Physician self-referral
Encyclopedia
Physician self-referral is a term describing the practice of a physician
ordering tests on a patient and having them performed either by themselves or by a facility from which they receive a financial incentive
for the referral
.
There are many forms of self-referral. Examples are: having an EKG done in your internists office, having an x-ray done in your physicians office, suggesting a surgery that would be done by the physician suggesting it, or the ordering of imaging tests done at a facility owned or leased by the ordering physician.
It has been long recognized that the ability to self refer is an incentive to physicians to order more tests than they might otherwise. Laws designed to control this have been passed: Stark Law
I and II. However the exceptions designed to allow necessary testing in physicians offices have been exploited to largely nullify the intent of the law. In particular, the in-office exception, which allows testing on equipment in the physicians office, has resulted in many physicians purchasing high-tech and expensive equipment such as CT scanners, MR scanners, and Nuclear Scanners for their own offices. Such purchases were not foreseen at the time that the laws were written.
The incentive for this practice is in large part the result of rapidly declining reimbursements for what has been termed “cognitive” physician care, i.e. the time spent talking to a patient and determining what course of diagnostic testing or treatment is best for that patient. Many clinical physicians feel that in order to have a financially viable practice, it is necessary to have income streams derived from patient testing.
The impact has been greatest in the field of imaging or Radiology
. It is important to understand that the revenue derived from performing imaging exams comes from two sources: the facility fee and the professional fee. The facility fee is reimbursement for the use of the machine and all the associated technical costs. The professional fee is the amount paid for interpretation of the results by the Physician. Physician owners of the imaging machinery can derive profit from the venture by collecting both of these fees. The fees are paid by the patient, the patient's insurance company or the government.
For example, when a patient is seen at a hospital and receives a CT scan, a technical fee is paid to the hospital to cover the costs of the CT machine and running it. The professional fee is charged by the Physician Radiologist to interpret the exam and document the findings. This is the common ethical standard for the practice of imaging in medicine.
In the case of self referral, for example, you would be seen in a doctor's office and that doctor would recommend a study that is performed at the doctors office and possibly interpreted by the doctor who tells you the exam is necessary. This is usually the case for procedures such as Echocardiography and Nuclear Cardiac Imaging. Here, the physician or Cardiologist would collect the entire technical and professional fees for themselves. In other settings, such as orthopedic offices, it is common practice to bid out the important Radiologist's interpretation of the cases to lowest bidder and only pay them a portion of the professional fee for the interpretation, pocketing the difference.
. One vendor of medical imaging equipment has marketing information to physicians which states:
“Are you dissatisfied with declining reimbursement rates, escalating demands on your time and increased competition? You can counteract these prevailing trends by capturing new revenue opportunities through providing diagnostic imaging services, such as MRI and CT, in your own office. Instead of sending your patients—and revenue—to another provider, your patients will appreciate the convenience, while you increase your bottom line.”
There is a large volume research that indicates that this practice has a major effect on increasing medical costs in the US. In 2004, Levin estimated the cost of unnecessary self referred imaging to be conservatively, $16 billion per year. Reviews of the literature supporting this statement have been published in the Journal of the American College of Radiology.
However, many of the studies completed on imaging do not take into account that significant improvements in the technology have occurred, which is why the usage has increased over the last decade. Even with the increase in outpatient MRI, it still accounts for only about one half of one percent of all healthcare spending in the United States.
1) Radionuclide myocardial perfusion imaging (RMPI) is used to assess the effect of coronary artery disease on the heart. Among doctors who specialize in the field of radiology, the utilization rate for this exam increased by 2% over the period 1998-2002. Among cardiologists, the rate increased by 78%. The vast bulk of this large increase occurred in cardiologists' private offices' where they both recommend the exam and collect the fees to perform the exam, rather than in hospital settings where they do not benefit financially from ordering these tests.
2) A recent study by Gazelle, et al., found that a patient being cared for by a physician who self referred imaging studies was 1.196 to 3.228 times more likely to have an imaging study as compared to a patient being cared for by a physician who did not self refer.
3) Between 2000 and 2005, ownership or leasing of MRI scans by non-radiologists grew by 254%, compared with 83% among radiologists. By 2005 in the Medicare population, nonradiologist physicians performed more than 384,000 MRI examinations on units they owned or leased, and their share of the private-office MRI market had increased from 11% in 2000 to 20% in 2005.
