WV HEALTH CARE AUTHORITY
IMAGING
CON STANDARDS MEETING
November 12, 2008 - 1:00 p.m. ET
Conference Reference #137202
Ms. Sonia Chambers: My name is Sonia Chambers and I’m Chair of the West Virginia Health Care Authority. I have with me today Sam Kapourales and Marilyn White, who make up the--we--the three of us make up the Board of the West Virginia Health Care Authority.
We are in the process of going through--having a--I guess a public input process on Certificate of Need in West Virginia, and are going through the service by--reviewable service by reviewable service, talking about whether--allowing folks who have an interest to comment on whether certain service--certain services ought to continue to be reviewable.
We have lumped a few together today under imaging. And in a minute--after we go around the room and hear from folks on the phone--have them identify themselves, Dayle will briefly go over the standards that we’re going to talk about today, and then we’ll open it up for comments by those who are here or on the phone.
I would also tell you that we are happy to accept written comments. We would ask that you have those here within 30 days of today’s meeting. You’re welcome to submit those.
And I would also tell you that we are recording these conversations so that people who are not here still can see the interplay. And those will be--once they are completed, those will be posted and available on our website.
So, why don’t we start here, and we will go around the room?
Again, I’m Sonia Chambers. We have Sam Kapourales and Marilyn White, and then we’ll go around the room and let folks identify themselves, and then we’ll do the phones.
Ms. Kim Hoffman: Kim Hoffman with Alliance Image.
Ms. Raymona Kinneberg: Raymona Kinneberg, Bill Crouch and Associates.
Mr. David Jarrett: David Jarrett with Charleston Area Medical Center.
Ms. Jill McDaniel: Jill McDaniel, Hospital Association.
Mr. Bill Wright: Bill Wright with Radiology Incorporated.
Mr. Ed Hamilton: Ed Hamilton, Mountain State Blue Cross/Blue Shield.
Ms. Sheila Kelly: Sheila Kelly, Certificate of Need Division.
Mr. Steve Dexter: Steve Dexter, Thomas Health Systems.
Mr. Tim Adkins: Tim Adkins, Health Care Authority.
Mr. Dayle Stepp: Dayle Stepp, CON.
Marianne Kapinos: Marianne Kapinos, Health Care Authority.
Ms. Cindy Dellinger: Cindy Dellinger, Health Care Authority.
Mr. Mark Morris: Mark Morris, Consumer Advocate.
Ms. Amy Tolliver: Amy Tolliver, West Virginia State Medical Association.
Mr. Jim Thomas: Jim Thomas, Attorney, Jackson Kelly.
Ms. Kay Myers: Kay Myers, Health Care Authority.
Mr. Fred Early : Fred Early, Mountain State Blue Cross/Blue Shield.
Ms. Sonia Chambers: All right. On--and on the phone, who do we have?
Mr. Jim Boxal: Jim Boxal [sp], American College of Cardiology.
Ms. Gwen Goldfarb: Gwen Goldfarb [sp], West Virginia Chapter of the American College of Cardiology.
Mr. Phil Wright: Phil Wright, The Health Plan.
Ms. Keri Covar: Keri Covar [sp], Society of Cardiovascular Computed Tomography.
Ms. Nancy Vest: Nancy Vest [sp], WVU Hospitals.
Ms. Angela Swagger: Angela Swagger [sp], WVU Hospitals.
Ms. Jill Parsons: Jill Parsons, St. Joseph’s Hospital.
Ms. Terri Allman: Terri Allman, St. Joseph’s Hospital.
Ms. Sonia Chambers: Anybody else on the phone? I will also remind you that, since this is being recorded, if you would please identify yourself before you speak so that we can accurately attribute comments to the right person. All right. There’s no one else available--on the phone or either here. Dayle, we have a few standards to consider, right?
Mr. Dayle Stepp: Yeah, I’ll try to go through them quickly.
This one’s from [unintelligible] BTC services. They’re pretty tight [unintelligible] GT they’re required to give us 30 days notice and document the cost that’s less than two million for cardiac CT angiography. They have to project 700 scans per year, and they can’t expand to other CT usage without further CON review.
And then multi-use CTs have to project 3,000 scans annually. They all have to address standards on quality, accessibility, and cost, and financial feasibility.
For MRIs, the first unit, they have to have done 2,000 procedures on a mobile unit in the past 12 months if they want add a unit, 3,500 on the existing unit or units, and 2,600 on the mobile unit.
Ms. Sonia Chambers: Dayle, with MRI, that’s also limited to acute care--.
Mr. Dayle Stepp: --Acute care--.
Ms. Sonia Chambers: --Facilities--.
Mr. Dayle Stepp: --Hospitals, correct. And they also have other standards on quality, consumer care and cost for PET, which is also limited to acute care facilities. For the [unintelligible] units, they had to have 950 on a mobile unit and 1,250 annually. For mobile PET services, it has to be on site [unintelligible] have to identify all owners of the equipment, the fair market value capital expenditure by the host hospital, and then [unintelligible] to the authority, and then they also have quality and cost standards.
Ms. Sonia Chambers: Okay. So, those services that are reviewable are CT, MRI and PET, correct? MRI and PET are limited to acute care facilities?
Mr. Dayle Stepp: Correct.
