JACR: Top 5 tips for ending self-referral
After a review of nearly a dozen studies of self-referred imaging by nonradiologists, the authors of a study published in the April issue of the American Journal of Roentgenology concluded that self-referral “invariably” leads to higher utilization—meaning that if policymakers wish to cut the volume and costs of diagnostic imaging, closing the loophole of the Stark Law needs to be top priority.

Since the first study of utilization resulting from self-referred imaging, published almost 40 years ago in 1972, every study recent and past has demonstrated dramatic increases in volume associated with self-referred imaging. The Stark Law, named after Congressional Representative Pete Stark, D-Calif., and passed to curb imaging orders related to conflicts of interest, included a loophole called the in-office ancillary services exception.

The original intention was to allow simple imaging exams, such as x-rays, to be performed for straightforward problems like determining whether an ankle was sprained or broken. “However, the intent of the in-office exception seems to have been subverted in the last 15 years, as physicians have increasingly begun placing more high-tech equipment (e.g., MRI, CT, and PET scanners) in their offices to do tests that are elective in nature and not truly ancillary to the original office visit by the patient,” explained David C. Levin, MD, and Vijay M. Rao, MD, from the Center for Research on Utilization of Imaging Services, part of the department of radiology at Thomas Jefferson University Hospital and Jefferson Medical College in Philadelphia.

“The evidence shows that self-referral invariably leads to higher utilization and the attendant higher costs,” Levin and Rao wrote. They argued that radiologists need to be aware of the evidence, not only to be efficacious advocates for reducing overuse, but also because radiologists are part of the problem.

Levin and Rao reviewed nearly a dozen studies, pointing the finger at surgeons, orthopedists, cardiologists, neurologists and rheumatologists, along with radiologists. In some studies, following the purchase of an in-office modality, referrals shot up almost immediately by as much as 700 percent. These well-established trends result in unnecessary radiation and wasting of patient, payor and taxpayer dollars, the authors pointed out.

Levin and Rao offered radiologists five recommendations for ways in which they are partly responsible for the growth of self-referred imaging and can therefore help bring about its finale. First, radiologists themselves need to order fewer tests. The road to establishing reasonable levels of imaging is setting benchmarks within the hospital and counseling referring physicians.

Second, a recent study showed that only 3 percent of ordering physicians use the American College of Radiology’s (ACR) appropriateness criteria as a primary resource when deciding on the apposite test. The guidelines are available on the web, and Levin and Rao said the organization needs to do a better job of broadening physician awareness about their usefulness.

“Third, radiologists have not been diligent enough at consulting with referring physicians before imaging studies get done and weeding out those that are unnecessary or inappropriate for the patient’s clinical condition,” the authors noted. This trepidation is likely the outcome of fear that physicians will take their business elsewhere, suggsted Levin and Rao. So what’s the solution? Levin and Raofrom recommended close cooperation with physicians from other specialties to establish benchmarks, educate and jointly develop rules.

Levin and Rao’s fourth recommendation aimed the smoking gun back at radiologists, citing a study showing that radiologists were responsible for adding on a large number of unnecessary series or sequences. In this area, radiologists need to be aware, cease and desist, offered the researchers.

Finally, the authors called for compromise between the ACR and radiology benefits management companies (RBMs), a prospect already in the making. The ACR had previously endorsed computerized decision support, while criticizing RBMs for interfering with patient care. Recently, the ACR and the Radiology Business Management Association (RBMA) issued joint best practices guidelines for RBMs, which the authors called “reasonable and achievable.”

In opposition to the American Medical Association (AMA), which favors maintaining the in-office ancillary exception to the Stark Law that allows for self-referral, the authors said that when most physicians reflect on the zero-sum nature of medical imaging and the limited resources that can be dedicated to such tests, physicians will realize that non-self-referring physicians are victimized by the trend. Aside from a carve-out for nuclear cardiology exams, Levin and Rao called for the Centers for Medicare & Medicaid Services (CMS) and the U.S. Congress to close the loophole on the Stark Law and gut self-referral.