Self-referral provision may sugarcoat bitter pills in House reform

Some have blamed in-office self-referral for imaging's fall from grace, alleging that overprescription of imaging exams for personal gain and the low-quality images that often result have tarnished the specialty's reputation. Now relief may come from an unlikely quarter: healthcare reform.

Tucked in among proposals for reimbursement cuts and sales taxes on medical equipment in the House of Representatives' Affordable Health Care for America Act is a "sunshine" provision that would require docs who bill Medicare for imaging exams done on their own patients to disclose any financial interest they have in conducting those exams. If the legislation goes through as currently written, beginning in March 2011, these physicians will have to report annually to Medicare on their ownership stake in imaging operations. The proposed legislation also calls for a study to evaluate the costs, extent of use, and impact on Medicare from such self-referrals. Of great interest to the imaging community, it specifically calls attention to providers of advanced diagnostic imaging and radiation oncology.

It's not blind luck that this provision was included in the House bill. The American College of Radiology has been fighting for legislation that would limit self-referrals for a long time. Successes in the late 1980s and early 1990s, commonly known as Stark I and II, named for Congressman Pete Stark (D-CA), directly attacked self-referral. Exceptions to these laws, however, have allowed the practice of self-referral to continue.

Until now, efforts to close loopholes in the Stark laws have fallen short. The college has had more success with state governments than on Capitol Hill, but even these successes have been hard fought and produced limited results. Often the best results have been achieved indirectly, through a (state) government-mandated quality assurance program applied to all imaging facilities, for example. Requirements for stringent record keeping on patient radiation exposure and use of metrics addressing image quality—such as contrast resolution, noise, and artifacts—have forced marginal imaging providers in New Jersey to get out of the business.

Private payers have also chimed in with restrictions that have shaken out underperforming self-referrers. Several Blues, for example, require of interpreters that they be accredited or have achieved a certain level of training, or can document their expertise.

The House bill on healthcare reform offers the best hope yet of reining in self-referral. The reach of healthcare reform would be national and uniform. And, as written by the House, it would target precisely the source of the imaging community's problems.

Given the less-than-positive aspects of the House healthcare reform legislation for radiology, its sunshine provision, at least, will provide a sugar coating for the bitter pill of reimbursement cuts and equipment taxes that will come with its passage.