For other examples, see
.
One of the current areas of change in medicine is in the location and interpretation provider of advanced medical imaging studies. (Advanced imaging studies include MRI, CT, Ultrasound PET and PET/CT) The trend for non radiology based physicians to evaluate their patients’ imaging studies began more than thirty years ago. For example, many years ago the majority of X-ray’s were interpreted by radiologists. Today it is very common of other physicians to read these studies. The same type of change is occurring today in the area of advanced imaging.
In the past, advanced medical imaging studies were provided in hospitals and privately owned imaging centers, and the studies with some notable exceptions were only evaluated by radiologists. As an example of an exception, beginning with the formation of the American Society of Neuroimaging in 1975, neurologists began to develop both research and clinical interests in the newest imaging techniques of the time to help evaluate their patients in non-invasive ways. This organization is still very active today in support of the training of its members to properly use advanced imaging techniques to evaluate their patients’ conditions. In general in addition to this early adapting neurology group, other specialties such as cardiologists, neurosurgeons, and orthopedic physicians became more interested in using advanced imaging techniques as they continued to be refined and developed over the last two decades.
This evolving change in the delivery of these services has resulted in the current debate between radiologists and other medical specialists over the control and use of advanced medical imaging.
The radiology side of the debate centers on redefining the term self-referral. Historically self-referral described the normal practice of a physician diagnosing a patient and then treating that individual if the required treatment was within the scope of practice for that doctor. For example if an orthopedist sees a patient and diagnosis a sprain or fracture they would most likely treat that condition. That is self-referral in its simplest form.
Unfortunately, several radiology authors have successfully used this term to describe the idea of self-referral for imaging services with the connotation that it is an undesirable and wasteful practice.
This is an unfortunate self-serving effort on their part. Self-referral for imaging services in and of itself is not improper if the following conditions are met: the physician who orders and provides the study is properly trained; the test being provided is appropriate to evaluate the patient’s symptoms and the need for the test meets generally accepted medical guidelines for the study provided.
The correct term for the practice of improperly using imaging services that concerns radiologists and all competent physicians is over-utilization. The practice of using imaging studies when they are not really needed is a cause for great concern that should be addressed. There are at least three sources of improper or over-utilization: 1) Physicians who order an imaging study that is an ordering mistake; 2) Radiologists who suggest additional imaging studies to confirm a diagnosis when the additional study is not actually needed to make the diagnosis; 3) clinical imagers who over-utilize.
However, this theory of potential over-utilization has not been tested in a systematic, organized fashion.
Cost-effectiveness. MRI is a very serious tool that has transformed medical practice, saved lives, and contributed to lowering costs by keeping patients out of hospitals and emergency rooms. All this costs less than one percent of total expenditure on health care. Far from representing a frivolous misuse of resources, we point out that Japan now has twice the number of MRI scanners per million citizens, and seven other countries, including Italy, have also overtaken the US. In Great Britain, a successful model for socialized medicine, Rothwell et al. have shown that acute assessments followed by immediate and appropriately triaged medical treatment in the outpatient setting for patients with transient ischemic attacks, which include imaging studies such as MRI and CT of the brain, reduces the risk of early recurrent stroke after TIA or minor stroke by 80% (ref 1). In just this one example, benefits accrue not just to the individual, but to society as a whole. For example, preventing up to 80% of recurrent strokes would have the potential to save the medical system of any large developed country tens of billions of dollars per year in hospital and long term treatment costs that would otherwise be associated with these preventable strokes. A single-specialty monopoly in the provision of imaging services would obviate such improvements in the delivery of health care and cause unneeded suffering. A substantial underestimation (ref 2) of the need for outpatient services as such as TIA clinics, including clinics with in-house imaging capabilities, may result in a crisis in the efficient, effective and safe delivery of health care as the population of many developed countries ages.
