Time has come for action on in-office self-referral abuses

November 2, 2005

The link between inflated imaging utilization and self-referral is one of the great lessons of recent diagnostic imaging history. Dozens of studies since those by Jean Mitchell and Dr. Bruce Hillman in the late 1980s have confirmed the intrinsic problems of self-referred medical imaging: Physicians will refer patients to imaging equipment they own more often than physicians who do not share in the profits of those referrals. No evidence shows that these extra referrals save lives or lead to earlier recovery. One must conclude that a proportion of self-referred imaging is wasteful and unnecessary. It is an invitation to misuse the trust invested in physicians and their professional relationships with patients.

The link between inflated imaging utilization and self-referral is one of the great lessons of recent diagnostic imaging history. Dozens of studies since those by Jean Mitchell and Dr. Bruce Hillman in the late 1980s have confirmed the intrinsic problems of self-referred medical imaging: Physicians will refer patients to imaging equipment they own more often than physicians who do not share in the profits of those referrals. No evidence shows that these extra referrals save lives or lead to earlier recovery. One must conclude that a proportion of self-referred imaging is wasteful and unnecessary. It is an invitation to misuse the trust invested in physicians and their professional relationships with patients.

The evidence has been compelling enough for Congress and at least 24 states to pass laws restricting referring physician ownership of outpatient imaging centers. The practice of self-referral to imaging services performed within the confines of a physician's office was exempted. At that time, the decision was thought to have minor economic implications. Although diagnostic ultrasound was often performed in doctors' offices, it was considered a cost-effective alternative to expensive CT and MRI. Radiography was a common feature in group practices for evaluating sprains and fractures. Although its misuse exposes patients to unnecessary radiation, the financial costs were not worth the worry.

Our cover story ("Specialists garner a bigger share of medical imaging," page 68) shows that in-office self-referral has exploded for the high-cost modalities that were assumed to be beyond the reach of physicians in a position to abuse them. Our investigation found:

- Many group practices have grown large enough to afford MR, CT, and even PET/CT systems in some situations.

- The loss of regulatory restrictions-mainly state certificate-of-need laws-and private payer rate cuts have encouraged groups to look to high-tech imaging as a source of replacement income.

- Leasing practices, especially highly profitable "per-click" leasing deals, have further encouraged physicians to bring imaging into the fold.

- Overall, referring physicians are less well trained than radiologists to assure that imaging operations are properly managed and the images are accurately interpreted.

- Despite specialty society practice guidelines, utilization, measured as the number of examinations prescribed, varies widely.

The last two points are especially worrisome and illustrate a problem that goes beyond concerns over cost: the issues of patient care and quality. As the scattergrams on pages 79 and 81 reveal, utilization rates in self-referred settings are all over the map, a clear indication that imaging standards are not being applied. Compound this with the growing interest in CT and the relative unawareness among nonradiology specialists of radiation dose concerns, and you have a situation that could put patients at risk.

All these developments were unanticipated when Congress and state legislatures drafted their bans on self-referral. The situation now needs urgent attention. As much as we'd like to think that most physicians can overcome economic temptation and limit self-referral abuse, the record shows that they have not.

The approach advocated by the ACR, quality standards for imaging as suggested by MedPAC, does show promise. That strategy, which would have Medicare endorse appropriateness criteria, accreditation programs that enforce standards for equipment performance, and privileging criteria to define educational standards for imaging performance and interpretation, moves the debate away from turf and toward quality. It would permit nonradiologists to conduct imaging but would help assure training and competence and apply safeguards against abuse.

These steps may not solve all the turf problems created by in-office self-referral, but they are a step toward better quality of care in medical imaging. That is something radiologists, as the leaders in medical imaging, can stand behind.