CRS Puts Halt to California Broker Bill

A California bill that would have paved the way for the brokering of diagnostic imaging services has been amended, much to the relief of the legislation's opponents.

SB 1071, introduced in the California legislature last month by Democratic Senator Edward Vincent, would have created an exemption to state provisions prohibiting the corporate practice of medicine for nonphysician entities that broker patients for diagnostic imaging. The bill would have allowed the entity to choose the provider, facilitate review, and bill and collect for services. It is similar to legislation already passed in Florida and New York.

"It is basically an attempt by brokers of imaging services to create an exemption from current law. The proponents are brokers that broker patients between payors and providers, and then control the referral and profit from it," says Bob Achermann, executive director of the California Radiological Society (CRS), which recently led a letter-writing campaign against the bill. "The whole process interferes with the relationship between referral physician and radiologist, and a bill like this would take away all restrictions on brokers."

He points to the potential direct financial incentive for entities to obtain CT and MRI services as cheaply as possible to maximize profits. "SB 1071 doesn't have any limits on what they can charge," he says.

However, Achermann says the bill was "gutted and amended" at a recent Senate hearing, to the point where it now essentially restates the existing state law. "We're happy about that, but there's still a lot of work to be done," he says. Now that the bill has passed in its current form, the CRS will be participating in discussions with the Medical Board of California to determine if there were any mutually agreeable amendments to resolve the proponents' concerns.

ULTRASOUND ANTICIPATES PITCHERS' INJURIES

Researchers at Thomas Jefferson University Hospital, Philadelphia, are using high-resolution ultrasound to identify abnormalities in athletes' elbow ligaments before the onset of pain.

Looking at both arms of 26 major league baseball pitchers, researchers recently performed ultrasound examinations of the ulnar collateral ligaments (UCL). Repetitive stress on the UCL anterior band can lead to injuries requiring surgery. Although such injuries are common in pitchers, they are difficult to diagnose. An MRI can detect acute ruptures, but partial tears and chronic injuries require a more invasive and costly procedure.

The study, published in the April issue of Radiology, showed that while under stress, the UCL anterior band in the pitching arms of 26 major league pitchers remained thick (6.3 mm) but decreased in thickness (5.5 mm) in the nonpitching arm, reflecting the loss of elasticity in the pitching arm. The ultrasound results also showed micro-tears in the anterior band of the UCL in 18 of the 26 cases. Only three of the 26 nonpitching arm ultrasounds revealed micro-tears.

Table 1. Full-field digital mammography market: Procedural volume vs installed base (United States), 2000-2009. Source: Frost & Sullivan.

Levon N. Nazarian, MD, lead author of the study and professor of radiology at the Jefferson Medical College of Thomas Jefferson University, said, "This preliminary research confirms that ultrasound is a quick means of evaluating the anterior band of the UCL. By studying the UCL in this detail, we have produced new data that is useful not only for these baseball players, but also for physicians diagnosing UCL injuries in other athletes."

FFDM REGISTERS RAPID GROWTH

According to a new analysis by Frost & Sullivan, the emergence of full-field digital mammography (FFDM) is rapidly leading to the demise of analog mammography in highly industrialized countries.

Table 2. Analog screening mammography market: Procedural volume vs installed base (United States), 1999-2009. Source: Frost & Sullivan.

North American, Japanese, and Rest-of-World X-Ray Mammography Markets, the company's new report, shows that the industry created revenues of $241.2 million in 2002 and is expected to reach $528.2 million in 2009. And even though the mandatory equipment specifications of the Mammography Quality Standards Act created high demand for analog equipment in 1999 and 2002, hundreds of mammography facilities have shut down in recent years.

"This has everything to do with the economic dynamics of mammography," says medical imaging research analyst Antonio Garcia. "All of the closings, coupled with the

problems in attracting radiologists into mammography, and reimbursement being lowthis is the background. Also, a lot of mammography facilities have been consolidated into larger facilities, and revenues are limited. Digital systems have some considerable economic benefits over analog systems: They don't require film processing, and you can do twice the amount of patients in the same time frame as analog."