Quality. Modern MRI scans are very complex yet most are still read by general radiologists with no specialist training. A recent editorial in the Journal of the American College of Radiology (Scott Atlas MD,Neuroradiologist, Nov 2007) laments that “radiology is still practiced to a great extent at a general practitioner level. A substantial proportion of imaging studies are interpreted by individuals with only resident-level training. Does a general radiologist understand more about imaging the brain than a neurologist who sees these patients and their brain images all day long? The uncomfortable truth is income concerns are more important than patient care.” Independent organ-specific subspecialty societies have their own imaging certification and accreditation processes, including rigorous certification examinations, to ensure quality and patient safety. For example the United Council for Neurologic Subspecialties (ref 3) requires that all Neurologists seeking certification in Neuroimaging first study for and take a rigorous, validated, multiple choice examination with quantitative pass/fail criteria. In comparison, for a Radiologist to become certified as a Neuroradiologist subspecialist, a subjective oral examination process is utilized. General Radiologists may in fact professionally interpret brain scans with no such subspecialty certification required whatsoever, under the currently established system of healthcare provision in the United States.
In other words, the patient with a complex disease such as multiple sclerosis is cared for by a highly trained specialist in this area but his brain image may be read by someone with little training. The same is true in cardiology. That is why medical specialists like neurologists, cardiologists and orthopedists are reading their own scans and in many instances practicing a higher quality of care for their patients. This should not be decried, but rather welcomed as it is not a mere turf battle between medical specialties but a development of central importance to the future of Medicine.
AMA Position. On two different occasions the AMA House of Delegates has said that medical imaging should be performed by all Physicians who are trained and qualified and not by only one specialty group such as Radiology. A single specialty monopoly would lead to lowered quality in those health care segments dependent upon imaging, as well as higher costs. Some advocates of a single-specialty monopoly over the provision of imaging studies continue to employ false and misleading claims in discussions with Medicare advisory agencies and insurance companies regarding self referral. News articles and editorials presenting one-sided views and skewed data in support of a single-specialty monopoly over imaging technologies have also been employed (Levin, Me and My MRI, New York Times).
The absolute growth of expenditures for imaging in the United States, when expressed in dollar terms, is therefore for the most part due to radiology utilization patterns and not due to self-referral by clinicians such as cardiologists, neurologists and orthopaedic surgeons. The radiologist-led argument that the growth of imaging is due to abuse by other specialties is therefore statistically disingenuous. It exploits the fact that the natural growth rates of smaller niches in many ecosystems, economic and otherwise, are often higher than the growth rates of the largest niche player, then uses this to imply that the growth of the smaller niches is also very high in absolute terms, which is not necessarily true. To some policy makers, physicians and patients, this is viewed as an attempt by radiology as a special-interest group to divert regulatory attention away from its own extremely high share of healthcare dollar expenditures towards other, smaller imaging-based specialties in an effort to stave off Medicare reimbursement cuts for radiology services.
Medicare initiatives to achieve tighter quality control in the provision of medical services may also be rendered moot in the specific niche of radiologist-provided imaging studies, should anti-self-referral arguments hold sway. This would be due to the loss of quality reference points provided by other specialist-imagers, who, it might be argued, actually define the standard of care in the ordering, performance and interpretation of diagnostic imaging studies due to their direct involvement in patient outcomes.
Self-referral is also not something that radiologists themselves, the main proponents of the “self-referral” argument, are somehow immune to. In fact, a substantial percentage of imaging studies are self-referred by radiologists in the form of recommended repeat or follow up imaging studies to clarify findings on the initially ordered studies. The ordering clinician will usually order the recommended examination, and this is good care, however the recommendation for follow up studies has the potential for misuse in order to increase business for radiology practices. This form of self-referral, as practiced by radiologists, deserves greater scrutiny because, expressed as a total of all imaging expenditures in absolute dollar terms, it may represent literally billions of dollars in unnecessary yearly national health care expenditures and may in fact be a larger number than self-referral expenditures resulting from the performance of imaging studies by all other clinical specialties combined.
will be addressed when the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) study now under design at Centers for Medicare and Medicaid Services (CMS)is completed. This study will use point-of-order and point-of-service online approval systems together with medical society developed standards. A move towards a standards-driven imaging order system will help to eliminate overutilization, wherever it comes from.
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
ordering tests on a patient and having them performed either by themselves or by a facility from which they receive a financial incentive
Incentive
In economics and sociology, an incentive is any factor that enables or motivates a particular course of action, or counts as a reason for preferring one choice to the alternatives. It is an expectation that encourages people to behave in a certain way...
for the referral
Referral (medicine)
In medicine, referral is the transfer of care for a patient from one clinician to another.Tertiary care is usually done by referral from primary or secondary medical care personnel....
