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Turf Wars in Radiology: PossibleRemedies for Self-Referral That

Could Be Taken by Federal or StateGovernments and Payers

David C. Levin, MDab, Vijay M. Rao, MDa

The time seems to be ripe for reforms that will address the rapid growth of self-referral in diagnostic imaging bynonradiologist physicians. The authors present a possible course of action containing six elements that federalor state governments and/or payers could take that would assist them in their efforts to control this ubiquitousproblem: (1) a legislative ban on self-referral for certain types of imaging, (2) mandatory accreditation and/orsite inspections of all imaging facilities, (3) the limitation of imaging privileges among nonradiologists, (4) therequired precertification of all self-referred imaging examinations, (5) the auditing of records of physicians whoself-refer, and (6) certificate-of-need laws.

Key Words: Medical economics, diagnostic radiology, radiology, radiologists, departmental management,socioeconomic issues

J Am Coll Radiol 2004;1:806-810. Copyright © 2004 American College of Radiology

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n earlier articles in this series, we summarized the pub-ished evidence pertaining to various aspects of the prob-em of self-referral in diagnostic imaging. This evidenceemonstrates first that self-referral leads to higher utili-ation, much of which is medically unnecessary [1]. Sec-nd, the evidence shows that nonradiologist physicianso not interpret images as accurately as radiologists [2].hird, the quality of the images produced in the offices ofonradiologist physicians is often unsatisfactory [3].here is thus little doubt that self-referral is bad foratients and bad for our health care system, which isorced to pay for it. It is also bad for hospitals, whichtand to lose much of their outpatient imaging referralusiness.What can be done to curb self-referral in diagnostic

maging? In another earlier article in this series [4], weouched on some of the steps that could be taken by

Department of Radiology, Thomas Jefferson University Hospital and Jeffer-on Medical College, Philadelphia, Pennsylvania.

HealthHelp Networks, Inc., Houston, Texas.

Corresponding author and reprints: David C. Levin, MD, Department ofadiology, Gibbon 3390, Thomas Jefferson University Hospital, Philadel-hia, PA 19107; e-mail: david.levin@mail.tju.edu.

Editor’s Note: This is the sixth in a series of articles by the authors on theopic of self-referral in medical imaging. These articles provide insight into thehenomenon of self-referral and its consequences. Although the authors gen-rally substantiate their assertions with references to previous literature, I also

eave given them considerable leeway to express their opinions.

06

adiologists. In the time since that article was written,ore scrutiny than ever before has been focused on the

ssue of self-referral and overutilization in imaging. Forxample, an article in the New York Times [5] describedhe installation of magnetic resonance imaging (MRI)nits in the offices of orthopedic surgeons and otheronradiologist physicians in Syracuse, New York, andeported that in that region, the utilization of MRI hadisen by 23% in 1 year alone. An article in the Bostonlobe [6] discussed the rapid increases in costs of ad-

anced imaging techniques, such as MRI and computedomography (CT), that are being borne by payers in

assachusetts. The American Medical News (the weeklyewspaper of the American Medical Association) [7] re-orted on the March 18, 2004, meeting of the Medicareayment Advisory Commission. The commission is an

nfluential body of health policy experts that advisesongress on Medicare payment policy. At the meeting,

he commissioners and invited speakers spent consider-ble time discussing the rapid growth in imaging costsmong self-referring nonradiologist physicians and pos-ible strategies from the private sector for dealing with theroblem. An article in Health Affairs [8], an influential

ournal devoted to health policy, described how financialressures on physicians are causing them to become morentrepreneurial and indicated that investment in imagingnd laboratory equipment is the primary strategy they are

mploying. Finally, in an article in the New York Times

© 2004 American College of Radiology0091-2182/04/$30.00 ● DOI 10.1016/j.jacr.2004.05.027