Ms. Sonia Chambers: Okay. Then, there is also--can you briefly go over the shared mobile services exemption?
Mr. Dayle Stepp: The shared mobile services [unintelligible]--.
Ms. Sonia Chambers: --Hold on a second, Dayle. Somebody who is on the phone, I’m guessing they’re cradling the phone on their ear while they’re moving around. If you would be willing to put your phone on mute, we’re hearing a lot of moving around and fairly heavy breathing. Okay, Dayle--.
Mr. Dayle Stepp: --Okay. The exemption for shared mobile services. Again, it’s similar to the PET for mobile services. It has to be onsite at least two days a month. It has to be shared with another acute care facility. They have to identify the owners of the equipment, the type of equipment, the fair market value, and the capital expenditure by the host hospital. And then, they also have, you know, some other information on quality and cost and feasibility.
Ms. Sonia Chambers: Okay. Questions of Dayle before we start into comments? This is a learned group, and they all--and everybody understands it. Okay.
All right. If there aren’t any particular questions, then I will open the floor for comments, particularly related to whether these services ought to continue to be reviewed under the CON law or not. And if nobody volunteers I’ll start picking on people. Raymona, you’re right there.
Ms. Raymona Kinneberg: I think there’s a lot of evidence that--regarding self-referral of physicians who have their own imaging equipment, increasing utilization. I’ve got less than a page here summarizing one study done by Georgetown University. And for that, and a lot of other reasons, I believe that all of these services should remain [unintelligible].
Ms. Sonia Chambers: Okay. Did we have somebody join us on the phone?
Ms. Pat Woods: Yes, this is BMS. This is Pat Woods and Stacy Henshaw.
Ms. Sonia Chambers: Hi, guys.
Ms. Pat Woods: Sorry we’re late.
Ms. Sonia Chambers: That’s all right. Okay. David?
Mr. David Jarrett: Yes, we feel that they should continue to be reviewed and [unintelligible].
Ms. Sonia Chambers: Okay. Jill?
Ms. Jill McDaniel: I’m Jill McDaniel with the West Virginia Hospital Association. I think over the last couple of years, these hospitals associations have been pretty strong advocates with respect to the reviewability of imaging services, as to the [unintelligible]. We have submitted many reports and studies by governmental agencies in the last couple years, as well as other organizations with an interest in healthcare economics. [Unintelligible] points to a concern that the availability of equipment may also drive healthcare for--I’m sorry, may drive utilization and, subsequently, healthcare costs.
And there are all--there were also some issues related to quality. And many reports have documented concerns with overuse of imaging technologies and concerns with the level of oversight of the technology itself, depending on the site of the service.
There was an interesting study that was just published this month in the journal Health Affairs, and it is about--the entire issue is about technology [unintelligible]. And in this particular article, [unintelligible] Lawrence Baker and Company. It’s called--it’s entitled, "Expanded Use of Imaging: Technology and the Challenge of Measuring Value." And it really questions whether the benefits are worth the cost and suggest that you know, this is going to be an ongoing need to evaluate that issue.
They cite that, between 1995 and 2005, for Medicare patients, MRI procedures tripled. And also in that same period, CT procedures doubled. And then, they pointed out that one new MRI machine added in a market had 733 procedures and $550,000 in Medicare spending annually, just for Medicare. That’s not even taking into consider the other payers.
For CT, one new CT unit in the market adds 2,224 procedures and $685,000 in Medicare spending.
So, I think, you know, this is just one other report that has come out that there’s a very consistent pattern with the research that raises a very significant question. So, for all those reasons, the Hospital Association supports continued Certificate Of Need review for imaging services.
Ms. Sonia Chambers: Okay. Kim?
Ms. Kim Hoffman: We--honestly, with Alliance Imaging, we provide a lot of services to surrounding hospitals. So, we don’t really have--.
Ms. Sonia Chambers: --Don’t have a position--.
Ms. Kim Hoffman: --One way or the other.
Ms. Sonia Chambers: Okay. Work our way down the table.
Mr. Bill Wright: Bill Wright with Radiology Incorporated. Our position is that CON review imaging services should remain.
Ms. Sonia Chambers: Ed, or Fred?
Mr. Ed Hamilton: One of the difficulties that I have with the CONs as they stand right now is that perhaps it might be worthwhile to look at combining them into one set of criteria, or one set of similar criteria. It seems to be something that’s done in other states. It’s just kind of, you know, drill them down to something that’s fairly homogenous.
Obviously, when you take CT and PET and MRI, they’re not completely different, but there’s some similarities, but differences, too. So, that would be one thing that I think would--might be worthwhile.
The other--you know, as far as the CON as a concept itself, I think there’s--even in our organization, there’s two differing opinions. First of all, recognizing that--you know, the CON process keeps a cap on the number of machines out there, serves the economic purpose of making sure that, you know, the horse stays in the stable, so to speak.
The economic studies, the Congressional Budget Office analysis, all indicates that the presence of more machines means more utilization, meaning more money. The next step that comes after that is [unintelligible] really attached anything [unintelligible] of a increased cost of what the quality issues are. There seems to be no redeeming factors as far as an increase in quality to the increased number of scans, you know, brought about by the increased number of machines.