.
There are many forms of self-referral. Examples are: having an EKG done in your internists office, having an x-ray done in your physicians office, suggesting a surgery that would be done by the physician suggesting it, or the ordering of imaging tests done at a facility owned or leased by the ordering physician.
It has been long recognized that the ability to self refer is an incentive to physicians to order more tests than they might otherwise. Laws designed to control this have been passed: Stark Law
Stark Law
Stark law, actually three separate provisions, governs physician self-referral for Medicare and Medicaid patients. The law is named for United States Congressman Pete Stark, who sponsored the initial bill.- Physician self-referral :...
I and II. However the exceptions designed to allow necessary testing in physicians offices have been exploited to largely nullify the intent of the law. In particular, the in-office exception, which allows testing on equipment in the physicians office, has resulted in many physicians purchasing high-tech and expensive equipment such as CT scanners, MR scanners, and Nuclear Scanners for their own offices. Such purchases were not foreseen at the time that the laws were written.
The incentive for this practice is in large part the result of rapidly declining reimbursements for what has been termed “cognitive” physician care, i.e. the time spent talking to a patient and determining what course of diagnostic testing or treatment is best for that patient. Many clinical physicians feel that in order to have a financially viable practice, it is necessary to have income streams derived from patient testing.
The impact has been greatest in the field of imaging or Radiology
Radiology
Radiology is a medical specialty that employs the use of imaging to both diagnose and treat disease visualized within the human body. Radiologists use an array of imaging technologies to diagnose or treat diseases...
. It is important to understand that the revenue derived from performing imaging exams comes from two sources: the facility fee and the professional fee. The facility fee is reimbursement for the use of the machine and all the associated technical costs. The professional fee is the amount paid for interpretation of the results by the Physician. Physician owners of the imaging machinery can derive profit from the venture by collecting both of these fees. The fees are paid by the patient, the patient's insurance company or the government.
For example, when a patient is seen at a hospital and receives a CT scan, a technical fee is paid to the hospital to cover the costs of the CT machine and running it. The professional fee is charged by the Physician Radiologist to interpret the exam and document the findings. This is the common ethical standard for the practice of imaging in medicine.
In the case of self referral, for example, you would be seen in a doctor's office and that doctor would recommend a study that is performed at the doctors office and possibly interpreted by the doctor who tells you the exam is necessary. This is usually the case for procedures such as Echocardiography and Nuclear Cardiac Imaging. Here, the physician or Cardiologist would collect the entire technical and professional fees for themselves. In other settings, such as orthopedic offices, it is common practice to bid out the important Radiologist's interpretation of the cases to lowest bidder and only pay them a portion of the professional fee for the interpretation, pocketing the difference.
Risks of Self-Referral
The risk to the physician-owner of such a venture is minimal, since the physician-owner has it in his power to increase the volume of scans to any point necessary to insure profitability. This is recognized by the vendors of the machinery, who have moved aggressively to sell imaging machines to physicians who are not board certified or specialized in radiologyRadiology
Radiology is a medical specialty that employs the use of imaging to both diagnose and treat disease visualized within the human body. Radiologists use an array of imaging technologies to diagnose or treat diseases...
. One vendor of medical imaging equipment has marketing information to physicians which states:
“Are you dissatisfied with declining reimbursement rates, escalating demands on your time and increased competition? You can counteract these prevailing trends by capturing new revenue opportunities through providing diagnostic imaging services, such as MRI and CT, in your own office. Instead of sending your patients—and revenue—to another provider, your patients will appreciate the convenience, while you increase your bottom line.”
There is a large volume research that indicates that this practice has a major effect on increasing medical costs in the US. In 2004, Levin estimated the cost of unnecessary self referred imaging to be conservatively, $16 billion per year. Reviews of the literature supporting this statement have been published in the Journal of the American College of Radiology.
However, many of the studies completed on imaging do not take into account that significant improvements in the technology have occurred, which is why the usage has increased over the last decade. Even with the increase in outpatient MRI, it still accounts for only about one half of one percent of all healthcare spending in the United States.
