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Journal of General Internal Medicine

, Volume 25, Issue 10, pp 1057–1063 | Cite as

Laboratory Test Ordering at Physician Offices with and without On-Site Laboratories

  • Tara F. Bishop
  • Alex D. Federman
  • Joseph S. Ross
Original Research

Abstract

Background

Physician self-referral, ordering a test or procedure or referring to a facility in which a physician has a financial interest, has been associated with increased utilization of health care services.

Objective

To examine the association between on-site laboratories and laboratory test ordering among visits to group-practice physicians.

Design

Cross-sectional study using data from the 2005 and 2006 National Ambulatory Medical Care Surveys.

Study Population

Visits by adults to non-federally-funded, non-hospital-based group practices. Primary analyses focused on visits to physician owners; secondary analyses focused on visits to non-owners.

Main Measures

Ordering of five laboratory tests: complete blood count (CBC), electrolytes, glycoslyated hemoglobin A1c (HbA1c), cholesterol, and prostate-specific antigen (PSA).

Key Results

There were 19,163 visits to group-practice owners with 51.9% to a practice with an on-site laboratory. Visits to primary care physicians were more likely to be to a practice with an on-site laboratory when compared with visits to specialists (64.4% vs. 34.0%, p < 0.001). Among visits to specialist group owners, all five tests were ordered more often if there was an on-site laboratory, even after accounting for patient and practice characteristics: CBC: adjusted odds ratio[OR] = 8.01, 95% Confidence Interval [CI], 5.00–12.82, p < 0.001; electrolytes: aOR = 3.51, 95% CI, 1.93–6.40, p < 0.001; HbA1c: aOR = 4.91, 95% CI, 1.75–13.78, p = 0.003; cholesterol: aOR = 3.32, 95% CI, 1.85–5.93, p < 0.001; and PSA: aOR = 3.84, 95% CI, 1.93–7.65, p < 0.001. This association was not found among visits to primary care physician owners and all practice non-owners (both primary care and specialists). The estimated excess spending on these five tests by specialist owners with on-site laboratories was $75 million per 100 million visits.

Conclusions

In a nationally representative sample of visits to physician-owned group practices, specialist owners with on-site laboratories were more likely to order five common laboratory tests, potentially resulting in millions in excess healthcare spending.

KEY WORDS

physician self-referral reimbursement/incentive laboratories/economics laboratories/utilization 

Notes

Acknowledgements

This project was not directly supported with external funds. Drs. Ross and Federman are both currently supported by the National Institute on Aging (K08 AG032886 and K23 AG028955-01, respectively) and by the American Federation of Aging Research through the Paul B. Beeson Career Development Award Program.

Conflict of Interest

None disclosed.