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Levin, Rao/Turf Wars in Radiology 807

agazine [9], Senator Hillary Clinton decried the facthat one-third of the money Americans spend on healthare goes toward wasteful and duplicative procedureshat fail to improve patient health, including imaging.

ore such articles in the media will probably have ap-eared by the time you read this.It is thus clear that the issue of self-referral in imaging

as aroused the consciousness of both the public andolicymakers. Accordingly, the time is right to considereforms that could limit the recent rapid growth in theosts of self-referred imaging and its attendant patientafety issues. In this article, we expand on our earlieriscussion and present a course of action: a series ofpproaches that could be adopted by federal or stateovernments and/or health care payers. Some of thesepproaches may be unpalatable to other physicians andven to some radiologists, but we present them in theope of stimulating debate on this important issue.

N OUTRIGHT BAN ON SELF-REFERRALOR CERTAIN TYPES OF IMAGING

he Stark laws prevent physicians from referring patientso imaging centers in which they or family members havefinancial interest. Unfortunately, these laws contain auge loophole—the so called in-office ancillary servicesxemption—that allows a physician to put any imagingquipment he or she chooses into his or her own office.or political reasons, it may be difficult to close this

oophole at the federal level. However, the state of Mary-and has a more restrictive self-referral law on the booksthe Maryland Health Occupations Article §-301[k][2], 1993). This law contains a similar in-officencillary services exemption but specifically states thathe exemption does not apply to MRI, CT, or radiationncology (T. Burnes, ACR, personal communication).n August 2003, E. Steven Amis, chairman of the Boardf Chancellors of the ACR, wrote the Maryland attorneyeneral asking that the law be enforced. In January 2004,he Maryland attorney general issued an opinion address-ng the question of whether, under this law, an orthope-ic surgery group could install an MRI unit in its office.he opinion stated that the language of the law reflectedlegislative intent to prohibit referrals for in-office MRIr CT studies, unless the equipment is owned by a prac-ice made up entirely of radiologists. It went on to statehat the law barred a physician in the orthopedic group orny other nonradiologic medical practice from referringatients for MRI or CT using scanners owned by thatractice. This clearly struck a major blow at self-referralor diagnostic imaging. Although it may be a bit prema-ure to try to ascertain the long-term effects of this ruling,arly indications are that it has significantly slowed the

nstallation of CT and MRI units in the offices of non- s

adiologist physicians in Maryland (C. Citrin, personalommunication). Efforts are currently under way in sev-ral other states, such as Texas (T. Fletcher, personalommunication) and Indiana (K. Applegate and K. Ko-ecky, personal communication), to get similar legisla-ion enacted.

ANDATORY ACCREDITATION AND/ORITE INSPECTIONS OF ALL IMAGINGACILITIES

equiring the mandatory accreditation of diagnostic fa-ilities has been tried before, and it seems to work. Theest known example in imaging is the requirement thatll mammography facilities be certified by the U.S. Foodnd Drug Administration. This began in 1994 after pas-age of the Mammography Quality Standards Act of992, which in turn, grew out of the mammographyccreditation program of the ACR [10,11]. To receiveertification from the Food and Drug Administration, aammography facility must be accredited by an ap-

roved accrediting body, such as the ACR, and pass annnual inspection. This policy keeps low-quality provid-rs out of the field and helps assure both patients andayers that all mammograms will be done properly. Evenefore the Mammography Quality Standards Act, Con-ress adopted the Clinical Laboratory Improvementmendments of 1988 [11-14], which were subsequently

mplemented in 1993. The amendments require clinicalaboratories that perform moderate-complexity or high-omplexity testing to meet minimum standards for qual-ty assurance, personnel training, patient test manage-

ent, and proficiency testing. Monitoring is conductedy accrediting organizations approved by the U.S. De-artment of Health and Human Services.There is thus precedent for the governmental over-

ight of diagnostic testing. One can envision the enact-ent of similar federal or state laws that extend to all