Examples of Self-Referral
Examples of evidence that self referral increases utilization and costs:1) Radionuclide myocardial perfusion imaging (RMPI) is used to assess the effect of coronary artery disease on the heart. Among doctors who specialize in the field of radiology, the utilization rate for this exam increased by 2% over the period 1998-2002. Among cardiologists, the rate increased by 78%. The vast bulk of this large increase occurred in cardiologists' private offices' where they both recommend the exam and collect the fees to perform the exam, rather than in hospital settings where they do not benefit financially from ordering these tests.
2) A recent study by Gazelle, et al., found that a patient being cared for by a physician who self referred imaging studies was 1.196 to 3.228 times more likely to have an imaging study as compared to a patient being cared for by a physician who did not self refer.
3) Between 2000 and 2005, ownership or leasing of MRI scans by non-radiologists grew by 254%, compared with 83% among radiologists. By 2005 in the Medicare population, nonradiologist physicians performed more than 384,000 MRI examinations on units they owned or leased, and their share of the private-office MRI market had increased from 11% in 2000 to 20% in 2005.
For other examples, see
Defense of Self-Referral - A Radiologist's Perspective
Defense of the practice of self referral is often rationalized and cloaked in a single word, "convenience". The self-referring physician claims that they perform the examination in the office strictly for the convenience of the patient. This is the primary explanation for self referral. However, the convenience argument does not justify unnecessary exams, increasing medical costs to society, or the absence of peer-reviewed quality imaging performed for the sake of profit. Often, the patient cannot be seen by the physician on the same day the study is performed, negating the argument.Self-Referral: A Healthcare Advocate's Perspective
Health care systems are no static institutions, as evidenced by the fast development of the area of advanced medical imagingMedical imaging
Medical imaging is the technique and process used to create images of the human body for clinical purposes or medical science...
.
One of the current areas of change in medicine is in the location and interpretation provider of advanced medical imaging studies. (Advanced imaging studies include MRI, CT, Ultrasound PET and PET/CT) The trend for non radiology based physicians to evaluate their patients’ imaging studies began more than thirty years ago. For example, many years ago the majority of X-ray’s were interpreted by radiologists. Today it is very common of other physicians to read these studies. The same type of change is occurring today in the area of advanced imaging.
In the past, advanced medical imaging studies were provided in hospitals and privately owned imaging centers, and the studies with some notable exceptions were only evaluated by radiologists. As an example of an exception, beginning with the formation of the American Society of Neuroimaging in 1975, neurologists began to develop both research and clinical interests in the newest imaging techniques of the time to help evaluate their patients in non-invasive ways. This organization is still very active today in support of the training of its members to properly use advanced imaging techniques to evaluate their patients’ conditions. In general in addition to this early adapting neurology group, other specialties such as cardiologists, neurosurgeons, and orthopedic physicians became more interested in using advanced imaging techniques as they continued to be refined and developed over the last two decades.
This evolving change in the delivery of these services has resulted in the current debate between radiologists and other medical specialists over the control and use of advanced medical imaging.
The radiology side of the debate centers on redefining the term self-referral. Historically self-referral described the normal practice of a physician diagnosing a patient and then treating that individual if the required treatment was within the scope of practice for that doctor. For example if an orthopedist sees a patient and diagnosis a sprain or fracture they would most likely treat that condition. That is self-referral in its simplest form.
Unfortunately, several radiology authors have successfully used this term to describe the idea of self-referral for imaging services with the connotation that it is an undesirable and wasteful practice.
This is an unfortunate self-serving effort on their part. Self-referral for imaging services in and of itself is not improper if the following conditions are met: the physician who orders and provides the study is properly trained; the test being provided is appropriate to evaluate the patient’s symptoms and the need for the test meets generally accepted medical guidelines for the study provided.
The correct term for the practice of improperly using imaging services that concerns radiologists and all competent physicians is over-utilization. The practice of using imaging studies when they are not really needed is a cause for great concern that should be addressed. There are at least three sources of improper or over-utilization: 1) Physicians who order an imaging study that is an ordering mistake; 2) Radiologists who suggest additional imaging studies to confirm a diagnosis when the additional study is not actually needed to make the diagnosis; 3) clinical imagers who over-utilize.
