Imaging self-referral: An inside manifesto

By Dr. Bill W., contributing writer

March 19, 2009 -- Author's note: This is a composite view assembled from discussions with a number of radiologists who benefit from imaging self-referral.

My name is Bill W. Like the fellow in the AA meetings. I'm a radiologist, and I'm addicted to imaging self-referral.

Maybe you know something about this, maybe you participate too, and maybe you don't care. But you should. For your wake-up call, I think it's time to share an inside view of a very ugly issue.

“This is an immoral, unethical situation. Patient trust is being perverted to allow the unscrupulous to indulge their greed and entitlement.”

Maybe you know me, maybe you don't. I could be your partner, I live in your city or state. My location and all that don't matter, but my story does. Maybe you will be able to resist the poison that drew me in.

I didn't have much of an opinion about self-referral early on. It didn't matter to me who owned the scanner. If we, the radiologists, couldn't or didn't, what difference did it make if it belonged to the hospital or to some internists across the road?

In fact, my politically minded partner (doesn't every group have one?) rallied us all around the idea of urging the clinical docs to buy their own equipment. After all, if they received income from ordering a scan, business would boom, and we would benefit by reading the images. How right he was.

Doc Politic was so enthralled with his idea that he went all around town convincing as many clinicians as possible to jump on the bandwagon. "Buy yourselves a scanner!" he crowed. "You scan 'em, we'll read 'em."

And so it was. The first operation purchased an old, used scanner, and proceeded to attempt high-level vascular imaging studies while the shiny new multidetector-row CT scanner in the hospital sat idle. But that wasn't enough for us. If we even heard so much as a rumor about an internist or orthopod installing an MRI or a CT system (or even a digital x-ray machine!), we were on the phone offering our services. After all, we reasoned, someone had to read the exams. The patient might as well get the benefit of our expertise, and we might as well make the money. Everyone wins.

Doctors can be a greedy lot, the understatement of the century. And they are not immune to feelings of entitlement: "I went to school for umpteen years and I deserve ..." Since their estimate of their value to society is undermined by cuts to their normal reimbursement -- payment for seeing patients -- they are on the prowl for the money they think should be theirs.

When you toss in a wet-behind-the-ears 25-year-old MBA-educated business manager, and a dose of my partner, Doc Politic, you get a group of physicians who are ready, willing, and anxious to get into the imaging business.

Of course, the equipment vendors are only too happy to oblige. For the right price, just about anyone can lease a shiny new multislice CT scanner, and be the best on the block. But since the patients don't know the difference anyway, why not just buy an old used clunker that just barely does the job? The radiologists will still read the pictures. My group, and many like ours, never met a scanner they wouldn't read from. There's an old saying in this business: "Never tell a doc his scanner sucks."

Today, we are the kings of outside reading in our region. We interpret hundreds and hundreds of exams every day from clinician-owned equipment. We even station three or four radiologists onsite at the largest clinics. Yes, we make a lot of money on all this, but maybe we make less than you would have guessed. All of Doc Politic's shenanigans have bought us a fraction of the take. We make thousands of dollars a day in this manner, while our colleagues make tens and hundreds of thousands. But it's all good, isn't it? Everybody wins.

Radiologists function at the pleasure of the clinicians. This is obvious. The internists and surgeons own the patients, a sentiment that becomes more sinister as we progress through this maze. With limited exceptions, we radiologists cannot control where a patient goes for an examination, nor can we even decide on our own what study to perform. That is in the hands of the patient's doc, and the patient trusts his doc quite literally with his life. That trust, that bond should be sacred. We all take the Hippocratic Oath, which reads, in part:

I will follow that method of treatment which according to my ability and judgment, I consider for the benefit of my patient and abstain from whatever is harmful or mischievous. ... Into whatever patient setting I enter, I will go for the benefit of the sick and will abstain from every voluntary act of mischief or corruption and further from the seduction of any patient.

Quite noble and humbling. I remember well speaking these words at my graduation. A Latin phrase completes the picture: Primum non nocere -- First, do no harm. Sadly, in the quest for remuneration, these sentiments are easily put aside or given no more than basic lip service. Our clinical docs led the way down this path, and I followed willingly.

The breach in trust lies in the ability of our friends to generate money by ordering a test that they don't actually perform. We don't look askance at the surgeon who recommends, then performs an operation. This is his skill, his area of expertise. We respect his judgment, even though he stands to profit from the operation he has suggested. It quickly becomes clear if he is performing too many procedures, too many unnecessary surgeries. This occurs quite rarely.

But when the internist orders a CT scan on the machine in his office, he profits instantly without any further effort on his own. He deludes himself, and his patient, about the motivation behind the scan and even the presence of the scanner in his office altogether. It's here for your convenience, he tells his grateful, trusting patient, and so it would seem.

