Fran Lowry

December 02, 2011

December 2, 2011 (Chicago, Illinois) — Physicians who own their imaging equipment are more likely to refer their patients for unnecessary imaging exams, according to research presented here at the Radiological Society of North America 97th Scientific Assembly and Annual Meeting.

In a study that compared referral patterns for magnetic resonance imaging (MRI) in physician groups with and without a financial interest in the equipment, researchers found that 42% of all studies ordered by those with a financial interest were negative, compared with only 23% of the studies ordered by those with no financial interest.

"Self-referral, whereby a nonradiologist physician orders imaging exams and refers patients to imaging services that he or she owns or has a financial interest in, has been shown to be an important contributor to escalating medical costs," said coauthor Ben E. Paxton, MD, from Duke University Medical Center in Durham, North Carolina.

"We can't say for sure whether this is a conscious decision to self-refer. It's possible that people who are under the financial pressure of ownership make unconscious decisions or have a lower threshold for imaging their patients," added senior author Ramsey Kilani, MD, also from Duke University Medical Center.

Self-Referral on the Increase

The practice of self-referral is increasing, the Duke team reports.

From 2000 to 2005, ownership or leasing of MRI equipment by nonradiologists grew by 254%; by radiologists, it grew by just 83%. According to the US Government Accountability Office, the proportion of nonradiologists billing for in-office imaging more than doubled from 2000 to 2006. During that same time period, private office imaging rates by nonradiologists who control patient referral grew by 71%.

Dr. Kilani and colleagues performed a retrospective review of 500 consecutive diagnostic lumbar spine MRIs ordered by 2 orthopedic physician groups serving the same community. The first group had a financial interest in the MRI equipment used; the second had no financial interest in the equipment.

Of the 500 lumbar spine MRIs that were reviewed (250 in each group), 163 were negative (106 in the financial-interest group and 57 in the nonfinancial-interest group). The researchers found that there were 86% more negative scans in the financial-interest group than in the nonfinancial-interest group (P < .0001).

They also found that there was no difference in the average total number of positive lesions per scan in either group. For the financial-interest group, there were 3.93 positive lesions per scan; for the nonfinancial-interest group, there were 4.31 (P = .9783).

Increased Use Results From Ownership

Dr. Kilani said that this study does not reveal what the physicians who self-referred were actually thinking. He added: "I think the broader issue is the outcome, and the outcome of self-referral is increased utilization, regardless of whether the motivation is conscious or unconscious."

He said that, going forward, there should be transparent and comprehensive reporting requirements for the ownership of imaging equipment.

"One of the problems that we don't talk about in this paper, but we have in other papers, is that the ownership of imaging equipment is very opaque," Dr. Kilani said. "In many cases, Medicare and other private payers do not even know who they are paying, because there are very elaborate corporate structuring, leasing arrangements, and other things that have been done to create barriers to transparency with regard to equipment ownership."

There are laws against self-referral in some states — "some strong, some not so strong" — but many of these are circumvented, he said. "So that would be a good first step in resolving the situation. However, you cannot even analyze the magnitude of the problem accurately without knowing how widespread this is."

Self-Referral Called a Destructive Practice

"This is just another example of how destructive self-referral is in radiology," David Levin, MD, emeritus professor of radiology at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, told Medscape Medical News.

"There have been dozens of other studies of self-referral, and every single one of them — every single one — shows the same thing: self-referral invariably leads to higher utilization. The practice is unethical, because it creates a conflict of interest. Personally, I also think it's immoral," said Dr. Levin, who was not part of the study.

There are lots of things that could be done to stop this practice, Dr. Levin said, agreeing with the study authors.

"For example, the state of Maryland has an antiself-referral law that prohibits orthopedic surgeons from operating an MRI unit in their own offices. It's the only state in the country that has an antiself-referral law that really has teeth. So in Maryland, if you are not a radiologist, you cannot operate either a CT [computed tomography] or MRI scanner in your office."

Other states have taken similar steps based on administration, not legislative action, he said. "Certain state administrative bodies can prevent, through administrative rules, the installation of this kind of equipment in nonradiology offices. So the states can do something about it."

But, said Dr. Levin, the major impetus for such measures should come from commercial payers.

"They should just draw the line and refuse to pay for this. In Philadelphia, where I live, the major commercial payer is Independence Blue Cross. They established this policy a few years ago. They will not pay for outpatient CT or MRI unless you are a full service image provider and you provide all imaging services, including mammography.... The result is that there is not a single cardiology practice in the Philadelphia area that has its own CT scanner. The payers can put a stop to it," he explained.

Patients who realize that they are being referred for a scan using equipment that is owned by their physician might occasionally challenge whether they really need the exam, but these patients are the exception and not the rule, Dr. Levin said.

"Self-referring physicians rely on the fact that patients are not going to challenge them. I think it puts patients in a difficult spot because they don't like to challenge their doctors," he said.

Dr. Paxton and Dr. Levin have disclosed no relevant financial relationships. Dr. Kilani reports a financial relationship with FrontRad Technologies.

Radiological Society of North America (RSNA) 97th Scientific Assembly and Annual Meeting: Abstract SSK08-07. Presented November 30, 2011.

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