Economic Incentives to Over-Utilize
When a radiologist owns equipment he or she has exactly the same pressures to use this equipment as private practice in-office imagers does. Both groups have facility rent, equipment lease payments, service contracts and employees to pay. The in-office clinical imager can certainly over utilize through self referral, while the radiologist can over utilize by suggesting that more testing is needed to be definitive in the diagnosis for the referring physician. The radiologist request for additional clarifying studies is a powerful tool. Ignoring the request becomes a medical liability issue if the request is genuine and the referring physician will not know that until the additional study is actually done.However, this theory of potential over-utilization has not been tested in a systematic, organized fashion.
Organ-Specific Subspecialists Who Perform Imaging Studies: Counterarguments to a Single-Specialty Monopoly on Imaging
Overview. Doctors referring patients to a facility in which they had invested has been the standard of care in the United States for over a century. Applied to blood tests, EKG’S, echocardiograms, cardiac stress tests, neuroimaging studies on patients with multiple sclerosis or transient ischemic attacks, gall-bladder surgeries, bariatric weight reduction surgeries, colonoscopies and immediate in-clinic imaging studies on patients with urinary tract obstruction, for example, that arrangement often ensures higher quality of service because the physician who interprets the tests knows the patient. This applies especially well to MRI, a tool that has transformed medical practice. Radiologists (who also invest in MRI facilities but don’t see patients to refer) use the myth of self-referral inflating healthcare costs to protect an average income far higher than that of other specialists who do see patients.Cost-effectiveness. MRI is a very serious tool that has transformed medical practice, saved lives, and contributed to lowering costs by keeping patients out of hospitals and emergency rooms. All this costs less than one percent of total expenditure on health care. Far from representing a frivolous misuse of resources, we point out that Japan now has twice the number of MRI scanners per million citizens, and seven other countries, including Italy, have also overtaken the US. In Great Britain, a successful model for socialized medicine, Rothwell et al. have shown that acute assessments followed by immediate and appropriately triaged medical treatment in the outpatient setting for patients with transient ischemic attacks, which include imaging studies such as MRI and CT of the brain, reduces the risk of early recurrent stroke after TIA or minor stroke by 80% (ref 1). In just this one example, benefits accrue not just to the individual, but to society as a whole. For example, preventing up to 80% of recurrent strokes would have the potential to save the medical system of any large developed country tens of billions of dollars per year in hospital and long term treatment costs that would otherwise be associated with these preventable strokes. A single-specialty monopoly in the provision of imaging services would obviate such improvements in the delivery of health care and cause unneeded suffering. A substantial underestimation (ref 2) of the need for outpatient services as such as TIA clinics, including clinics with in-house imaging capabilities, may result in a crisis in the efficient, effective and safe delivery of health care as the population of many developed countries ages.
Quality. Modern MRI scans are very complex yet most are still read by general radiologists with no specialist training. A recent editorial in the Journal of the American College of Radiology (Scott Atlas MD,Neuroradiologist, Nov 2007) laments that “radiology is still practiced to a great extent at a general practitioner level. A substantial proportion of imaging studies are interpreted by individuals with only resident-level training. Does a general radiologist understand more about imaging the brain than a neurologist who sees these patients and their brain images all day long? The uncomfortable truth is income concerns are more important than patient care.” Independent organ-specific subspecialty societies have their own imaging certification and accreditation processes, including rigorous certification examinations, to ensure quality and patient safety. For example the United Council for Neurologic Subspecialties (ref 3) requires that all Neurologists seeking certification in Neuroimaging first study for and take a rigorous, validated, multiple choice examination with quantitative pass/fail criteria. In comparison, for a Radiologist to become certified as a Neuroradiologist subspecialist, a subjective oral examination process is utilized. General Radiologists may in fact professionally interpret brain scans with no such subspecialty certification required whatsoever, under the currently established system of healthcare provision in the United States.
In other words, the patient with a complex disease such as multiple sclerosis is cared for by a highly trained specialist in this area but his brain image may be read by someone with little training. The same is true in cardiology. That is why medical specialists like neurologists, cardiologists and orthopedists are reading their own scans and in many instances practicing a higher quality of care for their patients. This should not be decried, but rather welcomed as it is not a mere turf battle between medical specialties but a development of central importance to the future of Medicine.