ypes of imaging facilities. There are several ways moni-oring could be conducted. One way would be to requireCR accreditation. As is well known within the radiol-gy community, the ACR has an extensive and effectiveccreditation program covering virtually all types of di-gnostic imaging [4,15]. Another way would be to con-ract a program out to radiology utilization managementompanies. In one western state recently, a single experi-nced radiologic technologist employed by such a com-any and armed with a checklist was able to inspect 462maging facilities in slightly more than 1 year. This rep-esented most of the imaging facilities in that state [16].f note, 1% of radiologists’ sites failed, whereas one-

hird of nonradiologists’ sites failed. Thus, accreditationrograms incorporating site inspections would seem fea-

ible and relatively inexpensive, and a federal or state

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808 Journal of the American College of Radiology/Vol. 1 No. 11 November 2004

overnment mandate would be the most effective way ofnforcing them. Such programs could be useful in limit-ng self-referral, at the same time helping improve theuality of patient care.

If efforts to institute accreditation programs throughegislation are unsuccessful, the payers themselves couldonsider doing so. According to ACR estimates, approx-mately 20 payers in various states require ACR accredi-ation for certain imaging modalities, primarily MRI,T, positron emission tomography, and cardiac nuclear

maging (P. Wilcox, ACR, personal communication).ther payers have contracted with radiology utilizationanagement companies to control self-referral through

rograms combining site inspections with limitations onmaging privileges for nonradiologist physicians [17,18],s is discussed below.

IMITATION OF IMAGING PRIVILEGES

rivileging programs have been instituted by certain pay-rs [17,18], and the effects have been favorable. Under arivileging program, physicians in certain nonradiologicpecialties are given privileges to perform and be reim-ursed for certain types of imaging studies, but not oth-rs. Verrilli et al. [17] based their privileging of nonradi-logist physicians in Massachusetts on whether imagingas an accepted part of a specialty’s practice, whether

raining was available to its residents, and whether theyere credentialed in imaging at local hospitals. In therivileging program instituted by Moskowitz et al. [18]or a health plan in Connecticut, a multispecialty physi-ian board granted limited imaging privileges to primaryare physicians and seven other specialties. For example,rthopedic surgeons were allowed to perform skeletaladiography; primary care physicians were allowed toerform chest, rib, and extremity radiographs; and car-iologists were allowed to perform chest radiographs,chocardiography, and cardiac nuclear imaging. Otherpecialists were not allowed any imaging privileges.hese programs in Massachusetts and Connecticut com-ined site inspections with limitations on imaging privi-

eges for nonradiologist physicians. A more completeescription of these and other similar programs will behe subject of a later article in this series, but we willimply point out here that in Massachusetts, 18% ofonradiologists stopped billing payers for imaging with-ut even going through the inspection process. In Con-ecticut, 32% stopped billing the payer either becausehey refused to go through the inspection process or theyid go through it and failed. One would assume that theites that stopped billing were generally the low-qualityroviders.Another company has more recently developed an ex-

ensive imaging privileging program covering 43 nonra- s

iologic medical specialties or subspecialties and over60 Current Procedural Terminology 4 codes (C. Farn-worth, HealthHelp, Inc., personal communication).esearchers at the company retrospectively applied therivileging limitations to all billings for imaging studiesn several commercial payer populations and determinedhat up to 13% of all imaging dollars paid would haveeen disallowed if the privileging program had been inlace. Of course, some of these examinations—perhapsalf—would have been medically necessary and thereforeventually referred to radiologists, but the savings wouldave been substantial nevertheless.Although privileging programs in imaging have never

een initiated legislatively by either the federal or stateovernments to our knowledge, it seems likely that theombination of mandated accreditation and privilegingimitations for nonradiologist physicians could help sub-tantially in curbing self-referral. If federal or state legis-ation cannot be accomplished, the experiences of Verrillit al. [17] and Moskowitz et al. [18] have shown thatndividual payers can successfully implement such pro-rams.

