordering of these tests did not vary because of age, gender, medicaid eligibility or urologist practice type or location. Other reasons for ordering more imaging by self-employed urologists included patient preference, legal concerns, and medical ambiguity.
Dr Hollingsworth feels that this study has direct relevance to some of the measures being addressed in health care reform in the Affordable Care Act of 2010. I would agree. However, I believe that the other reasons mentioned such as medical-legal concerns and proper testing play a more significant role in the number of imaging tests ordered by urologists. In addition, the hospital-based urologists may be pressured to order less testing that may be necessary to diagnosing the patient. For instance, a patient is referred for blood in the urine and is a smoker. This patient work-up includes imaging studies such as a CAT Scan to properly evaluate the kidneys and ureters. With an ultrasound, the significance of a kidney mass or kidney stone could be missed at a higher rate than with a CAT scan. The ultrasound is cheaper, but in this situation less accurate for evaluation of kidney masses or stones. which are a source of blood in the urine.
I am all for cutting costs, especially in cases of over utilization of imaging or other studies by all physicians, not just urologists. However, I do not believe in reducing costs at the expense of proper diagnosing for patient care. Dr Hollingsworth is correct in stating that the Center for Medicare and Medicaid are being charged with innovations to reimbursement models for physicians according to appropriate utilization (ordering of tests, imaging). But again, we must not loose site of proper care to the patient.