Self-referral for Imaging Leads to Overuse, Higher Costs, Studies Show

Self-referral of imaging services by non-radiologists doesn’t necessarily benefit patients, and can lead to overuse and increased spending. Those are the conclusions of a series of studies published this week in the December issue of Health Affairs.

The findings bolster the arguments against other specialists purchasing and using imaging equipment. Proponents say self-referral provides convenience for patients and often improved quality of care.

Not so, researchers found.

"The publication of these articles in a concentrated fashion by the country’s most prestigious health policy journal should put an end to any doubt on the part of patients and payers and fair-minded physicians that the in-office ancillary service exception needs to be eliminated," said Alan Kaye, MD, chair of the radiology department at Bridgeport Hospital, Yale New Haven Health System, in Bridgeport, Conn. "I really do think this is the tipping point."

The self referral issue was also raised in an article this week in the Wall Street Journal, which examines urologists’ use of IMRT (intensity-modulated radiation therapy) for the treatment of prostate cancer. Use of the radiation therapy has spiked in recent years, and the newspaper’s analysis shows IMRT use (which brings in big money) is higher in states where most of the urology groups that own the equipment are located.

"It’s becoming pervasive," Kaye said of imaging self referral, adding that studies have shown "virtually all" diagnostic imaging growth has come from self-referred situations.

Here’s a quick look at a few of the Health Affairs articles:

• In one article, American College of Radiology senior researchers Jonathan Sunshine and Muthreyi Bhargavan tested the theory that self-referral leads to a shorter turnaround time for imaging services. In examining how often an office visit and imaging procedure take place on the same day, they found that only 15 percent of Medicare patients received same-day service for high-tech imaging, such as nuclear medicine, CT, and MRI.

• Another study by Laurence Baker, chief of health services research at Stanford University, found that when non-radiologists acquire MRI equipment, the overall spending and use rise. For example, the number of MRIs ordered by orthopedists rose 38 percent within 30 days of a first visit by a patient. “Attention should be paid to ensuring that advanced medical equipment acquired in physician practices is used appropriately,” Baker wrote.

• A third study found that imaging self-referral was frequently associated with higher costs and didn’t always translate into shorter illnesses. "Self-referral was associated with significantly and substantially higher episode costs for most of the combinations of medical conditions and imaging that we studied. There was no decrease in the length of illness, except when doctors self-referred patients to receive x-rays for a few common conditions. These findings indicate that except for x-rays, constraining the self-referral of imaging may be appropriate," authors Sunshine, Bhargavan, and Danny R Hughes wrote in the abstract.

"We need more and more articles like this to educate the people in Washington, the regulators and the policy makers, about what the real facts are," said Robert Pyatt, MD, a radiologist at Chambersburg Imaging Associates in Chambersburg, Penn. He added that as budgets become tighter and healthcare spending rises, "the country just can’t afford this."

Pyatt, who reviews CT scans for accreditations, said he’s seen more urology and cardiology groups seeking to have their scanners accredited. One problem with the practice of self referral is that the quality of the scans can suffer, he said. Kaye agreed, adding that the articles "did not discuss the underappreciated aspects of ways that quality suffers in self-referred situations. Hopefully we will have a chance to learn about these in future publications."