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Imaging Self-Referrals Don't Reduce Sick Days, Costs

Cheryl Clark, for HealthLeaders Media, December 7, 2010

The authors looked at 733,459 episodes of care involving 470,530 unique patients age 65 or older.  Federal rules prohibit physicians from referring patients to a facility in which the doctor has a financial interest, but those rules exempt some ancillary services, including imaging, if they are delivered in a physician's office. Conditions evaluated ranged from back pain, headache, digestive neoplasms, heart disease, extremity fractures, dislocations, and respiratory disease.

With some exceptions when the test ordered was an X-ray, Hughes wrote, "Physician self-referral for imaging is not associated with significant benefits for patients in either illness duration or healthcare costs," they concluded.

For example, when physicians self-referred patients with sinusitus for X-rays in their offices, there was a 7.8% shorter duration of episode and 3.6% higher cost.  "This amounts to 1.3 illness-free days gained at a cost of $3.92."

"Medicare's current exemption for self-referred imaging should be narrowed so that it includes only X-rays, not other forms of imaging," the authors conclude.  "To the extent that state laws or private payers permit self-referral for imaging, they would also do well to follow this policy."

Hughes' finding is consistent with a 2005 report by the Medicare Payment Advisory Commission, which looked at 22 medical condition—imaging combinations for Medicare beneficiaries in six major U.S. markets.  "Med-PAC found that self-referring physicians had higher ratios of observed-to-expected spending on imaging than doctors who did not self-refer."

In a second article, Sunshine and Bhargavan went further. They said that despite physician contentions that self-referral imaging provides same day-service, and thus convenience for patients, in fact that is only true for 74% of x-rays.  When ordering self-referral for more advanced procedures such as computed tomography and magnetic resonance imaging, only 15% of those tests are offered on the same day.

"Policymakers attempting to make the use of imaging more responsible should consider narrowing Medicare's special provision allowing referrals to a physician's own practice so that the provision covers x-rays only," they wrote.

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