So, that’s the next step that’s coming, is trying to quantify is there any redeeming value to more machines, more scan spending, more money. And the studies seem to indicate at this point, no, there isn’t any.
So, from that standpoint, the CON process keeps a lid on the number of machines as they expand. The interesting thing that the Congressional Budget Office also brought up, as it relates to Medicare, is Medicare needs to get a handle on it.
So, you’re going to continue to see the proliferation of radiology benefit managers. So, you’re going to see Medicare, at some point, moving to pre-certification on these services.
The--one of the problems I have with the CONE process--the CON process is that it doesn’t hit all of the machine. You know, we’re talking about predominantly those that are in hospitals. Those that are on streetcorners, the medical office building, in some states detached buildings, are unregulated.
So, there could be some opportunity there, so to speak, to make sure that every machine that qualifies under the guidelines is reviewed, not just those associated with hospitals, because that’s where you expansion is. Your expansion's outside the hospital. It’s not inside the walls of [unintelligible].
The other side of the story is there’s people in our organization that feel that we don’t need CON on it, and that we need the competition. And the competition will result in lower prices.
Once again, we know that the proliferation of machines is going to represent more money going out, more scans, but then, you know, if we’re talking about machines that are on every street corner, with the competition you may see lower prices. And when the radiology benefit and management goes into effect, you may see regulation of the number of scans at lower prices.
So, there may be some benefit to that, also. From that standpoint, I’m not sure that we have a specific opinion at this point.
Mr. Fred Early: Do you want me to break the tie?
Mr. Ed Hamilton: Go ahead.
Ms. Sonia Chambers: I thought you might.
Mr. Fred Early: That’s right [unintelligible] our [unintelligible]--.
Ms. Sonia Chambers: --You’re going to--you need to come sit up here so we can hear you--.
Mr. Fred Early: --This is Fred Early from Mountain State Blue Cross and Blue Shield. And I think at this stage, our position would be that the Certificate of Need process should remain in place for the imaging services.
But, I do--one additional element, that is that I think that some additional follow-up, whether you would call it, you know, ultimate retrospective analysis, but to tie more into the quality standards associated with that. I think that there could be a little more substance in that end of the process as well, not just once they’re approved, what occurs to continue to see whether or not they’re--the quality initiatives are being met and whether there should be an opportunity or ramifications if they’re not.
Ms. Sonia Chambers: Ed, can you--this is Sonia Chambers. Can you please tell me what you meant by the standards don’t seem to hit all of the machines? Are you talking about all of the machines that are listed in the standards, be they PET, CT, or MRI?
Mr. Ed Hamilton: Well, the question I have is, if we have a cardiologist that wants to install a CT machine to do CT angiopathy--?
Ms. Sonia Chambers: --Uh-huh--.
Mr. Ed Hamilton: --Is that going to fall under the standard?
Ms. Sonia Chambers: Yes.
Mr. Ed Hamilton: As the price drops on the technology, is it going to fall out from under the standard?
Ms. Sonia Chambers: No, no. Now, Ed, here to--there are--you weren’t here for our last--when the--before the last standards--you weren’t in your current position.
Heretofore, CT was not a specifically regulated service. It was--well, it was, and then it was taken off how many ever years ago. And--how many, Raymona?
Ms. Raymona Kinneberg: 2000.
Ms. Sonia Chambers: Two thousand, that’s what I thought. It was taken off in 2000. It was put back on because the price was dropping, because from 2000 on, CT machines were generally above the $2 million threshold and were, therefore, caught that way.
As the price dropped, we became concerned--the Authority became concerned that there would not be regulation of those. And the standards were changed so that they are specifically as CT regulated. And we went through a very heated, lengthy debate in the legislature, and then after that in developing the standards--to set the standards for that.
Before they were specifically--before the rule and the law were specifically changed, there were some physician offices who did acquire, particularly CT angiography machine--64 slice machines because they were under the $2 million threshold.
Unidentified Man: The same hold for MRI.
Unidentified Man: [Unintelligible--.]
Ms. Sonia Chambers: --No, all of the--.
Unidentified Man: --The MRI have always been subject to review no matter who.
Unidentified Man: I see. To me, that represents some inconsistency. You could have some abuse there on the MRI side.
Unidentified Man: So, it’s subject to review [unintelligible]--.
Ms. Sonia Chambers: --What--no, they’re--they have--.
Unidentified Man: --They’re subject [unintelligible]--.
Ms. Sonia Chambers: --They’re--.
Unidentified Man: [--Unintelligible--.]
Ms. Sonia Chambers: --Yes--.
Unidentified Man: --Okay, regardless of monetary--.
Ms. Sonia Chambers: --Yeah--.
Unidentified Man: --Standards.
Ms. Sonia Chambers: Yes.
Unidentified Man: Okay.
Ms. Sonia Chambers: CT was on--was specifically on the list of services until 2000. It was then taken off the list of services. However, most of the CT acquisitions were reviewable because they were over $2 million. There was a period of time when the price began to drop below two million that they were not subject to review, and there were some in the state that were purchased. And those--many of--a number of those providers came--either came through review or questioned us about whether they were reviewable, and our decision was that they were not, because they were--.
Unidentified Man: [--Unintelligible--.]
Ms. Sonia Chambers: --Not because they were below two million--.
Unidentified Man: --MRI is also reviewable no matter--.
