In Review - News from the 2004 Meeting of the RSNA

Radiologists prepare for attack on wasteful imaging

Medicare data reveal that self-referral has eroded radiology's control over medical imaging practices

By: James Brice

Radiologists are gathering ammunition to protect themselves and to guide policy-makers in efforts to reverse the rapidly rising cost of diagnostic imaging.

Talks about appropriate utilization and self-referral were as ubiquitous as Dr. David Levin at the RSNA meeting. The former chair of radiology at Thomas Jefferson University has become the profession's leading expert on utilization trends and self-referral. He has produced numerous studies since the late 1980s documenting the costs of self-referred medical imaging.

Levin's recent studies, based on tabulations drawn from Medicare Part B fee-for-service utilization databases, focus on the in-office exemption in federal self-referral law that otherwise forbids a physician from referring Medicare and Medicaid patients to services in which that physician has an ownership interest. The practice of referring patients for imaging with office-based equipment has fueled improper use of the technology, he said.

"Inappropriate utilization by nonradiologists is the most pressing policy issue confronting radiologists," Levin said during a plenary session.

Levin and his Thomas Jefferson University colleagues, including current radiology chair Dr. Vijay Rao, arrived in Chicago with research further documenting the relationship between self-referral and utilization growth. The findings, which build on Levin's previous work, suggest that the greatest opportunities to lower imaging costs and cut waste lie outside radiology.

The group found that nonradiologists were the main source for the 14.3% rise in Medicare outpatient imaging from 1999 to 2002. Among radiologists, imaging during the three-year period rose 12%, about half the growth rate of nonradiologists and four times slower than the growth in cardiologists' utilization.

Another study found that Medicare relative value unit rates per 1000 population for cardiovascular imaging performed by cardiologists jumped 110% between 1993 and 2002, more than twice as fast as the 50% increase among radiologists. According to Levin, radiology's participation in cardiovascular imaging will probably continue to erode unless radiologists actively pursue new cardiovascular CT, MR, and PET procedures.

Cardiology's grip on cardiovascular imaging was further documented in a study of nuclear myocardial perfusion imaging. Between 1998 and 2002, cardiologists recorded a 78% increase in the use of these frequently self-referred procedures, compared with 2% growth for procedures performed by radiologists and 42% growth for other physicians. The trend reflects a pattern that Levin identified in a 2002 report (Radiology 2002;222[1]:144-148). In that study, he uncovered a 36% increase in nuclear myocardial perfusion imaging between 1996 and 1998. The growth rate for radiologists was 4%.

From 1997 to 2002, diagnostic imaging shifted rapidly from inpatient to office and imaging centers, where radiologists have relatively less control, Rao said. The number of RVUs rose 29% during the five-year period. Hospital inpatient and outpatient imaging increased 7% and 13%, respectively.

A comparison of geographic differences in utilization rates from 1997 to 2002, presented by Thomas Jefferson University researcher Laurence Parker, Ph.D., revealed that cardiologists have higher growth rates for Medicare-reimbursed imaging than radiologists or any other physicians who perform medical imaging.

And cardiologists are gaining more influence in image-guided vascular applications outside the heart, according to another Thomas Jefferson University study. From 1997 to 2002, the number of noncardiac, peripheral angioplasty, and intravascular stent placements performed by cardiologists increased 181%, compared with 398% for vascular surgeons and 29% for radiologists. During that period, radiology's share of this business dropped 21 percentage points to 42%, said radiology fellow Dr. Jeffrey Gordon.

Such information has been crucial to educational efforts aimed at the Medicare Payment Advisory Commission (MedPAC), the Blue Cross Blue Shield Association, and other governmental and private groups that want to reduce the cost of imaging, said Cherrill Farnsworth, executive director of the National Coalition for Quality Diagnostic Imaging. A 2004 Blue Cross Blue Shield report on medical imaging predicted that diagnostic imaging in the U.S. will exceed $100 billion in 2005, Farnsworth said during a plenary session.

Private insurers have seen their diagnostic imaging costs rise at least 20% per year for each of the past four years, she said. A report filed with the commission in October 2004 by MedPAC senior analyst Ariel Winter noted that Medicare spent $6.5 billion on medical imaging in fiscal 2002. This constituted 14% of total spending for services provided through the Medicare fee schedule. CT, MR, and nuclear medicine utilization grew 15% per year from fiscal 1999 to 2002.

"Any cost that rises faster than an insurer's ability to raise premiums attracts high-level attention," Farnsworth said.

In the private sector, Highmark Blue Cross Blue Shield announced an imaging privileging program in August that may reduce in-office self-referral substantially, according to Levin. To be paid for MR, CT, or fluoroscopic services, providers must offer radiological services covering at least five imaging modalities. Among numerous requirements, a radiologist must also be onsite during all normal business hours.

"All of this gives me hope that this problem is going to be attacked vigorously," Levin said.

At the state level, attention has focused in the past year on Maryland, where Attorney General J. Joseph Curran Jr. ruled last January that state self-referral law prohibits an orthopedist group from referring patients for tests on MR or CT scanners owned by that practice.

At the federal level, MedPAC has proposed various solutions to Congress. They include preauthorization, coding edits to discourage redundant and repeat studies, physician profiling to identify frequent referrers, radiation management education, site inspections, privileging to limit reimbursement to qualified physicians, and differential payment based on the provider's ability to reach performance standards.

Some actions, such as coding edits that would lower reimbursement rates for repeat studies, will hurt radiologists as well as nonradiologists who perform medical imaging. But some sacrifice by radiologists is needed to turn the tide, Levin said.

"We cannot succeed in our fight against self-referral if we insist that the policy-makers only get the other guys," he said. "We have to accept some of the burden ourselves."