RSNA News - November 2004

Radiologists Take Steps to Curtail Inappropriate Imaging Utilization

If we're going to control the costs of imaging in this country, something has to be done to control self-referral.
— David C. Levin, M.D.

Despite federal legislation against it, self-referral—mainly by non-radiologists—remains a major force behind inappropriate imaging utilization, according to David C. Levin, M.D. "If we're going to control the costs of imaging in this country, something has to be done to control self-referral," says the professor and chairman emeritus of the Department of Radiology at Thomas Jefferson University Hospital (TJUH) in Philadelphia.

David C. Levin, M.D.		Vijay Rao, M.D.
Thomas Jefferson University Hospital		Thomas Jefferson University Hospital

Dr. Levin and his colleagues, TJUH chairman Vijay Rao, M.D., Andrea Maitino, M.S., and Larry Parker, Ph.D., will present 10 new studies on the subject at RSNA 2004 in Chicago. Their research provides further evidence of the role of self-referral in rising utilization.

"For example, we looked at changes in utilization of cardiac nuclear scans between 1998 and 2002. It turns out that the overall utilization rate per thousand Medicare beneficiaries went up by 43 percent, a sharp rise for this procedure," explains Dr. Levin. "Separating that out, we find that the utilization rate among radiologists went up by two percent, while among cardiologists it rose by 78 percent—this is all new volume generated primarily by self-referral."

Other findings by the TJUH team:

• Cardiovascular imaging (CVI) represents 29 percent of the total noninvasive diagnostic imaging (NDI) market. Between 1993 and 2002, the CVI workload grew more than twice as rapidly as all other non-CVI NDI.
• Cardiologists now predominate in CVI, primarily as a result of their high utilization of echocardiography and CV nuclear medicine.
• Among radiologists, the utilization rate of NDI (Medicare) dropped almost four percent from 1993 to 1999, but it subsequently rose almost 12 percent from 1999 to 2002. Utilization by non-radiologists grew about twice as rapidly as utilization by radiologists between 1999 and 2002.
• Between 1997 and 2002, interventional radiologists' share of the percutaneous peripheral vascular intervention market declined substantially, but their total procedure volume continued to grow. This, therefore, continues to be an expanding field for radiologists.
• Rates of growth in reimbursements to orthopedic surgeons for total MR imaging, musculoskeletal MR imaging and spine MR imaging were far higher than the rates of growth for radiologists, according to Medicare Part B data for 1997 through 2002.

"Since MR imaging by orthopedic surgeons is performed in a largely self-referred setting, this raises the concern that if the trend continues, it could become a significant cost driver for the Medicare program," writes the TJUH group.

"Orthopedic surgeons really don't belong in the business of owning MR scanners," says Dr. Levin. "That's a weakness in the Stark laws and in the healthcare system as a whole. Orthopedic surgeons have no training in how to operate an MR unit, but one of the major problems is that once physicians are licensed to practice medicine in any given state, they can pretty much do whatever they want, even if they've never been trained."

The Stark Law

Stark II, introduced by Congressman Pete Stark (D-Calif.), prohibits a physician from referring a Medicare or Medicaid patient to an entity in which that physician has a financial interest, whether it's an investment interest or a compensation arrangement, absent regulatory exceptions. One such exemption is the "in-office ancillary service exception," which allows physicians to legally self-refer patients for imaging in their own offices and bill Medicare under their group practice number under specified conditions.

"One of the things that has confused and confounded radiologists is the fact that if the Stark anti-self referral law was adopted for the purpose of trying to curtail the abuse of self-referral, then why does this in-office ancillary service exception exist?" asks Thomas Greeson, J.D., of Reed Smith, LLP, in Falls Church, Va.

"The reason," he explains, "is that Congressman Stark chose to curtail the passive investor/referring physician. An example at the time the law was adopted was the orthopedic surgeon with a limited partnership interest in an imaging center across town or in the same office building where he refers his patients for imaging. The limited partnership interest produced a return merely from the referral of the patient to that imaging center in which the orthopedic physician had an investment interest. This profit solely from a passive referral of patients is what Congressman Stark was trying to prevent. What has transpired, of course, is the proliferation of many imaging arrangements designed to meet the in-office ancillary service exception—hence the growing debate as to whether further steps should be taken to close the in-office ancillary services loophole."

Dr. Levin says he believes it's highly unlikely that Stark II will be toughened soon because there are too many physicians and medical groups who benefit from self-referral who want to keep the loopholes open.

The only way to counter the influence of special interest groups on Capitol Hill, says Dr. Levin, is for insurers and employers to step up to the plate and take action to limit self-referral. "This responsibility doesn't fall solely on the health plans that keep raising premiums. It also falls on those who are ultimately paying—businesses."

N. Reed Dunnick, M.D., professor and chairman of the University of Michigan Department of Radiology, says a solution must be found soon before over-utilization bankrupts the entire healthcare system. "We don't want to withhold medical care from people," he says. "We want to eliminate those examinations that don't need to be performed in the first place. Our field is changing rapidly and we need to communicate to our colleagues about the appropriate use of our tools. The American College of Radiology (ACR) has done a great job of creating appropriateness criteria, but we all have a responsibility to educate ourselves, our colleagues and our referring physicians. I think academic medical centers should take the lead on this."

Dr. Dunnick, who also chairs the Intersociety Committee, adds that if minimum standards existed, it might help to decrease inappropriate utilization, especially that which has been encouraged by self-referral.

"The Mammography Quality Standards Act (MQSA) is an excellent model," he says. "MQSA has improved the quality of mammography. As an unintended consequence, many who had been doing mammography in their offices or as a sideline voluntarily gave up mammography as they did not meet MQSA standards. I believe the pursuit of quality is what is important here."

The Intersociety Committee is preparing a report on inappropriate imaging utilization as a result of discussion at its annual meeting in July. The report will make recommendations on such things as education, generating data, mandating accreditation and extending oversight to outpatient imaging. It is expected to be released in 2005.