AMA Position. On two different occasions the AMA House of Delegates has said that medical imaging should be performed by all Physicians who are trained and qualified and not by only one specialty group such as Radiology. A single specialty monopoly would lead to lowered quality in those health care segments dependent upon imaging, as well as higher costs. Some advocates of a single-specialty monopoly over the provision of imaging studies continue to employ false and misleading claims in discussions with Medicare advisory agencies and insurance companies regarding self referral. News articles and editorials presenting one-sided views and skewed data in support of a single-specialty monopoly over imaging technologies have also been employed (Levin, Me and My MRI, New York Times).
Statistics and Imaging Utilization Trends: Magnitudes versus Percentages
While radiologists often speak passionately about self-referral as a phenomenon specific to non-radiologist physicians, the radiology profession as a whole provided 86% of the imaging services from 1999 to 2006 (the very rapid growth period for imaging). The percentage growth rate of imaging utilization by radiologists, when applied to the 86% total of all imaging studies and converted to a magnitude or a whole dollar amount, dwarfs by far the growth rate, in dollars, of self-referred studies performed by organ-specific clinician imagers. It is true that the percentage growth rates of imaging self-referred by some specialties are higher than percentage growth rates of radiology studies as a whole. It is hence the relative growth rates in imaging per specialty that some radiologists have used to make their case, rather than the fiscally relevant (and more honest) figures associated with growth rates per specialty in absolute dollar terms.The absolute growth of expenditures for imaging in the United States, when expressed in dollar terms, is therefore for the most part due to radiology utilization patterns and not due to self-referral by clinicians such as cardiologists, neurologists and orthopaedic surgeons. The radiologist-led argument that the growth of imaging is due to abuse by other specialties is therefore statistically disingenuous. It exploits the fact that the natural growth rates of smaller niches in many ecosystems, economic and otherwise, are often higher than the growth rates of the largest niche player, then uses this to imply that the growth of the smaller niches is also very high in absolute terms, which is not necessarily true. To some policy makers, physicians and patients, this is viewed as an attempt by radiology as a special-interest group to divert regulatory attention away from its own extremely high share of healthcare dollar expenditures towards other, smaller imaging-based specialties in an effort to stave off Medicare reimbursement cuts for radiology services.
Medicare initiatives to achieve tighter quality control in the provision of medical services may also be rendered moot in the specific niche of radiologist-provided imaging studies, should anti-self-referral arguments hold sway. This would be due to the loss of quality reference points provided by other specialist-imagers, who, it might be argued, actually define the standard of care in the ordering, performance and interpretation of diagnostic imaging studies due to their direct involvement in patient outcomes.
Self-referral is also not something that radiologists themselves, the main proponents of the “self-referral” argument, are somehow immune to. In fact, a substantial percentage of imaging studies are self-referred by radiologists in the form of recommended repeat or follow up imaging studies to clarify findings on the initially ordered studies. The ordering clinician will usually order the recommended examination, and this is good care, however the recommendation for follow up studies has the potential for misuse in order to increase business for radiology practices. This form of self-referral, as practiced by radiologists, deserves greater scrutiny because, expressed as a total of all imaging expenditures in absolute dollar terms, it may represent literally billions of dollars in unnecessary yearly national health care expenditures and may in fact be a larger number than self-referral expenditures resulting from the performance of imaging studies by all other clinical specialties combined.
Solutions to Overutilization
OverutilizationOverutilization
Overutilization refers to medical services that are provided with a higher volume or cost than is appropriate. In the United States, where health care costs are the highest as a percentage of GDP, overutilization is the predominant factor in its expense...
will be addressed when the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) study now under design at Centers for Medicare and Medicaid Services (CMS)is completed. This study will use point-of-order and point-of-service online approval systems together with medical society developed standards. A move towards a standards-driven imaging order system will help to eliminate overutilization, wherever it comes from.
External links
- Diagnostic Imaging Online
- Self referral Reform
- American College of Cardiology
- American Society of Nuclear Cardiology
- American Heart Association
- The American Academy of Neurology
- United Council for Neurologic Subspecialties
- American College of Radiology
- American Academy of Orthopaedic Surgeons
- American Medical Association
- RADPAC