A controversial practice in which physicians self-refer patients for imaging tests with the doctors' own equipment does not result in shorter length of illness. And rather than reducing costs, the cost per episode of care generally averages 4% to 10% higher when the physician self-refers a patient.
Those are findings from one of five reports on self-referral imaging published in the December issue of Health Affairs. The articles question current policy and practice that allow physicians to refer their patients for testing with imaging devices they themselves own.
The first report isby Danny Hughes, assistant director for research at the American College of Radiology, with ACR researchers Jonathan Sunshine and Myrthreyi Bhargavan.
The authors say their results strenuously refute claims by some physician groups that self-referral, which can allow same-day service as the visit with the physician, results in a quicker diagnosis, and thus keeps cost of care lower and speeds patient recovery. In fact, the authors suggest, the practice leads to more testing, and radiation exposure, which carries its own set of hazards.
"In our 20 analyses, 13 showed significantly higher costs with self-referral, and only one showed a significantly lower cost," the authors said.
Additionally, the authors found that the cost of the imaging procedure itself were on average 27% to 40% higher when the test was self-referred, and non-imaging costs were not lower.
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.
A third paper, by Laurence Baker, chief of health services research at Stanford University, specifically examines increased billing for MRI scans by orthopedists and neurologists, who purchased or contracted for use of the machines and started billing for these tests between 1999 and 2005.
Once they started billing for the MRI tests, "the number of MRI procedures used within 30 days of a first visit increased by about 38%," he wrote. Also, spending for other aspects of care rose as well.
These specialists "changed their practice patterns, increasing the use of MRI for their patients" in what Baker called "a distinct and easily observable jump." Even more interesting, he wrote, "the change appears primarily to reflect doctors' recommending MRI for patients for whom they would not have recommended the service before they acquired the ability to bill."
Much of the observed increase, he continued, did not take place on the same day of the initial visit, in effect diminishing "the argument that convenience was the central driver."
He suggested that such practices run the risk of increasing inefficiencies by promoting the overuse of new services.
A fourth paper, the second by Baker, looked at use of a newer technology, CT angiography, which is safer and more cost-effective than traditional catheter angiogram of the carotid arteries, the leading cause of stroke.
Although growth in the use of this test expanded the number of patients getting tested, a Health Affairsstatement saysthe authors found no evidence that it also increased the use of treatments for carotid artery disease. The authors note that the use of new technologies often spreads beyond situations in which value is clear.
The fifth paper, by Bruce Hillman, a professor of radiology at the University of Virginia in Charlottesville, called the practice of self-referral "a conflict of interest" from which physicians who are not radiologists benefit financially.
Even though the 2005 Deficit Reduction Act called for Medicare to place limits on imaging self-referral payments, and the March health reform law mandates physicians to disclose their ownership interests, "the rewards for imaging self-referral remain strong" and may result in a lot of unnecessary testing and exposure to risks such as dangerous levels of radiation and reactions to contrast dyes, Hillman wrote, with co-author Jeff Goldsmith, president of Health Futures Inc., a healthcare consulting firm in Charlottsville.
"Restricting self-referral is not merely an economic issue for Medicare," they wrote. " Physicians' conflicts of interest strike at the heart of the integrity of the physician-patient relationship." They urged Congress to ensure that Medicare beneficiaries, "to the maximum extent possible, receive only medically necessary imaging studies, regardless of who owns or operates the equipment."
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