Ms. Sonia Chambers: --MRI has, and continues to be, specifically reviewable, as does PET.
Unidentified Man: Okay. What about reporting of utilization, because, you know, it would be good to see that.
Mr. Dayle Stepp: This is Dayle. Here on the table there are some utilization reports, and these are coming off the uniform financial reports for the hospitals. The MRI's there and the PET's there. The CT is there for hospitals. There is about 15 or 18 CT units that were acquired during this period when CT was not set up to be reviewed that are in physician’s offices, or maybe clinics. So, everything else--the hospitals report all their utilizations. So, the only utilization that’s not reported is these 15 to 18 units that may be--that are out there in physicians’ offices, or cardiology--a group practice.
Ms. Sonia Chambers: That were not subject to review--.
Mr. Dayle Stepp: --That were not subject to review--.
Ms. Sonia Chambers: --And therefore are not required to report any utilization to us.
Mr. Fred Early: Sonia, this is Fred. I--Fred Early again. One follow-up question that--and I apologize if I should know this and just don’t recall. For those 15 to 18 units that came in during the moratorium period that were not subject to review at the time, when and if it comes the time and place for replacement technology for those units, will that be subject to review, or do they get the free pass at that point in time?
Ms. Sonia Chambers: They would not be subject to review because that’s simply a replacement of an existing service.
Mr. Fred Early: What if it’s an upgrade? What if the--?
Ms. Sonia Chambers: --Unless [unintelligible]--.
Mr. Fred Early: --Technology goes from x-slice to y-slice? Is that--?
Ms. Sonia Chambers: --If it--.
Mr. Fred Early: --Considered a replacement, or is that considered a different animal--?
Ms. Sonia Chambers: --If it’s a CT it’s a CT--.
Unidentified Woman: --[Unintelligible] two million, it’ll be subject to review.
Mr. Fred Early: So, replacement is replacement regardless if it does expand beyond the current--.
Unidentified Man: --Technology--.
Mr. Fred Early: --Technology available? Okay. Well--.
Ms. Sonia Chambers: --Currently that’s the case.
Mr. Fred Early: --Okay. That--I mean, that could be perceived as a gap in the regulation of that. But--I mean, if I have a four slice and I want to buy, you know, the next generation and it comes to a price of $1.9 million, that’s a pretty big hole to drive that truck through. So--.
Unidentified Man: --Well, if you can get a used 16 for 100,000--.
Mr. Fred Early: --Well, I’m thinking more of the 64-slice, or the next generation of 128-slice and those type of things. If they’re going to be viewed as replacement for somebody having a four or 16-slice machine, then I think that that’s a gap.
Ms. Sonia Chambers: I think, under the current law, there really isn’t a differentiation in that type of technology.
Mr. Fred Early: Other than the $2 million threshold.
Ms. Sonia Chambers: Other than the $2 million threshold.
Ms. Marianne Kapinos: This is Marianne Kapinos. Well, the current differentiation is low-dose, multi-use, and cardiac CT.
Ms. Sonia Chambers: Right.
Ms. Marianne Kapinos: So, those [unintelligible] everything else is lumped into those multi-use.
Unidentified Man: Okay.
Ms. Marianne Kapinos: And if they have a multi-use that came in with the--when it wasn’t a listed service and they want to upgrade it within that category, and it’s left the two million--.
Unidentified Man: --Right--.
Ms. Marianne Kapinos: --Then it’s not going to be subject to review.
Mr. Fred Early: Okay, all right.
Ms. Marianne Kapinos: If it’s over two million, it will be.
Mr. Fred Early: All right.
Ms. Amy Tolliver: [Unintelligible--.]
Ms. Sonia Chambers: --Wait--this--and this is Amy Tolliver who’s asking a question--.
Ms. Amy Tolliver: --Yeah. And I was clarifying--if they had a unit that was subject to review, and now they want to--there’s no differentiation between if they acquired it when it--.
Ms. Sonia Chambers: --Correct--.
Ms. Amy Tolliver: --[Unintelligible] subject to Review Board--.
Unidentified Woman: --Right--.
Ms. Sonia Chambers: --Correct--.
Ms. Amy Tolliver: [--Unintelligible.]
Unidentified Woman: Right.
Ms. Sonia Chambers: Right.
Ms. Amy Tolliver: So, those facilities that would have a unit that was subject to review, it’s time they purchase it--.
Ms. Sonia Chambers: --Right--.
Ms. Amy Tolliver: --And now they want to go from a 16 to a 24, they could do that?
Ms. Sonia Chambers: That is correct.
Unidentified Man: Yeah.
Ms. Sonia Chambers: If they have CT services--.
Unidentified Man: --Right--.
Ms. Sonia Chambers: --Then they can replace and upgrade that unit. They can expand the number of units, and, as long as it is not over $2 million, they do not trigger review.
Ms. Raymona Kinneberg: It’s Raymona. I just want to follow on that because, you know, I’m not clear based on what Marianne said. If somebody acquired a CT unit during the time when it wasn’t subject to review, and that unit was only used for multi-purpose, not for cardiac, they could still upgrade to cardiac CT without a CON?