Among the report's findings:

• Digital mammography is growing at a double-digit rate in North America;

• In 2002, analog screening mammography contributed more than 60% of total market revenues, versus 24% for full-field digital mammography. However, by 2009 full-field digital is expected to contribute 70% of the revenues in the market, compared to only 18% by analog;

• Analog procedures reached 34.4 million in 2002, with that number expected to peak at slightly below 35 million in 2003. But between 2002 and 2009, that number is expected to decline at a compound annual rate of 3.4%, ending the forecast period at 27 million;

• The United States, Canada, Western Europe, and Japan have become saturated and are unlikely to display any growth in the analog market; analog will probably grow in more undeveloped regions, such as Eastern Europe and Latin America.

INDUSTRY NEWS

InSight Health Services Corp, Lake Forest, Calif, has been named the winner in the best business turnaround category of the first American Business Awards competition. Nearly 500 nominations from companies spanning many industries were submitted for consideration in the competition...Voxar Ltd, Edinburgh, Scotland, and PointDx Inc, Winston-Salem, NC, have signed a licensing agreement as part of a lawsuit settlement. Voxar has taken a license under a number of patents from PointDx related to virtual endoscopy, for an undisclosed sum...Siemens Medical Solutions, Malvern, Pa, is the 2003 recipient of the Product Differentiation Innovation Award in the US MR scanner market, according to Frost & Sullivan. The award reflects the company's work involved in the development of its 3-Tesla Magnetom MR systems. Siemens was selected for the award "as a direct result of its innovative ability to develop and introduce two 3-Tesla solutions," according to Frost & Sullivan research analyst Jim Clayton...URAC, Washington, DC, announced that its board of directors has approved the nation's first independent HIPAA Security Accreditation program for covered entities and business associates, and that 10 companies are currently in the process of seeking accreditation, including National Imaging Associates Inc, Hackensack, NJ. The URAC program enables health care organizations to validate their security compliance program and demonstrate to customers and business partners that they have taken the necessary steps to safeguard protected health information in accordance with HIPAA.

PRESENTED AT THE ARRS

PROMPT PAYMENT ANALYSIS

Have the prompt payment laws enacted by 47 states solved the problem of delayed and ignored claims? When the Radiological Society of New Jersey put the New Jersey Prompt Payment Law under analysis recently, the results were less than encouraging, according to Lawrence Swayne, MD, Morristown Memorial Hospital, Morristown, NJ, who presented the results at the 103rd annual meeting of the American Roentgen Ray Society on May 5. The study was a retrospective analysis of 78,618 claims from 11 radiology practices and looked at six payors that represented 71% of the market. The New Jersey law mandates the payment of claims within 30 days of electronic and 40 days of non electronic submission. The study, however, found that only 75% of the claims were paid within 40 days, none of the payors were in compliance with the law, and 6% of claims were never paid at all.  Disputes were not the primary cause of tardy and missing payments: 88% of late paid claims and 68% of unpaid claims were never disputed. The cost to the practices was calculated as $19,000 in lost interest on late paid claims and $587,000 annualized lost revenue from unpaid claims. The study concluded that active enforcement is needed in addition to the passage of prompt payment legislation in order to ensure results.

Diffuse opacities are associated with highest mortality rate.

WHAT SARS LOOKS LIKE

In a session added to the program just days before the meeting began, Narinder Paul, MD, a radiologist at Princess Margaret Hospital, Toronto, Canada, gave a presentation on "SARS: The Radiological Pattern of Disease-Initial Experience." The hospital was both the site of the outbreak as well as the location of the containment of the disease. A total of 149 cases were reported between February 23 and May 2, with 22 resulting in death. The Toronto outbreak was initiated by a medical resident who contracted the disease while visiting China, and in turn infected her family and coworkers.

