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Medical Imaging War Pits Doctor vs. Doctor

 |  By jcantlupe@healthleadersmedia.com  
   February 10, 2011

The fallout is just beginning in Maryland over the state’s highest court’s decision last month that upheld a state law prohibiting physicians from referring patients for MRI, CT and radiation therapy services to providers in their own group practice.                                                                              

Radiologists, who applauded the court’s decision, and orthopedists, who were on the losing end of the court’s determination, each say their arguments were made on behalf of patients. But the court battle also was about doctor vs. doctor, over money, with the backdrop of healthcare reform in the debate.

The radiologists say the case was one of selfish self-referral, pure and simple. “Studies have shown that there is very little, if any patient benefit to self-referral of advanced imaging and radiation therapy,” says John A. Patti, MD, chair of the American College of Radiology board of chancellors, quoted by John Commins in HealthLeaders Media. “Instead the practice often results in significant unnecessary utilization of imaging, unwarranted radiation exposure, lower quality of care and increased cost that is ultimately passed on to patients.”

Siding with the radiologists, Baltimore Sun columnist Jay Hancock also wrote recently that having the door open for such self-referrals is, “what’s choking American healthcare.” He added, “The system is becoming unaffordable because of many unneeded heart stents, lab tests, surgeries and MRI scans.”

Lost in all this, says the American Academy of Orthopaedic Surgeons, is that having the in-office referrals makes healthcare easier for patients. “Significant technological advances have been made in our field so that patients can receive timely and available screenings from the comfort of their doctor’s office,” says John J. Callaghan, MD, president of the academy.

“This ruling could have a dramatic effect on the treatment and quality of the care of Maryland patients,” Callaghan says. “In the interests of our patients, the academy will maintain our commitment to this issue.”

Self-referral has been a stormy issue nationally for years. In its recent decision, Maryland’s highest court affirmed a 2007 decision by a lower court prohibiting the self-referral of patients. The Maryland State Board of Physicians had not taken a position on the issue regarding MRI machines and other equipment until 2006.

The American Association of Orthopaedic Surgeons has been following the case closely as it unfolded over three years ago. In 2007, the American Association of Orthopaedic Surgeons filed an amicus brief in the case, along with the American Association of Neurological Surgeons, the Society of Cardiovascular Computed Tomography, the American Urological Association and the American College of Surgeons.

 “There is a very significant health care policy discussion to happen here, …it’s wrong,” says attorney Howard Rubin, who represented a dozen practioners, emergency medicine doctors, and urologists involved in the case, says of the Maryland high court’s decision. “It shuts down ability of a patient where to get their scans.” 

“The heart of our healthcare policy is moving toward integrated systems,” he adds, “as opposed to fragmented, created silos. It’s a question of trust.” But there are doctors who don’t trust the motives of other doctors. Laura I. Thevenot, CEO of the American Society for Radiation Oncology says that the ruling preserved strong patient protection against abusive physician self-referrals.

“Today’s ruling represents a victory for patients in Maryland,” she says. “We hope this decision will jump start congressional action to ensure that all Americans can make independent treatment decisions based on quality care, not perverse financial incentives.”

The federal Accountable Care Act requires self-referring physicians to disclose their financial interest to patients and tell them about other facilities near them. Last year, the American College of Radiology says it unsuccessfully led an effort to put language in the federal ACA that would eliminate the in-office ancillary services, exception for advanced imaging and radiation therapy.

An article in the January issue of HealthLeaders Media, explains that Medicare payments for non-invasive diagnostic imaging (NDI), including MRI and computed tomography (CT ) scans are now higher to non-radiologists than to radiologists, citing an article in the Journal of the American College of Radiology.

Self-referral among non-radiologist physicians is behind the change, says David Levin, MD, of the department of radiology at Thomas Jefferson University Hospital in Philadelphia. Non-radiologists have become increasingly aggressive in their performance and interpretation of imaging, according to Levin. If policymakers, healthcare executives and other leaders want to control the costs of imaging, they need to either bar self-referrals or significantly restrict them, he said.  “This is what is driving up costs.”

Levin acknowledges the issue of self-referrals is “a political hot potato.”

No kidding. In Maryland, the issue won’t stop with the state medical board, or the high court. There is now legislation being considered in Maryland’s General Assembly, where lawmakers will debate whether to implement the self-referral exemptions that the orthopedists want. And there will be more debate, too, doctor vs. doctor.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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