Ms. Sonia Chambers: That’s correct. What they--under the new standards--this is Sonia. Under the new standards, there--because there are lower volume thresholds for the cardiac CT, the standards related to cardiac CT say that, if you purchased a cardiac CT and went through review using only cardiac numbers, if you then want to have a multi-purpose machine, you have to go through review using the numbers for multi-purpose. But, the reverse is not--.
Ms. Raymona Kinneberg: --That’s not my question.
Unidentified Man: It was a great answer, though.
Ms. Sonia Chambers: Part of your question. But, your question is, if they acquired a multi-use CT, and they--while--and did not go through review because it was not subject to review, and they want to go to a cardiac CT, it is not reviewable. They are already a provider of CT services.
Ms. Raymona Kinneberg: And vice-versa. If they got a cardiac CT, you want to show the multi-use, that’s not renewable.
Unidentified Man: [Unintelligible] that is subject to review.
Ms. Sonia Chambers: Right.
Ms. Raymona Kinneberg: If they required a cardiac unit when there was--.
Ms. Sonia Chambers: --Right--.
Ms. Raymona Kinneberg: --No review, they can’t go to multi-use?
Unidentified Man: Well, the standards say a provider proposing to perform only CCTA may not expand the use of the CT scanner to perform scans other than CCTA unless it obtains a Certificate Of Need for multiple use CT scan services.
Ms. Sonia Chambers: I think--.
Unidentified Man: --Yeah--.
Ms. Sonia Chambers: --Your question would be somewhat debatable, and I’m sure there would be people who would have very strong feelings on both sides of that, if that situation presented it to ourselves--to us, and I’m sure we’d have to work through that.
Mr. Fred Early: Do you--does the Health Care Authority have knowledge of--I mean, you’ve mentioned the 15 to 18. Do you know how many are out there? Do you know how many may be exclusively for CCTA at this point in time that could even be in that scenario?
Ms. Sonia Chambers: We only know that anecdotally--.
Mr. Fred Early: --Yeah--.
Ms. Sonia Chambers: --Really. Well, some of them did get determinations of reviewability for it--.
Mr. Fred Early: --Right--.
Ms. Sonia Chambers: --From us. Others may not have. I mean, we’re aware of two of them--.
Mr. Fred Early: --Right--.
Ms. Sonia Chambers: --You know.
Mr. Fred Early: All right. Thanks.
Mr. Bill Wright: Sonia?
Ms. Sonia Chambers: Yes, sir?
Mr. Bill Wright: Bill Wright. Who checks the quality on these?
Ms. Sonia Chambers: Who checks the quality, meaning what?
Mr. Bill Wright: Well, a lot of times--we run into this all the time, where we have an MRI done, and the tertiary hospital won’t accept it because of the quality. My question is, is the quality of all of these machines up to par? And if not, who checks those to see if they are a quality machine in today’s world?
Mr. Dayle Stepp: This is Dayle. All of these machines are inspected and certified by the Division of Radiological Health within DHHR.
Ms. Sonia Chambers: Oh, within public health?
Mr. Dayle Stepp: Right.
Unidentified Man: In public health.
Ms. Sonia Chambers: They check the calibration--.
Mr. Dayle Stepp: --Right--.
Ms. Sonia Chambers: --And things, but they--do they check the practitioners?
Mr. Dayle Stepp: No.
Unidentified Woman: No.
Unidentified Man: No.
Unidentified Woman: But, the standards are pretty clear that the practitioners have to be certified and accredited.
Unidentified Man: Right. [Unintelligible.]
Mr. Dayle Stepp: Hmm.
Ms. Sonia Chambers: All right. Phil, while you’re--you have the floor--.
Mr. Phil Wright: --Uh-oh--.
Ms. Sonia Chambers: --What--?
Mr. Phil Wright: --Well, I just--we’re torn between this one because the CON definitely prevents competition. There’s no question about that. And we’ve had--you know, we’re in a panhandle. We’ve had companies come in across the river, in the other states, and they bring on the cost at half what we’re paying. So, it eliminates competition.
But, on the other hand, we know that, if you don’t have limitations on the number of these images--imaging machines, your costs are going to go way up. So, we’re kind of torn in between.
I just get upset because, you know, there’s way too much use of the MRI today. We’re--you know, if a doctor knows a person has a baker’s cyst, they do an MRI to confirm it. It doesn’t change the treatment. It just costs more money in the healthcare arena. And the problem--that’s the problem we run into all the time, but, you know, we’re torn what to do with a CON because we know it limits the number, which helps the cost. But, we know having the CON prevents competition, which drives the cost. Okay?
So, it--it’s not--in the healthcare world, it’s not like retail. You buy a TV--plasma TV 10 years ago, it’s one-tenth the cost today than it was 10 years ago. MRI costs don’t change. They stay the same all the time. They don’t come down.
That’s the problem you run into in healthcare. And I don’t know what to do with that Sonia, but, you know, it’s a double-edged sword.
Ms. Marilyn White: Phil, this is Marilyn.
Mr. Phil Wright: Hi, Marilyn.
Ms. Marilyn White: Hi. Question. Just--I don’t know, but I’m sitting here thinking, over-utilization, I totally agree with. I know that we have that. But, I’m not sure that I think that should be governed by a regulatory Board like our Board. I think that that is the responsibility of the third-party payers, and--well, the payers period, because before they pay somebody they should make sure that that person meets their criteria.
