Physician self-referral: Scourge or service?

By Kate Madden Yee, staff writer

November 3, 2009 -- With Congress bearing down in its efforts to craft and pass a comprehensive healthcare reform bill before the end of the year, medical imaging advocates have been lobbying for provisions that would curb physician self-referral, claiming that the practice has contributed to the fantastic spike in utilization of advanced imaging and, therefore, healthcare costs.

But other industry watchers say that the self-referral issue is more complex than that.

" 'Self-referral' is really the wrong term for what we're all trying to fix," said Edward Eichhorn, president of Medilink Consulting Group in Dumont, NJ, which provides healthcare management services for the radiology market. "It's really overutilization we're talking about. And a radiologist can overutilize like anyone else. The pressures in imaging are the same, no matter what kind of doctor is performing the exam."

Whether the term self-referral or overutilization is used, however, the problem of how to curb healthcare costs remains, according to attorney David Romano of Arent Fox in Washington, DC, in an editorial published this month in the Journal of the American College of Radiology (November 2009, Volume 6:11, pp. 773-779).

"Over the years, studies focusing specifically on self-referral have shown a tendency for increased utilization of services, including imaging services, when referring physicians have ownership interest in the services," he wrote. "Although there may be those who continue to challenge the notion that self-referral and increased utilization go hand in hand, the real question -- the dilemma, if you will -- is not whether it exists but what, if anything, to do about it, and how to go about doing something."

Bad readings, bad faith

Watching nonradiology specialists like orthopedic surgeons use imaging rubs radiologists the wrong way, and it's no wonder, with the amount of training that imaging specialists go through, according to Eichhorn.

"Radiologists have spent a long time developing their expertise," Eichhorn said. "They don't want their turf attacked by other specialties."

And besides the territory issue, radiologists see the fallout from bad readings performed by untrained personnel every day, according to a poster on AuntMinnie's Forums. Those bad readings directly contribute to the overuse of imaging that has become such a government target.

"Let's say I get a carotid MRA with a script saying, '80% to 99% Right Carotid Stenosis,' " one poster wrote. "The outside ultrasound was done at an internist's office on a bad scanner with a bad tech with an outside radiologist who doesn't care about the quality of the reads. We do an MR angiography study, and the carotids are normal. No harm done right? Maybe the patient worried a little but the internist is a few bucks richer and so is the radiologist, and in the end the right diagnosis was made. The problem is that if the test had been done right in the first place you wouldn't need to do the $500 MRA. I see this every single day."

The scenario isn't limited to ultrasound or MR, according to another poster.

"I see CTs and MRs ordered daily based on films taken and read at physician offices that are read just plain wrong," the poster wrote. "If we had done them, then the CT or MR wouldn't have been ordered. In some ways though, this is 'good' self-referral, because I get to make money from the error. But I would just as soon do right by the patient."

Slings and arrows

But radiologists aren't victims in the battle over imaging; they self-refer, too, said a Georgia-based cardiologist who requested anonymity.

"Radiologists self-refer all the time," the cardiologist told "When they suggest another imaging study, it gets into their report and becomes a necessity for the referring physician. It would be of interest to take that out of reports and communicate that information with a phone call instead, discussing the relative merits of one versus another approach to the diagnosis for the patient. That would reduce radiology self-referrals a lot."

If a nonradiologist is playing by the rules -- that is, getting and using training for imaging -- they should be able to use that training, Eichhorn said (although he emphasized that he has not worked with orthopods in his practice and is not familiar with self-referring orthopedists). Take neurologists, for example: The United Council for Neurologic Subspecialties has created fellowship programs where physicians can be trained in neuroimaging modalities such as MR, CT, and ultrasound.

"If there's a standard and the doctor meets the standard, he ought to be able to do what he's been trained to do," he said. "I can understand why that scares radiologists. But things change. And it's not fair to group all neurologists and cardiologists with physicians who overutilize just because they self-refer.”

So-called self-referral is part of medicine, according to Dr. Mircea Morariu, a neurologist in Delray Beach, FL. Morariu gives courses on reading MR exams at the American Academy of Neurology and the American Society of Neuroimaging; he did a neuroimaging fellowship in reading MR and CT at the Dent Neuroimaging Center in Buffalo, NY. He also reads neuroimaging exams as an independent contractor for imaging companies in his area.

"What's troubling is the 'us versus them' mentality," he said. "Radiologists have come to feel that more and more specialists are encroaching on their turf. But self-referral is inherent in the practice of medicine: If a patient comes to see me after having had a seizure, and I want them to have an EEG, am I supposed to refer them to another neurologist so as not to self-refer? Labeling self-referral as unethical only as it applies to imaging services is a self serving financial argument. If this was really a moral argument, we'd have heard complaints years ago."

The Georgia cardiologist echoed Eichhorn's and Morariu's perspectives.

"Cardiologists have invested a huge amount of money in training, good training, for CT and MRI interpretation skills," he said. "Like it or not, healthcare is a free market, and referring physicians can choose their readers based on experience and clinical knowledge."

And if imaging interpretation is part of a free healthcare market economy, then painting an accurate picture of what services radiology offers is key, one Forum poster wrote. Radiologists need to boost governmental and referring physician awareness, or self-referral by nonradiology physicians will only increase.

"No one knows what [radiologists] do, why we're important, and that there are differences in scanner quality," the poster wrote. "It's our own fault for not getting the word out."

CMS ... to the rescue?

Last year, the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 was passed by Congress and became law; it goes into effect in January 2010. One of its components is the Medicare Imaging Demonstration, which is a two-year project the Centers for Medicare and Medicaid Services (CMS) is conducting that will collect data regarding physician use of advanced diagnostic imaging services such as MRI, CT, and nuclear medicine. X-ray, ultrasound, and fluoroscopy are not included in the demonstration.

The project will develop imaging appropriateness criteria, and physician practices will be assessed accordingly. Physicians will apply and report the criteria at either point of care or point of ordering: Under the point-of-care model, physicians must confirm with the beneficiary that the imaging service was provided, document the appropriateness of the service using the criteria, and submit the information electronically.

Under the point-of-order model, a computerized order entry system with decision support will automate the process. There will be no prior authorization of services allowed in the demonstration, according to CMS.

If the project proves effective, Medicare may adopt a Web-based approval system for imaging rather than relying on radiology benefits management (RBM) companies and a preauthorization model, which many criticize as being too blunt an instrument for managing imaging costs, Eichhorn said.

"In the end, there are bright people on both sides of the issue," he said. "If this demonstration works, it could help refine how imaging decisions are made and finally address the self-referral issue in a more sophisticated way."

By Kate Madden Yee staff writer
November 3, 2009

Self-referral foes fail to add amendment to healthcare reform bill, September 24, 2009

Self-referral amendment doesn't make the cut in House reform bill, August 3, 2009

Hopes dim for House anti-self-referral amendment, July 24, 2009

Self-referral bill may be folded into health reform, July 21, 2009

House bill would close Stark in-office loophole, July 2, 2009

Copyright © 2009


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