Physician Ownership of y
p
Medical Equipment
JJames D
D. R
Reschovsky,
h k Ph
Ph.D.
D and
d
Hoangmai H. Pham, M.D., M.P.H.
C t ffor St
Center
Studying
d i H
Health
lth S
System
t
Ch
Change
Background
 Rapid equipment ownership growth
 Allowed by Stark loopholes
 Likely linked to flaws in fee setting
 Trend associated with growth in volume of associated services
 Possibly due to induced demand
 Unknown whether additional use is appropriate
Past Research and Contribution
 Past research mostly on advanced imaging and equipment associated with ASCs
 Normally limited to specific type of equipment t, patient population, or geographic area
 Contribution:
 National physician data
p y
 Assess ownership rates for broad range of q p
equipment Data and methods
 2008 HSC Health Tracking Physician Survey
 National sample of patient care physicians  Mail survey
 N=4,720; RR=62%
 Survey asks whether practice/self owns or leases 5 types of equipment:





For lab testing (incl. routine blood tests)
X‐rays
Other diagnostic imaging (e.g. CT, MRI)
For non‐invasive testing (besides EKGs)
F i
For invasive procedures (e.g. endoscopy, cardiac cath.)
i d
(
d
di th )
Analysis sample
 Survey population excludes:
 Radiologists, pathologists, anesthesiologists
Radiologists pathologists anesthesiologists
 Federal employees
 Physician providing < 20 hrs/wk direct pt. care
Ph i i idi h / k di
 Analysis limited to physicians in physician‐
owned, community‐based practices  N= 2,689
, 9
Methods
 We present  Adjusted rates of ownership
 % for whom equipment located in separate business
 Number of types of equipment owned
 Covariates of interest:
 Physician specialty
 Practice size
 Market competition
 Adjusted rates shown (similar to unadj.)
Adjusted rates shown (similar to unadj )
Analysis sample characteristics
Specialty
Practice ownership
Adult primary care physicians
29.9
Full owner
50.9
General pediatricians
7.9
Partial owner
37.8
Cognitive specialists
17.1
Employee
11.3
Procedural specialists
17.6
Surgical Specialists
25.7
Not at all competitive
19.5
Other
1.8
Somewhat competitive
49.7
Very competitive
30.8
Size of practice
Perception of mkt. competition Years in practice
Solo/2 physicians
51.2
Group, 3‐10 physicians
33.7
<10
20.8
Group 11‐50 physicians
h i i
12.5
10 19
10‐19
33 7
33.7
Group >50 physicians
2.6
20+
45.5
Equipment ownership rates
35
330
32
28
26
25
21
20
15
15
17
10
5
0
Lab testing
X‐Rays
Adv. Imaging
Non‐Inv. Invas. Testing Procedures
d
Own 3+ types
Equipment ownership by specialty
p
y
50
45
40
35
30
25
20
15
10
5
0
Lab testing
X‐rays
Adv. Imaging
Non‐inv. Testing
Invas. Procedures
3+ types owned
44
40
44
42
34
32
31
21
15
9
2726 26
21
18
8 18
6
9
16
11
19 20
17
13
20
2224
17
11
5
a y ca e Pediatricians
ed at c a s
Primary care (ref)
Cog t e
Cognitive specialists
Procedural ocedu a
specialists
Su g ca
Surgical specialists
Equipment ownership, by practice Equipment ownership
by practice size
Solo/2 physician (ref)
Group 11‐50
Group 51+
66
70
58
8
60
40
60
58
8
55
50
50
52
49
33
22
19
13
36
34
30
30
20
Group 3‐10
25
22
12
11
15
10
0
Lab testing*
X‐Rays*
Adv. Imaging*
Non‐Inv. Testing*
Testing
Invas. Procedures*
Procedures
*Indicates all group practices significantly different from solo/2 phys. practices.
Equipment ownership, by physician Equipment ownership
by physician reported competitive situation
Not at all Somewhat
Very
40
35
30
26
28
32
30
25
255
29
28
22
20
35
20 21 21
15 15 15
15
10
5
0
Lab testing
X‐Rays*
Adv. Imaging
Non‐Inv. Testing*
Invas. Procedures
d
* Indicates physicians reporting very competitive situation significantly different from those reporting situation not at all competitive.
Other results
 Location of equipment predominantly in main practice not in a separate business
main practice, not in a separate business
 Practice ownership predominant, not personal ownership by practice physicians.
Discussion
 Rates of equipment ownership high
 Even among specialties where equipment not central to scope of care
 Some evidence to suggest that physicians responding to competitive pressures and perhaps low reimbursements.
h l i b
 Scale of practice assoc. with ownership, p
p
increases return on investment in equipment.
Policy implications/ responses
p
 Equipment ownership growth likely a response to incorrect price signals
 CMS often uses old data on cost of equipment, rates of use.
 Recent laws and regulatory changes are changing the landscape
 DRA of 2005
f  CMS revision of PE RVUs, imaging equipment use p
,
gy
assumptions, cardiology rules in 2010
 PACCA
 Disclosure requirements strengthened
 Limited attention beyond imaging equipment Li i d i b
d i
i i
Unanswered question: How concerned should we be?
 Physician equipment ownership potentially conveys benefits to patients
 E.g., convenience, rapid diagnostic results
g,
, p
g
 Physician equipment ownership associated with increased rates of use, but is this with increased rates of use
but is this overuse?
 What are impacts on quality of care?
Wh i
li f ?