In truth, the only real convenience is for our clinical brothers. They can get instant gratification of their desire for an answer, true, and they can placate patients who doesn't feel satisfied if they leave without a scan. Of course, generating a technical fee is quite convenient. I find it quite telling that the other modalities regularly utilized for the patient, such as nuclear medicine or even ultrasound, aren't provided in most offices, so the patient still has to make that inconvenient trip to the hospital. If the clinicians were so interested in patient convenience, they could offer lots of other things. How about extended office hours, valet parking, meals, or at least drinks and snacks? Nah. Convenience is a smokescreen, nothing more.

But, what's the problem? The docs own the patients, they make a profit, and we get our share. Everyone wins. But, remember Primum non nocere -- First, do no harm. We radiologists know that radiation, while not to be feared, is to be respected. It's like electricity: Used properly, it is our friend, but I would suggest that you avoid wetting your finger and placing it in the nearest socket. Radiation is not to be administered indiscriminately. It has the potential to do harm, and a scan using radiation, such as a CT scan, should not be ordered simply to generate income. But this is done dozens of times a day, every day. The ordering doc profits, and we profit.

Technology marches on, and newer scanners deliver lower and lower radiation doses. Perhaps this will no longer be germane to the discussion. But we still have the issue of morality. We know this practice is wrong, at least many of us realize it. We are all betraying the patient's trust. Remember, I will abstain from every voluntary act of mischief or corruption and further from the seduction of any patient. Isn't making a little extra money on some patients (mainly those with good insurance) a little corrupt? Are we not seducing the patient and trading on their naiveté? Ah, but every scan is justified isn't it? Perhaps, but then why are you ordering so many more now that you have your own machine?

There is some realization that we, the radiologists, have made this possible for them, even if we weren't the ones who actually placed the idea in their heads in the first place. But that doesn't go very far. There is certainly nothing resembling gratitude; rather we are viewed mostly as a commodity, more or less like a laboratory machine that spits out results when our button is pushed. There is incessant demand for instant results from the studies, no matter if we are reading something else on another patient. The chemistry computer can produce an answer instantly, so why can't you?

From our perch on the inside, we can see the entitlement, the arrogance this has prompted. These are OUR patients, and we deserve to profit from them. Of course, the constant refrain of "Order more scans!" from the youngster with the MBA wearing the Men's Wearhouse suit is generally audible in the background.

The entitlement mentality slaps us in the face in this venue. The absolute picture of arrogance can be seen in the smug and aloof manner in which the self-referring clinicians treat this situation. I've had many of them literally laugh in my face over this scam they are pulling. They know what they are doing, and they know I know, too. They don't care, because they are entitled to their ill-gotten gains, they deserve them, and no one will take it away from them.

If my friend the clinician's approach was truly benevolent, he would scan his patients at the same rate as his clinical brethren who don't have scanners. But this isn't the case. The literature shows, and my group has seen firsthand, that when technical income is generated by the stroke of a pen, two to eight times the number of scans are performed. Some place the cost at around $16 billion per year for this largess. Rather expensive for simple convenience.

And I'm bothered by something else. If the rate of scanning requested by those who profit thereof is normal, then those without scanners are underserving their patients. Since no one has come forth with the latter accusation, I have to think that the truth is rather the other way around -- that our friends and partners are overutilizing their equipment.

This situation will go on until something is done about it. The government will ultimately need to step in. Tremendous bellowing will be heard from the clinical world, and probably from radiology as well, since so much money is involved. Dozens of regulations, like the Stark laws, have been ultimately thwarted by the greedy. There has to be complete closure of loopholes for self-referral of advanced imaging, with severe penalties, like a fine amounting to 10 times the revenue generated thereof, AND I think there has to be jail time. This is a criminal practice, and it requires criminal punishment.

This is an immoral, unethical situation. Patient trust is being perverted to allow the unscrupulous to indulge their greed and entitlement. Radiologists who enable this, and I'm one of them, need to stop and look at what they are doing. This is dirty money we are generating, and we need to walk away. But I can't. The draw is too great. I wish I had realized what I was doing before I started down this path.

But believe me, I'm not the only animal in the trap. We aren't active participants, but we are enablers, or facilitators, or whatever you want to call it. The only real hope is for the government to shut down the self-referrers. And it will, in the process of ruining the rest of the U.S. healthcare system.

By Dr. Bill W. contributing writer
March 19, 2009

Study shows CT use has increased, diagnostic yield has not, March 3, 2009

CT utilization spikes among nonradiologists, December 17, 2008

Nuclear myocardial perfusion imaging: Vulnerable to self-referral? December 15, 2008

Health reform plan includes payment changes, November 13, 2008

CMS avoids tackling self-referral in MPFS and HOPPS rules, November 4, 2008

Copyright © 2009

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