Mr. Phil Wright: Now, we do that. And we don’t--.
Ms. Marilyn White: --And I know you do, but I think--Blue Cross is sitting here and I’m sure they do, and Medicare, but I don’t think that can be something that our Board can do.
Mr. Phil Wright: No, I agree. We’ve--when we decide to bring on a provider with those services, we go through a major quality check before we do any of that. And then, you know, it depends on where they’re at and what’s available within so many miles. We use a geo-access look.
But, the thing today, you know, it’s really--you’re caught in the middle on this one because cost and quality and CON just totally conflict, I think. It’s--the provider--the carriers are going to decide who they’re going to contract with. You don’t have to contract with everybody.
Ms. Marilyn White: Exactly.
Mr. Phil Wright: And that--to me, that means then you can drive it, if you have that ability, much better than if you have a CON in place. But, you know, I’m torn between this one because I’m kind of like Blue Cross. You have a CON that limits it. We know the overuse of this is ridiculous.
So, it’s probably better if you have a CON, but it’s probably not if you’re going to drive the cost down. So, what do you do? I mean, that’s something I think you’ve got to wrestle with to make a decision.
Ms. Sonia Chambers: Okay.
Steve?
Mr. Steve Dexter: Yeah.
Ms. Sonia Chambers: I think Steve has a--is not torn.
Mr. Steve Dexter: No, not at all. Not at all. Steve Dexter, the CEO of the Thomas Health System, which represents St. Francis Hospital and Thomas Hospital. We support the current CON process and an expansion of the process, particularly as it relates to physician ownership.
I think most of the studies have confirmed what other people have said, but just three I’d like to put on the record, one from Medpac [sp] report for March of 2005 on MRI referrals. Practices without a physician’s financial interest order MRIs on 18 percent of the patients. Practices where the physicians have a financial interest, 26 percent. That’s about a 30 to 35 percent differential based on physician ownership.
From the Oklahoma Workman’s Compensation claims from this past July, the odds of receiving complex spinal surgery were 65 times greater after physicians gained a financial stake in the hospital. And just a third one, from the GAO from 2000 to 2006, Medicare spending for imaging services paid to doctors more than doubled, with the added spending specifically going to CT, MRI, and PET.
I think the recommendation--my recommendation is that the CON be expanded even to hospitals specifically that have physician ownership, because you can have a specialty hospital that puts in an MRI with no obligation to provide any emergency room services or any safety net services.
So, I think the standard ought to be higher if there are--if there is physician ownership. I also think that we ought to go back in a minimum of the existing standards out there, add a reporting requirement, and put them under rate review. So, there’s one reason I think the CON office in West Virginia is uniquely qualified to control the cost of these services are because they can control the pricing of the service. And it’s a market right now where, if you’re a managed care company and you’re trying to negotiate it with a provider in Boone, you may only have one provider in Boone County, so there is no market out there.
There’s limited providers in West Virginia, and it’s just very difficult for the free market to work in this environment.
Ms. Marilyn White: Steve, this is Marilyn. Am I understanding you, that you are saying that you think we should be able to tell you, the hospital, what you can charge--?
Mr. Steve Dexter: --You already--.
Ms. Marilyn White: --For an MRI--?
Mr. Steve Dexter: --You already tell us what we can charge.
Ms. Marilyn White: Well--but you bundle all of that in a chart. It’s not specific, and I think this would be getting specific.
Mr. Steve Dexter: Yeah, I think that the--if you’re going to provide any of these services that fall under the CON, I think they ought to fall under rate review also to keep a level playing field.
Ms. Sonia Chambers: That--so, where--to follow-up on Marilyn’s questions--this is Sonia--right now we set an average for you guys, charge for discharge, charge for a visit--outpatient visit. Are you suggesting that we would specifically set rates for your price list of imaging, not just your, but anybody who does imaging services?
Mr. Steve Dexter: I think if there’s someone that’s providing these services to the community, they ought to fall under the same regulations that the hospitals do, which are currently under rate review, how you work out the specific mechanism of dealing with an imaging center, or a specialty hospital, or a full-service hospital. I mean, I think that we’d have to sit back and look on how to do that.
But, I think right now, the current system allows a freestanding center that has no obligation to take any Medicare, Medicaid, no-pays, not to have rate review when the physician owns it, and the study shows that the physician ownership in and of itself drives utilization.
Ms. Raymona Kinneberg: Right.
Mr. Steve Dexter: They’re the ones that ought to be regulated more than anyone else.
Ms. Raymona Kinneberg: This is Ramona.
I think that there’s some clarification, because I think Marilyn’s asking one thing, and it’s not quite the same answer.
What Marilyn was asking was whether the Health Care Authority should set specific rates for hospitals. I think what Steve is saying is not that the Health Care Authority set specific rates for hospitals. What he’s saying is, if you have a freestanding entity, they--that provides these services, they ought to be under rate review. I don’t think he’s saying anything about changing--.
Mr. Steve Dexter: --She’s my interpreter--.
Ms. Raymona Kinneberg: --The current method. Right.
Mr. Steve Dexter: Actually, you’re doing a good job. I appreciate that, Raymona.
Ms. Raymona Kinneberg: That was what I was trying to clarify--.
Ms. Marilyn White: --Yeah, I know--.
