A report issued yesterday by the Government Accountability Office (GAO) based on Part B claims data found that self-referred magnetic resonance imaging (MRI) services increased by approximately 84% from 2004 to 2010, whereas non-self-referred MRI services only increased by roughly 12%.  

For computed tomography (CT) over the same time period, the number of services performed by self-referrers increased by approximately 107%, in contrast to an increase of roughly 30% by non-self-referrers. GAO also found that in 2010 "providers who self -referred made 400,000 more referrals for advanced imaging services that they would have if they were not self-referring." As a result, GAO concluded that "financial incentives for self-referring providers were likely a major factor driving the increase in referrals."

Further, GAO estimated the fiscal impact of the 400,000 improper referrals on the Medicare program was "more than $100 million" just in 2010. However, aside from the monetary cost to the nation, GAO also highlighted the "unacceptable risks for beneficiaries" resulting from additional radiation exposure, particularly in the case of CT services, associated with these unnecessary referrals.

Yesterday's report is the first of a series from GAO on self-referral. Additional reports are expected on self-referral in physical therapy, anatomic pathology, and radiation therapy. 

Upon release of the report, the Alliance for Integrity in Medicare (AIM)—a coalition of provider organizations, including APTA, committed to ending the practice of inappropriate physician self-referral—applauded the findings. AIM said the report "substantiates our ongoing concerns with the misapplication of the in-office ancillary service (IOAS) exception to the physician self-referral law." The coalition urged Congress to "heed these critical findings and pass legislation to remove advanced diagnostic imaging, anatomic pathology, radiation therapy, and physical therapy from the IOAS exception, while preserving the ability of truly integrated multispecialty practices to continue providing high-value, high-quality care for Medicare beneficiaries under the self-referral law."

APTA will issue a separate statement, which will be highlighted in an upcoming News Now article, on GAO's report.

Eliminating physician referral for profit in physical therapy is one of APTA's public policy priorities. The Foundation for Physical Therapy recently awarded a $300,000 high-impact research grant to Jean Mitchell, PhD, to investigate the influence of physical therapy referral characteristics and practices on quality, cost effectiveness, and utilization.

The 6-Minute Walk Test (6MWT) distance may be a good indicator of lower limb muscle strength, and lower limb strengthening may improve gait capacity in patients with stroke, say authors of an article published in Journal of Rehabilitation Medicine.

A total of 24 patients (12 men and 12 women) participated in the study. Muscle strength (Medical Research Council [MRC] scale) and spasticity (modified Ashworth scale) were assessed prior to the 6MWT. Heart rate was recorded at rest and during the 6MWT. Participants were divided into 2 groups: (1) those with a high MRC sum score, and (2) those with a low MRC sum score. The relationship between the 6MWT distance and the other parameters was analyzed using a Spearman's rank correlation coefficient.

There was a significant and positive relationship between 6MWT distance and lower limb muscle strength, whereas no significant correlations were found between the 6MWT distance and spasticity, resting heart rate, and heart rate during the 6MWT.

Beginning 2013, BMJ will publish articles on drugs and devices only if the clinical trial data is made available for independent scrutiny—whether industry funded or not.

In an editorial published October 29, BMJ Editor in Chief Fiona Godlee says the recent "brave and benevolent" decision by GlaxoSmithKline (GSK) to allow access to anonymous patient level data from its clinical trials "really serves to highlight the rank absurdity of the current situation. Why aren't all clinical trial data routinely available for independent scrutiny once a regulatory decision has been made?"

Under GSK's new policy, an independent panel will assess all requests and access will be granted on the basis of a reasonable scientific question, a protocol, and a commitment from the researchers to publish their results. Godlee says it will be "particularly important to know how many requests are turned down and for what reasons." 

Godlee also writes that BMJ has intensified its efforts to help resolve a 3-year battle to gain access to full data on oseltamivir (Tamiflu). Taxpayers in the United Kingdom and around the world "have spent billions of dollars stockpiling a drug for which no one except the manufacturer has seen the complete evidence base," she says. 

Physicians and researchers at the Cleveland Clinic have voted weight-loss surgery as the top medical innovation for 2013, not for its effectiveness in reducing obesity but for its ability to control type 2 diabetes. 

People who reach 100 pounds or more above their ideal weight are almost never successful in losing weight and keeping it off for many years, says the clinic announcement. "Many diabetes experts now believe that weight-loss surgery should be offered much earlier as a reasonable treatment option for patients with poorly controlled diabetes—and not as a last resort."

Bariatric surgery was chosen as the top innovation "because Medicare has broadened its indication for payment, and Medicaid in many states follows Medicare," says Michael Roizen, MD, Cleveland Clinic chief wellness officer, in a Reuters News article. "A lot of the other (private) insurance companies started covering it, so it's much more accessible."

The clinic's list of the best medical innovations for 2013 also includes an almond-size device implanted in the mouth to relieve severe headaches, a handheld scanner resembling a blow dryer that detects skin cancer, better mammography technology, and new drugs to treat advanced prostate cancer.

Physicians and researchers at the clinic voted for what they thought were the biggest, most significant innovations from the 250 ideas submitted from their colleagues. One of the main criteria for getting on the list is the number of people that the product or procedure can potentially help, says Reuters.

Public and private payers are widely using performance measures to assess the use of low-value interventions, such as imaging for patients with uncomplicated low back pain, and using the results for public reporting and pay-for-performance, say authors of a position paper written on behalf of the American College of Physicians Performance Measurement Committee and published October 30 in Annuals of Internal Medicine.

The paper gives an overview of performance measures that target low-value services in order to help physicians understand the strengths and limitations of these measures, provides specific examples of measures that assess the use of low-value services, and discusses how these measures can be used in clinical practice and policy.

The discussion includes 2 categories of low-value  interventions: (1) those for which the harms probably exceed the benefits (eg, performing colorectal cancer screening for patients older than age 85 years) and (2) those that may provide benefits but for which a quantitative assessment of their benefits and costs by a multistakeholder group (patients, clinicians, and policymakers) suggests that the tradeoff between health benefits and expenditures is undesirable (eg, screening for cervical cancer in low-risk women aged 65 years or older and in women who have had a total hysterectomy for benign disease).

"Ideally, performance measures should be based on rigorous study designs (for example, randomized controlled trials) that assessed the benefits, risks, and costs of interventions," say the authors. However, to develop performance measures for low-value services, they suggest that researchers "will probably need to use data from different types of research design and methods, including subgroup analyses from clinical trials, cohort studies, cost–benefit analyses, and cost-effectiveness analyses."

"Just as with other performance measures, those for low-value services can be used in a variety of ways to improve quality and health care value," they add. 

Read more about the American College of Physicians' (ACP) high-value care initiative that aims to help physicians and patients understand the benefits, harms, and costs of interventions, and determine whether services provide good value. Go to the February 2011 issue of Annuals of Internal Medicine for free full text of ACP's clinical guideline for diagnostic imaging for patients with low back pain. The guideline calls for diagnostic imaging only if patients have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition. 

The Osteoarthritis Action Alliance (OAAA) recently posted a recording of its October 17 "lunch and learn" event titled Energy Balance and the Obesity Epidemic. This 30-minute presentation by weight control and obesity expert Steven Blair, PED, FACSM, offers some possible explanations about the causes of the US obesity epidemic. Blair discusses some of his research on this issue, including his energy balance study, which revealed critical information about the relationship between diet, weight, and energy expenditure. 

APTA is a member of OAAA.