The Mystery of the Hospital CLAUSTROPHOBIA CLUSTER

Recently a friend was told by his doctor he needed an MRI and said that he could get it at the hospital on the campus where the doctor’s office was located, or at a private imaging center two blocks away.

This reminded me of the mystery of the Claustrophobia Cluster about twenty years ago, in a community hospital that (CH) was part of the system where I was then CEO.

Our Teaching Hospital (TH) had just acquired a new state-of-the-art MRI, CH was only a little over a mile away, there was an MRI transfer protocol in place, and we ran a robust county-wide EMS transport system.

But almost every insured patient at CH who needed an MRI was referred to a “private” free-standing Imaging Center due to CLAUSTROPHOBIA. Somehow, also mysteriously, Medicaid patients and the uninsured made it to TH.

The problem was compounded by the fact that we were under a DRG reimbursement system where we got reimbursed an all-inclusive rate for every diagnosis, and had to pay for “outside” MRIs out of that bundled payment. These very expensive outside MRIs often meant that CH and the system lost money on many of these patients.

Since 1989 Federal Law “Prohibits a physician from making referrals for certain designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation),…

The following items or services are DHS: Clinical laboratory services; Physical therapy services; Occupational therapy services; Outpatient speech-language pathology services; Radiology and certain other imaging services; Radiation therapy services and supplies; Durable medical equipment and supplies; Parenteral and enteral nutrients, equipment, and supplies; Prosthetics, orthotics, and prosthetic devices and supplies; Home health services; Outpatient prescription drugs; Inpatient and outpatient hospital services. (A)

Whichever entity provides the service tacks on a Facilities Fee to the professional fee charged, for example, by a radiologist.

This raises the question of whether self-referral is a purely clinical recommendation or might “ownership” and the Facilities Fee be an influence.

We never solved the CLAUSTROPHOBIA CLUSTER mystery but we all can help make sure that a diagnostic or treatment referral is clinical and not financial:
– Ask the referring physician if he or she has a financial interest in any of the facilities on the list of sites. Make sure you have not signed away that right when registering.
– Make sure your insurance will cover the charges before you go to a diagnostic facility.
– If uncertain, get a second opinion from another physician who is not in a referral relationship with the first physician.

(A) https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/index.html?redirect=/physicianselfreferral/

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