Ms. Raymona Kinneberg: --With him. So, you believe that--well--and the problem is, I’m trying to think of--I guess I’m going to how you would actually do that, how you would actually do rate regulation for imaging centers or specialty physician-owned hospitals since it’d be a very different animal than an average charge per discharge.
Mr. Steve Dexter: Well--.
Ms. Raymona Kinneberg: --For--.
Mr. Steve Dexter: --But, we have average charge for discharge--.
Ms. Raymona Kinneberg: --Per--.
Mr. Steve Dexter: --An average for--.
Ms. Raymona Kinneberg: --Outpatient visits--.
Mr. Steve Dexter: --Outpatients. But, at the same time you--the Health Care Authority regulates, you know, Boone Memorial and the WVU Health Systems.
So, I think that you demonstrated an expertise to be able to handle a wide range of providers. So, I don’t have a specific plan on how you would do it, but I think it’s something that the Health Care Authority ought to do, that any of these CON services ought to be under rate review and a reporting review, including the 15 or 18 that were able to get in under the wire before this new public policy was put into place--which was put into place to serve the public interest.
Ms. Sheila Kelly: This is Sheila Kelly. I have a question, and I don’t know who would know the answer to this. Is there a huge variability in cost between different types of providers for the same MRI or CT procedure?
Ms. Sonia Chambers: Cost, or--?
Mr. Dayle Stepp: --Yes--.
Ms. Sonia Chambers: --Cost or charge?
Unidentified Woman: Charge.
Ms. Sheila Kelly: Charge.
Ms. Sonia Chambers: Charge.
Mr. Dayle Stepp: Well, the answer’s both.
Unidentified Man: Both.
Mr. Dayle Stepp: Yeah. If you have a CT scanner in a hospital ER, you’ve got to staff that thing 24 hours a day, seven days a week. If you have freestanding imaging center owned by a doctor, you staff it Monday through Friday, nine to five. You’ve got one employee. I mean, there’s a huge difference.
Ms. Sheila Kelly: Is the cost per scan in the environment that doesn’t require 24-hour emergency staffing lower? I realize that the cost to the facility providing it is lower. Is the fee or the charge lower?
Mr. Dayle Stepp: We don’t know. They’re not regulated, so I don’t think anybody could say whether the scan is less expensive or more expensive.
Ms. Sheila Kelly: Well, Phil or Fred, what do you guys see?
Mr. Phil Wright: I would hope it would be less since the cost is much higher.
Mr. Fred Early: I think--well, I just--I think some of the things that Steve--this is Fred Early again--are indicative of this in terms of some of the things they don’t have. You know, they don’t have the responsibility to take all comers, whether it be government programs that may pay less than commercial programs. They clearly don’t have a responsibility to deal with charity care or no-pays, so you don’t have that cost reabsorbed back into your structure for your charges.
So--but, typically you would see that the costs associated with that and per the charges associated with that would be lower than what you see from a facility that’s offering inpatient/outpatient full range of services.
Ms. Sonia Chambers: Phil, do you happen to know that off the top of your head?
Mr. Phil Wright: It’s [unintelligible] much less, both ways--.
Ms. Sonia Chambers: [--Unintelligible--.]
Mr. Phil Wright: --For the provider and for the carrier trying to contract with a provider.
Ms. Sonia Chambers: Yeah, just anecdotally from some of our meetings with physician-owned freestanding imaging centers, the--I believe claim they can do it for two thirds to a half of what the hospital would charge.
Mr. Dayle Stepp: Yeah, we saw 50 to 70 percent reduction.
Mr. Phil Wright: We would--I’d be happy to give you some ratios. I just don’t have them off the top of my head.
Ms. Sonia Chambers: Okay. I think that would be instructive.
Ms. Sheila Kelly: I believe--this is Sheila Kelly again. I believe that there are requirements in the standards for a certain proportion of charity care, with the exception of the 18 that slid in under the wire. I think that, at least for some of the imaging services, there are requirements for charity care.
Ms. Sonia Chambers: Steve, do you have anything else? [Unintelligible] your comments, and then I’m going to Amy.
Mr. Steve Dexter: Well, I think it’s not only a difference in charity care for a particular service. Imaging services are very profitable, so you can deliver that service and give a certain amount of charity care and still be very profitable. I don’t think you see nationwide hospitals opening--doctors opening up clinics for COPD or CHF that you lose a ton of money on, whereas, if you give no charity [unintelligible], you’re still going to lose a fortune regardless if you take care of no patients with [unintelligible].
So, being able to pick out service that are profitable in the current reimbursement environment--a charity care requirement is nice, it makes you feel good, but it’s really not addressing the issue that these are the services that support the entire [unintelligible].
Ms. Jill McDaniel: I’d like to respond to Sheila. The--this is Jill McDaniel. The standard for CT service is [unintelligible] specify certain thresholds for charity care and some Medicaid populations. That’s the only service that’s had this type of decision.
Ms. Sonia Chambers: Okay. Amy, did you want to ask Steve a question? And then, I’m going to let you have your turn.
Ms. Amy Tolliver: Well, I wanted to respond to the--.
Ms. Sonia Chambers: --Sure--.
