Self-referring physicians behind increase in diagnostic imaging

Physicians who refer patients to their own facilities or machines for scans account for much of the increase in diagnostic imaging ordered for privately insured patients said a Baylor College of Medicine expert in a commentary that appears in the current issue of the journal Medical Care.

Based on a study also appearing in the same issue, Dr. Vivian Ho, professor of medicine at BCM and associate professor of economics at Rice University, wrote: "Increases in utilization rates were substantially higher for scans performed by self-referring physicians than for images that originated from a referral to a radiologist or hospital."

The increase was seen mainly in those patients covered through private insurance that provided the physician with a fee for service reimbursement.

In the study upon which Ho was commenting, Dr. Jean M. Mitchell, professor of public policy at Georgetown University in Washington, D.C., reviewed data recorded between 2000 and 2004 from a large private insurer in California. This information was then compared to a report by the Medicare Payment Advisory Commission. Both reports showed an increased use of imaging tests for those with private insurance.

"Physicians seem to choose the self referral option, meaning they do the imaging in their own office, because they are reimbursed by private insurance companies," Ho said. "The other option would be to refer the patient to a radiologist or an outside diagnostic center."

Federal law does not allow reimbursements for many self-referral arrangements, unless the imaging is done in-office. This exception is allowed because physicians who perform the procedure in-office are providing a convenience to patients.

However, in most cases reviewed in the Mitchell study, the doctors did not have the imaging machinery in their offices. Physicians are able to skirt the restriction by leasing an imaging center's facilities and employees for a fixed period per week.

"This creates revenue for both parties involved," Ho said. "But it also raises a lot of questions such as would it have mattered if another test had been done, one that didn't receive a reimbursement?"

Ho said it is important to remember that imaging technology has advanced in the past years and now takes the place of much more invasive diagnostic measures such as surgery. However, she said, no one has studied whether one test would have had benefit over another during the course of a patient's illness.

Ho cites other studies of a trend toward manufacturing and marketing cheaper, lower quality imaging instruments. However, the level of reimbursement, regardless of the cost or quality of the equipment used, remains the same.

She writes, "The current reimbursement system lacks incentives to provide high quality imaging in a cost effective manner."

Finding an answer to this problem will take creativity.

"Doing away with the reimbursements will only penalize those physicians who are actually providing imaging in-office as a convenience to their patients," Ho said.

In her commentary she writes, "Unfortunately, the legal system, the method of reimbursing physicians, and our lack of tools to monitor appropriateness of testing have led to significant increases in diagnostic imaging, which likely provide little health benefit to patients."

The solution should involve policy makers, insurers, physicians and health service researchers.

"Only then can we insure that advanced imaging technologies yield a benefit, rather than become a burden to the health care system," said Ho.