The disease, which usually begins with a fever greater than 38 degrees (100.4 degrees F), is a form of potentially fatal pneumonia caused by the novel coronavirus. Symptoms include chills, headache, malaise, and body aches. Though CT was considered more sensitive than portable x-ray, the decision was made to obtain a single frontal view on the portable modality to avoid bringing patients to the radiology department, according to Paul.  About 75% of patients present with distinct radiological signs: 46% present with unilateral focal opacities; and 29% show bilateral multifocal opacities or diffuse opacities. Diffuse opacities are associated with the highest rate of mortality.

MALPRACTICE ISSUES

Failures of communication are the second leading cause of malpractice litigation after missed diagnoses, and a recent legal decision by the appellate court in Arizona has added weight to the burden on the radiologist, according to Leonard Berlin, MD, in a presentation on Malpractice Issues on May 5. Berlin cited Physicians Insurers Association of America research that concluded 80% of all radiological malpractice litigation at least in part involves a miscommunication. In 60% of the cases, the physicians were not contacted by the radiologist. While acknowledging that direct communications with physicians may not have been considered a responsibility of radiologists a decade ago, Berlin said:  "Now we have a duty to communicate directly with referring physicians and, in an increasing number of cases, with patients themselves."

In Stanley vs McCarver, AZ App 2003, a radiologist saw a lung cancer on a pre-employment chest x-ray and sent the report to the patient's employer. The patient was never informed of the findings, however, until 10 months later when lung cancer was diagnosed. The patient later sued the radiologist for failing to inform him directly of the findings and the Arizona  court affirmed his right to do so. The judge wrote: "The patient's primary physician should obtain and then advise the patients of results. If no referring physician [is available], the duty shifts to the radiologist. The radiologist bears the duty of direct communication with the patient."

"This, I assure you, will be repeated with other states," Berlin said. He advised attendees to familiarize themselves with the American College of Radiology Standard for Communications, the most recent revision of which was January 1, 2002, for it may well be perceived as a standard of care by the courts. Radiologists should also take steps to ensure that patient demographic information is correct, and document all communications with referring physicians and patients in a separate log next to the reading station. To protect against the number-one cause of malpractice claimsmissed diagnosesBerlin suggested the following techniques to minimize errors: maintain the knowledge base; defer to colleagues if uncertain; use comparison films; obtain patient history; if a physician comes down to review the films, take a second look with him or her; and insist on good technique and positioning. However, if a study is of poor quality, Berlin suggests including the following disclaimer: "I suggest we repeat the study when conditions permit."

DOCTORS UNAWARE OF RADIATION DOSE

In a study of 45 emergency department physicians by Yale University School of Medicine Departments of Diagnostic Imaging and Surgery to assess provider awareness of radiation dose associated with diagnostic imaging in the emergency department setting, researchers discovered that not only are emergency department physicians not informing patients of the risks and benefits associated with the study, but that only one in four correctly estimated that an abdominal/pelvic CT was equivalent to 100-250 x-rays in dose. A total of 78% said they are not outlining the risks and benefits of the examination and 91% do not mention dose. Future policies should focus on educating the medical community on current CT dose, according to Howard Forman, MD, who presented the results on May 5. Forman suggested putting the dose on the report and showing the dose with the examination in computerized physician order entry systems.

CANCER HOSPITAL VS GENERAL HOSPITAL

Intuitively, it makes sense that the reporting of CT scans would be a longer and more complex process at cancer hospitals than general hospitals. A retrospective study that involved 200 CT examinations (excluding head and spine) at Dana Farber Cancer Institute and Brigham & Womens Hospital in Boston, presented by Eric vanSonnenberg, MD, Dana Farber Cancer Institute, specified by how much. The study looked at the number of words reported per study, which averaged 268.6 at the general hospital and 311.4 at the cancer center. The percentage of studies compared with priors was 48% for the general hospital and 87% at the cancer center. The percentage of studies that involved measurements (an average of three per study) was 20% at the general hospital and 70% at the cancer center. Mean time per study was 1.17 minutes at the general hospital compared to 2.66 minutes at the cancer center.