How ‘In-House’ Imaging is Affecting My Radiology Practice

As a young attending radiologist, I have daily ups and downs. The ups include making interesting diagnoses or telling my breast imaging patients that they do not have cancer. The downs include being told by referring physicians to only perform the diagnostic mammogram and not the breast ultrasound - even though I think it is necessary - or being constrained by insurance companies on what test I can perform on a patient - even when I know the wrong test was ordered by the referring physician.

I feel the squeeze from both sides: the referring doctors and the insurance companies.

Since completing my fellowship just over a year ago, I have been working for a small private practice group in New Jersey. While practicing, I have seen things that I never saw in my training, including "in-house" imaging performed in referring physician offices.

Drs. David Levin and. Vijay Rao from the Department of Radiology at Thomas Jefferson University have written many articles about self-referral. The most recent discusses how CMS should close the loop hole on in-office ancillary services exception to the Stark Law. The article demonstrates the effects of in-house imaging towards the increase in health care costs.

Being on the front line in an outpatient setting, our business has been greatly affected by the in-house imaging since many of the primary care physicians have ultrasound technologists come to their office to perform screening carotid ultrasounds, abdominal ultrasounds, and pelvic ultrasounds. Many of them have also purchased their own bone density machines.

The most startling example of this is when the large OB/GYN group in my area started performing their own screening mammography. The OB/GYN group uses film screen mammography which is lower quality imaging when compared to digital mammography. However, the patients feel they are getting better care mostly because of the convenience. Just around when I started working at the group, we saw a large drop in ultrasound and mammogram referrals due to the increase in in-house imaging.

These issues come down to the fact that we have little say in the administration of health care. Radiologists have immense knowledge in medicine, including knowing the proper tests to order as well as making diagnoses that are difficult clinically but we are limited by the bureaucracy of health care. Patients have little knowledge of what role the radiologists play in health care delivery.

Over the past year, we have increased our direct-to-patient advertising to demonstrate the advantages of digital mammography which helped increase our mammograms. On the other hand, the ultrasounds and bone density studies have still not increased.

The problem is that we can't obtain our own patients and we are heavily dependent on referring doctors to send us patients. When the referring physicians feel they can do the imaging in their office, we have little power to change it. I continue to try and create and foster relationships with referring doctors but what I am more focused on is to create the relationship with the patients so they can understand our role in maintaining their health.

I have created patient-centered brochures discussing various health topics including joint pain, breast abnormalities, and the importance of preventative screening. I have also made myself available for patients in person or on the phone to discuss their findings. Being available for patients makes me feel more involved in their care and also helps them understand my role in their health care.

Vikash Panghaal, MD, MBA is a private practice radiologist with fellowship training in musculoskeletal radiology. He has additional training in business administration with a MBA in Health Care Management.