Demand for Imaging Creating Ethical Dilemmas

David C. Levin, M.D., of Thomas Jefferson University, outlined some of the ways that federal and state governments, the legal and legislative systems and some payors are working to curtail the practice of self-referral among physicians utilizing medical imaging.

Huge growth and rapid developments in imaging are creating ethical questions regarding which physicians should be performing and interpreting imaging studies, as well as questions about appropriate billing and self-referral.

Three researchers from Thomas Jefferson University in Philadelphia outlined results from studies of imaging utilization during an RSNA 2007 session. During his opening remarks, David Levin, M.D., described the conflict of interest that arises when physicians own or have financial interest in imaging equipment.

"When another doctor refers a patient to a radiologist, the likelihood is that the patient really needs the study," said Dr. Levin, a professor of radiology. "The doctor has no financial incentive to order it, because the doctor doesn’t make any money by ordering the test. If a physician owns an MR scanner, there is a conflict of interest, because the physician stands to gain by selfreferring that patient."

Dr. Levin updated the audience on ways the federal and state governments, as well as the legal and legislative systems and some payors, are working to curtail the practice of self-referral among physicians utilizing medical imaging. Maryland has a law outlawing such self-referral for MR and CT (see sidebar), he said, while a quality assurance program in New Jersey significantly reduced utilization among non-radiologist imagers. Medicare policies for 2008 will impact radiologists' reading contracts and non-radiologists' scan-lease arrangements, he said.

Utilization Increased in All Specialties

Laurence Parker, Ph.D. (left), and Vijay M. Rao, M.D., both of Thomas Jefferson University, discussed their studies of medical imaging utilization by specialty and geographic area.

Vijay Rao, M.D., chair of the radiology department, further explored the growth of imaging in her review of 2000–2005 Medicare patient files. "If you look at total Medicare payments for noninvasive diagnostic imaging over five years, it’s grown by 93 percent," she said. She reported finding steady increases in utilization among all specialties, noting, "Physicians who own equipment are doing their own imaging and utilize two to seven times more than physicians who do not own equipment."

Dr. Rao reported growth in overall diagnostic imaging at 25 percent, with radiologists seeing a 22 percent increase. Of other specialties, "Cardiologists really stood out," she said. Cardiologists saw a growth in utilization of 65 percent, she said.

"It's about three times the rate for other specialties," said Dr. Rao of the increase in cardiologist utilization. "That sort of raises a red flag as to why." Those facts are of particular concern for policymakers and payors who struggle with increasing demand and astronomical costs, she said. "Clearly imaging is growing at a very fast rate and I think we need to look at the total picture," she added.

Geographical Location Makes Big Difference

Laurence Parker, Ph.D., director of health services and outcome research for the Department of Radiology, took a geographic approach, examining MR imaging utilization among Medicare patients throughout the U.S. and its territories. He found that Delaware, Florida, Alabama, Maryland and Texas had the highest utilization, while Montana, Iowa, North Dakota, Virgin Islands and Hawaii had the lowest.

"It's not a surprise that Florida is at the top, because this is a Medicare population and it's geared toward retirees," said Dr. Parker. "With Delaware and Maryland, you’ve got states that are adjacent to places like D.C. and Philadelphia. It would be interesting to look at these claims again by provider location and see if the results change.

"As far as Alabama and Texas go, the Centers for Disease Control and Prevention does maps of chronic disease incidence rates and the southeastern states appear to have very high rates," continued Dr. Parker. He said he believes his study results confirm overall presumptions about medical care and its availability. "The very large differences in rates of utilization should be investigated, because it may mean that standards of care are different," he said.

In an effort to keep health costs down and control quality, many states currently require a certificate of need (CON) to acquire MR imaging, CT, ultrasound and radiation therapy equipment. A study comparing imaging utilization among states with and without CON programs would be warranted, said Dr. Parker.

Debate Continues Over Maryland Self-Referral Law

An appeals court will take up questions regarding the interpretation of a 1993 Maryland law prohibiting physicians from referring patients to diagnostic entities in which they have a financial stake.

As first reported by the American Medical Association's AM News on Dec. 17, 2007, a Maryland circuit court ruled last October that the statute—modeled on the federal Stark law—bans non-radiologists from referring patients within their practices for CT, MR and radiation therapy services. The circuit court heard the case after a group of 14 medical practices challenged the Maryland Board of Physicians, saying imaging is included in exceptions to the law allowing in-office referrals for ancillary tests.

In denying the challenge, the court stated that the statute's definition of ancillary services excludes MR and CT for all physicians except radiologists. Appealing to a higher court, the plaintiffs maintain that the circuit court's ruling is effectively a total ban on in-office imaging by non-radiologists, even though state and federal policy deem it proper under certain circumstances. The court ruling could have a significant financial and quality of care impact on physicians and patients, the plaintiffs told AM News.