Ms. Amy Tolliver: --Charity care discussion that’s going on, because I think it’s a little difficult to sort of sit around the table and say that, by the [unintelligible] requirement to provide charity care, that charity care isn’t being provided in those facilities. And I think that we need to understand that, and that physicians, in fact, do provide a large amount of charity care that’s out there.
However by nature of the physicians being individual providers, individual businesspersons, it’s not quite as easy to calculate that. But, there have been national studies that have done that and have shown that physicians are providing a vast amount of charity care.
And so, I just wanted to make sure that people understood that just because it’s not a requirement, that it’s not being done.
Ms. Sonia Chambers: Okay.
Mr. Steve Dexter: Amy, I think you’re correct, because physicians are [unintelligible] call at the ER. So, it’s not an issue of physician services. I’m more concerned about the imaging services, [unintelligible] technical [unintelligible].
Ms. Amy Tolliver: And I’m speaking to all services, not just to--.
Mr. Steve Dexter: --Yeah. And that, I guess, is another reason to have reporting requirements, so at least you can document whether these freestanding are providing charity care or not.
Ms. Sonia Chambers: Okay. Amy, do you have--it was your turn next. Do you have other comments?
Ms. Amy Tolliver: Well--and by nature of all of these meetings, the State Medical Association doesn’t have--at this point we aren’t sharing essentially a position, yes or no, on all these services. I think that we’re well aware of our position, where we stood on CT in the battle [unintelligible], I guess.
And so, I’ll just leave it at that. We just--we don’t have anything further to add regarding our position, yea or nay, on adding or taking away--.
Ms. Sonia Chambers: --Okay--.
Ms. Amy Tolliver: --[Unintelligible], you know?
Ms. Sonia Chambers: All right. Mr. Thomas?
Mr. Jim Thomas: No comment.
Ms. Sonia Chambers: No comments today, huh? Okay. Martha, no? Just happy to be here, right? Let’s see. Jill or Terri, do you guys have comments from St. Joe?
Ms. Jill Parsons: Yes. Obviously we support the CON process for imaging services. But, I think being a border facility, there are circumstances where we will see physicians or facilities that operate in the state of West Virginia have ease of access of taking these services across the river to Ohio with relative ease. And so, that obviously affects our ability to continue to provide these services in a cost effective and quality manner.
I think, too, the standards don’t necessarily take into account existing providers of the services in the market. For example, if a facility were replacing a mobile PET CT with a fixed site, none of the need methodology really addresses the--if there are other existing PET CT providers in that market and the volume and the quality that they provide. So, those are a couple of instances that affect us in this market.
And we had one other person join us.
Ms. Sonia Chambers: Oh?
Ms. Jill: It’s Dr. Pete Strobl, radiologist here at St. Joe’s.
Ms. Sonia Chambers: Okay. Dr. Strobl, would you like to offer any comments?
Dr. Pete Strobl: You know, as a hospital-based physician, I tend to agree with the CON needs in the state. We personally have lost a fair amount of business across the river because of the new facilities being placed there. So, in my mind, you know, I think--and some of these facilities are owned by physicians that, you know, I’ve worked with in the past, and it does leave a bit of a bad taste in your mouth to know that some of your colleagues might be going for easier money. [Unintelligible.]
Ms. Sonia Chambers: I’m sorry, we didn’t hear the last part after, “some of your colleagues”--.
Unidentified Woman: --Are going for easy money--.
Dr. Pete Strobl: --Are going for the easy money across the river rather than for good patient care. I mean, I--.
Ms. Sonia Chambers: --Okay--.
Dr. Pete Strobl: --Really agree that physician self-referral is [unintelligible] issues facing this country today as far as healthcare costs.
Ms. Sonia Chambers: Okay. All right. I think the only ones I have not given an opportunity to are the folks from the ACC.
Mr. Jim Boxal: It’s Jim Boxal from the ACC. Well, I think, as you well know, the ACC supports the current West Virginia CON on imaging.
Ms. Sonia Chambers: Okay. So, you support the current standards. Does that also--does the ACC have a position on whether there should be Certificate of Need for such imaging modalities?
Mr. Jim Boxal: Well, the ACC has traditionally not had any position on that as a whole. In West Virginia, we certainly support the CT standards that were adopted--I can’t remember whether it was earlier this year, or last year. It seems like it’s been forever as far as the discussion on that. But, the ACC traditionally has never taken a position on CON because of the division between hospital-based and physician practice-based members.
Ms. Sonia Chambers: Okay. All right. Anybody else? Oh, Angela or Nancy? Sorry.
Unidentified Woman: Oh, that’s okay. I don’t know that we really have anything to add. We support CON review on these services.
Ms. Sonia Chambers: Okay. And Pat or Stacy, do you guys want to comment?
Unidentified Woman: CMS supports the CON process.
Ms. Sonia Chambers: Okay.
All right, did I miss anybody? Anybody else? All right, I appreciate everybody’s time and effort this afternoon. We do have another meeting tomorrow, correct, on behavioral health. And we’re coming to the end of our list of services, are we not, our list of meetings?
Unidentified Woman: [Unintelligible.]
Ms. Sonia Chambers: Okay. I appreciate everybody’s attention and the--I would encourage anybody who wanted--who cited studies or whatever today to provide those to us with a written--with written comments, please, so that those can be included in an organized manner.
All right, thank you all very much.