Self-referral a significant factor in imaging growth, study finds

A study recently published in the Journal of the American College of Radiology has suggested that self-referral in medical imaging may be a significant contributing factor in diagnostic imaging growth.

“This meta-analysis of the available medical literature estimates that non-radiologist self-referrers of medical imaging are approximately 2.48 times more likely to order imaging than clinicians with no financial interest in imaging, which translates to an increased imaging utilization rate of 59.7%,” study author Ramsey K. Kilani, MD, stated in an American College of Radiology press release.

Self-referred imaging is identified as physicians or non-physicians who are not radiologists directing their patients to their own onsite imaging services — or the referral of patients to outside facilities in which the referring physicians have financial interest. In the current political and economic environment, the release noted, diagnostic imaging expenditure is one area of interest in the push to reduce health care costs.

Kilani and his team searched the MEDLINE database, finding 5 studies with 76,905,162 total episodes of care that met exclusion criteria. Using a relative frequency calculated through a numerator of patients imaged and a denominator of total patients seen, the group found that the self-referral setting housed an individual relative frequency of imaging that ranged from 1.6 to 4.5, with a combined relative frequency of 2.16 using a fixed-effects model and 2.48 using a random-effects model.

Government Accountability Office (GAO) data from 2006 has estimated the cost of increased imaging in the self-referral setting to be $3.6 billion, the study authors noted.

“According to the 2008 GAO report, $14.1 billion was spent on diagnostic imaging in 2006; of this amount, 64% ($9 billion) was to physician offices,” Kilani stated in the release. “Of that $9.0 billion, 68% went to non-radiologists. Using the 59.7% utilization fraction attributable to self-referral, a theoretical associated cost was calculated at $3.6 billion. The cost of this excess imaging to Medicare Part B is likely to be in the billions of dollars annually, on the basis of the best available data. This level of spending on potentially unnecessary medical imaging is concerning in light of the growing emphasis on reducing health care expenditures.”

Reference:

Kilani RK, Paxton BE, Stinnett SS, et al. Self-referral in medical imaging: A meta-analysis of the literature. J Am Coll Radiol. 2011. doi:10.1016/j.jacr.2011.01.016

I agree with the findings of Dr. Kilani’s article. I don’t understand why so many orthopedic surgeons are opposed to doing away with the in-office ancillary services exception (IOASE) to the Stark Laws. Most orthopedic surgeons do not own MRI units. Those who do own them are probably overusing them. When those few MRI owners drive up the costs of health care by overusing their scanners, the non-owning majority of orthopedic surgeons get hurt. That’s because physician reimbursement is a zero sum game. If imaging costs go up, there’s less money available to pay for things orthopedic surgeons do every day — like surgery and E&M. So if you are an orthopedic surgeon and don’t own an MRI machine, you should be just as opposed to the IOASE as I and other radiologists are.

— David C. Levin, MD
Professor and chairman emeritus
Department of Radiology
Jefferson Medical College
Thomas Jefferson University
Philadelphia, Pa

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