House panel chairs ask accountability office to probe imaging self-referral

At the request of the American College of Radiology, House Energy and Commerce chair Rep. Henry Waxman (D-CA), Ways & Means Committee chair Rep. Sandy Levin (D-MI), and Ways & Means Subcommittee on Health chair Rep. Pete Stark (D-CA) have called on the General Accountability Office to perform a study regarding the effects of physician self-referral of advanced medical imaging and radiation therapy treatments on Medicare spending.

Previous GAO reports, as well as peer-reviewed studies published in the Journal of the American Medical Association and elsewhere, have shown that when physicians refer patients to imaging facilities in which they have a financial interest, a process known as self-referral, utilization is significantly increased. Private insurance studies indicate that as much as half of self-referred imaging is unnecessary. The National Council on Radiation Protection and Measurement has cited self-referral as a primary, preventable driver of a sixfold increase to Americans’ radiation exposure from scans since 1980.

The March 2009 Medicare Payment Advisory Commission report to Congress (page 99, lower left) states that overall Medicare imaging utilization growth for 2006–2008 was 2% or less nationally, at or below the growth rate of other major physician services. However, the number of self-referred MRI and CT scans in the Medicare system, as well as Medicare spending on self-referred MRI and CT, grew at nearly double the rate of those performed by other providers.

Overall, appropriate use of imaging and radiation therapy treatments can be addressed by wider adoption of ACR Appropriateness Criteria, which help physicians prescribe the most appropriate imaging exam or radiation therapy procedure for a given clinical condition, and computerized physician ordering systems based on these criteria. In addition, accreditation of imaging facilities, to be mandated for nonhospital providers under Medicare, effective Jan. 1, 2012, should be expanded to radiation therapy facilities and include all providers (including hospitals). This can provide a baseline quality of care, cut down on radiation dose received from duplicative scans (as well as the cost of duplicative scans), decrease likelihood of adverse events occurring, and help to ensure that patients receive the appropriate dose per scan or treatment.

However, government regulation needs to address financially driven self-referral, which may not be rectified by quality measures. Congress and the regulatory agencies must do so by measures other than across-the-board reimbursement cuts, which only encourage more self-referral and restrict patient access to quality care by driving those who do not self-refer out of practice or forcing them to limit the number of Medicare patients they accept.

MRI, CT, PET, and radiation therapy procedures are not ancillary services. The Centers for Medicare and Medicaid Services should remove them from the “in-office ancillary exception” to federal law, which allows providers to directly profit financially from referring patients to scanners or radiation therapy equipment which they own.

CMS should clamp down on leasing arrangements. Currently, nonradiologists can lease time in an imaging center and claim that the center is thus part of their practice. By doing this, they can refer patients to be scanned in that center during the time they have leased. This creates a direct financial incentive to do more imaging, which studies have shown significantly increases the number of scans performed.

Elected officials, government agency staff, and referring physicians need to support these steps to eliminate financially driven self-referral and make sure that every patient receives the right scan or treatment, at the right time, for the right indication.

Click here to read the Congressional letter to the GAO.