References

  1. 1.
    Hartman M, Martin A, McDonnell P, Catlin A. National health spending in 2007: slower drug spending contributes to lowest rate of overall growth since 1998. Health Aff (Millwood). 2009;28(1):246–261.CrossRefGoogle Scholar
  2. 2.
    Congressional Budget Office. The Long-term Outlook for Healthcare Spending 2007. Washington: Congressional Budget Office; 2007.Google Scholar
  3. 3.
    Gabel JR, McDevitt R, Lore R, Pickreign J, Whitmore H, Ding T. Trends in underinsurance and the affordability of employer coverage, 2004–2007. Health Aff. 2009;28(4):W595–W606.CrossRefGoogle Scholar
  4. 4.
    Patient Protection and Affordable Care Act, P.L. 111–148, (2010).Google Scholar
  5. 5.
    Health Care and Education Reconciliation Act P.L. 111–152, (2010).Google Scholar
  6. 6.
    Mongan JJ, Ferris TG, Lee TH. Options for slowing the growth of health care costs. N Engl J Med. 2008;358(14):1509–1514.CrossRefPubMedGoogle Scholar
  7. 7.
    Vedentam S. Doctors Reap Benefits by Doing Own Tests. The Washington Post. July 31, 2009.Google Scholar
  8. 8.
    Thompson DF. Understanding financial conflicts of interest. N Engl J Med. 1993;329(8):573–576.CrossRefPubMedGoogle Scholar
  9. 9.
    Scott E, Mitchell JM. Ownership of clinical laboratories by referring physicians: effects on utilization, charges, and profitability. Med Care. 1994;32(2):164–174.CrossRefPubMedGoogle Scholar
  10. 10.
    U.S. Social Security Act. Sec. 1877., 42 U.S.C. 1395.Google Scholar
  11. 11.
    Levin DC, Intenzo CM, Rao VM, Frangos AJ, Parker L, Sunshine JH. Comparison of recent utilization trends in radionuclide myocardial perfusion imaging among radiologists and cardiologists. J Am Coll Radiol. 2005;2(10):821–824.CrossRefPubMedGoogle Scholar
  12. 12.
    Levin DC, Rao VM, Parker L, Frangos AJ, Intenzo CM. Recent payment and utilization trends in radionuclide myocardial perfusion imaging: comparison between self-referral and referral to radiologists. J Am Coll Radiol. 2009;6(6):437–441.CrossRefPubMedGoogle Scholar
  13. 13.
    Levin DC, Rao VM, Parker L, Frangos AJ, Sunshine JH. Ownership or leasing of CT scanners by nonradiologist physicians: a rapidly growing trend that raises concern about self-referral. J Am Coll Radiol. 2008;5(12):1206–1209.CrossRefPubMedGoogle Scholar
  14. 14.
    Mitchell JM. The prevalence of physician self-referral arrangements after Stark II: evidence from advanced diagnostic imaging. Health Aff (Millwood). 2007;26(3):w415–w424.CrossRefGoogle Scholar
  15. 15.
    Gazelle GS, Halpern EF, Ryan HS, Tramontano AC. Utilization of diagnostic medical imaging: comparison of radiologist referral versus same-specialty referral. Radiology. 2007;245(2):517–522.CrossRefPubMedGoogle Scholar
  16. 16.
    Hillman BJ, Joseph CA, Mabry MR, Sunshine JH, Kennedy SD, Noether M. Frequency and costs of diagnostic imaging in office practice–a comparison of self-referring and radiologist-referring physicians. N Engl J Med. 1990;323(23):1604–1608.CrossRefPubMedGoogle Scholar
  17. 17.
    Hillman BJ, Olson GT, Griffith PE, et al. Physicians' utilization and charges for outpatient diagnostic imaging in a Medicare population. JAMA. 1992;268(15):2050–2054.CrossRefPubMedGoogle Scholar
  18. 18.
    Winter A, Stensland J. Impact of physician self-referral on use of imaging services within an episode. In: Medpac, ed. Washington, DC; 2009.Google Scholar
  19. 19.
    U.S. Government Accountabiligy Office. HEHS-95-2: Medicare: Referrals to Physician-Owned Imaging Facilities Warrant HCFA's Scrutiny. Washington, DC: U.S. Government Accountability Office; October 20, 1994.Google Scholar
  20. 20.
    Centers for Disease Control and Prevention. NAMCS Scope and Design. Available at http://www.cdc.gov/nchs/ahcd/ahcd_scope.htm#namcs_scope. Accessed May 10, 2010.
  21. 21.
    Centers for Disease Control and Prevention. Physician Induction Interview. Available at http://www.cdc.gov/nchs/data/ahcd/namcs1-2006.pdf. Accessed May 10, 2010.
  22. 22.
    Katz MH. Multivariable Analysis: A Practical Guide for Clinicians. New York: Cambridge University Press; 2006.CrossRefGoogle Scholar
  23. 23.
    Centers for Medicare and Medicaid Services. 2006 Clinical Diagnostic Laboratory Fee Schedule. Available at http://www.cms.hhs.gov/ClinicalLabFeeSched/02_clinlab.asp#TopOfPage. Accessed May 10, 2010.
  24. 24.
    Rice TK, Schork NJ, Rao DC. Methods for handling multiple testing. Adv Genet. 2008;60:293–308.CrossRefPubMedGoogle Scholar
  25. 25.
    Mitchell JM, Sass TR. Physician ownership of ancillary services: indirect demand inducement or quality assurance? J Health Econ. 1995;14(3):263–289.CrossRefPubMedGoogle Scholar
  26. 26.
    Medicare Payment Advisory Commission. Clinical Laboratory Services Payment System. Washington: Medicare Payment Advisory Commission; 2007.Google Scholar

Copyright information

© Society of General Internal Medicine 2010

Authors and Affiliations

  • Tara F. Bishop
    • 1
  • Alex D. Federman
    • 1
  • Joseph S. Ross
    • 2
    • 3
  1. 1.Division of General Internal MedicineMount Sinai School of MedicineNew YorkUSA
  2. 2.Department of Geriatrics and Palliative MedicineMount Sinai School of MedicineNew YorkUSA
  3. 3.HSR&D Research Enhancement Award Program and Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Administration Medical CenterBronxUSA

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