X-Ray Vision

January 5, 2005

Specialists' referral of imaging patients to scanners the specialists own has been the subject of complaints among radiologists for years. A loophole in the federal ban on self-referrals, the "in office ancillary service exemption," permitted this practice. Whenever times got tight, the volume of complaints would increase, but little seemed to get done about it.

Specialists' referral of imaging patients to scanners the specialists own has been the subject of complaints among radiologists for years. A loophole in the federal ban on self-referrals, the "in office ancillary service exemption," permitted this practice. Whenever times got tight, the volume of complaints would increase, but little seemed to get done about it.

Now that's changing. The growth in imaging studies-by some estimates, they are increasing at three times the rate of growth for other healthcare expenditures-has gained everyone's attention. This, combined with a careful look at where that growth has occurred, has placed self-referral at center stage. Some restrictions on self-referral, for now at least, seem to be on the way.

Consider some of the recent developments.

At the 2004 RSNA meeting, the impact of self-referral dominated many scientific and plenary sessions. Dr. David Levin, the former Thomas Jefferson University radiology chair who has spent the better part of the last decade examining the growth of imaging studies performed by nonradiologists, was the lead author on 10 studies of the subject.

Just as Levin was present at the meeting, so was the American College of Cardiology, which, in a surprising move, distributed a position paper describing efforts by Levin and other radiologists to control access to imaging as an attack on the quality of patient care. The paper was endorsed by 17 other medical specialty organizations. (See article in the In Review supplement to this issue, page 5, and a commentary by columnist Brad Tipler at our RSNA meeting Webcast, http://www.dimag.com/webcast04/. The position paper is available at http://www.acc.org/advocacy/advoc_issues/imaging_113004.pdf.) According to Levin's research, cardiology has been a principal driver behind the surge in imaging studies.

In Pennsylvania, Highmark Blue Cross Blue Shield, the state's largest health insurer, has announced plans to toughen controls on who can collect payments for scans. Under one provision, anyone who bills for CT and MR scans must also offer four other imaging modalities. Some radiologists believe the restrictions could become a model for the rest of the nation (see article, page 9).

At the same time, the general news media have joined the medical media in examining the problem. Articles in The New York Times (including a commentary by Levin on July 6), The Boston Globe, and others have noted the impact that self-referral is having on soaring medical costs.

None of this activity, however, means that we can anticipate an overhaul of the law on self-referrals. That the ACC was able to persuade 17 other medical specialties to join a coalition suporting nonradiology ownership of imaging equipment shows just how strong the opposition to such a change. Similarly, a conservative business-oriented Congress is unlikely to embark on a course of action that would result in tighter regulation of medical practices.

Instead, radiologists will have to look for other ways to control self-referral. The Pennsylvania example above offers one approach. The state of Maryland has adopted legislation that includes an in-office ancillary services exemption, but it does not include MR, CT, and radiation oncology equipment. Private insurers and state and federal regulators may also consider privileging programs that set qualifications for those who operate imaging equipment and interpret images.

While the effect of programs like this is to protect radiology turf, they approach the question from a moral high ground: protecting the quality of patient care while also controlling the cost of providing it. Both are worthy goals, and both are areas in which radiology, with its extensive expertise in medical imaging, can lead the way.

What are your thoughts on this topic? Please e-mail me at jhayes@cmp.com