EQUIRE THE PRECERTIFICATION OFLL IMAGING EXAMINATIONS NOTEFERRED TO RADIOLOGISTS

maging precertification means that when an imagingxamination is ordered, either the ordering physician orhe providing physician must obtain prior approval fromhe payer before performing it. Approval is supposed toe based on the clinical indications for the study. Al-hough this technique has been used by some payers inhe past, it has fallen out of favor for several reasons. First,ome physicians have learned how to “game” the systemi.e., to provide clinical indications they know will resultn approval). Second, and more important, this can beonstrued as a denial of care, for which a payer can eithere taken to court or made the object of adverse publicity.There is another approach that could be used: requir-

ng the precertification of more complex imaging studies,ut only for those that are not performed by radiologists.adiologists are rarely ever in a position to self-refer.oreover, there is no financial incentive accruing to the

eferral of a patient to a radiologist by a physician innother medical specialty. Thus, these studies are likelyo be medically necessary. On the other hand, whenonradiologists perform imaging, it often or always is aelf-referral arrangement. The work of Hillman et al.19,20] and the U.S. General Accounting Office [21]eport of 1994 showed that self-referring physicians usemaging between two and eight times as frequently ashysicians who refer their patients to radiologists. This

uggests that at least half, and perhaps many more, of

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Levin, Rao/Turf Wars in Radiology 809

elf-referred imaging studies may be unnecessary, hencehe rationale for the precertification of those studies noteferred to radiologists. Any imaging examinations thatere subject to precertification but did not receive itould not be eligible for reimbursement. Precertificationnder these circumstances would not represent a denialf care, because there would always be the option ofeferring the patient to a radiologist.

UDIT PROVISIONS

his is closely related to the aforementioned precertifica-ion provision. If precertification were required for ad-anced imaging studies not referred to radiologists, itould create a record of all such examinations performedy self-referring physicians. The government agency orayer overseeing this policy should have the authority too into any physician’s office and check his or her patientharts to see if the actual indications for a self-referredmaging test were the same as those provided on therecertification request. Discrepancies would call forenalties, and this potential threat would likely reduceny tendency to provide bogus indications on a precerti-cation request.

ERTIFICATE-OF-NEED LAWS

number of states now have certificate-of-need (CON)aws in place that require state approval before certainypes of equipment can be installed in a hospital or pri-ate office or that apply to any equipment whose costxceeds a certain threshold. Sometimes these laws seemapricious, as when they are applied to public institutionsuch as hospitals but not to private entrepreneurs orhysician groups. By limiting the ability to install newmaging equipment, CON laws can make it more diffi-ult for self-referring physicians to get into the practice ofmaging. But of course, CON laws cut both ways, be-ause they also limit the opportunities for hospitals andadiologists to expand their imaging practices. Any CONeasures have to be instituted by state governments;

here are no payers with the ability to do so.

BLIGATIONS OF RADIOLOGISTS

he six measures described above would primarily affectonradiologist physicians who operate their own imag-

ng equipment. However, we radiologists cannot expectayers and/or state governments to target only “the otheruys” without showing a willingness to make some con-ributions of our own toward solving the problem. Per-aps the most important contribution we could make iso dedicate time and effort to educating referring clini-

ians about what imaging studies (or perhaps no imaging d

t all) are the most appropriate in a given set of clinicalircumstances. An interesting study by Taragin et al. [22]evealed that senior residents in internal medicine at aespected academic institution ordered the wrong imag-ng test approximately one-third of the time. Clearly, ourolleagues need education on this subject, and it is up tos to provide it. On an individual level, we can advise andonsult more often with referring physicians in our hos-itals or practice locales before going ahead to performhe studies they have ordered. On a national level, theery comprehensive and thorough ACR Appropriatenessriteria should be more widely disseminated. This coulde done by actively publicizing the fact that they arevailable on the Web free of charge to whoever wishes tose them. The ACR could also make them available freef charge to anyone wishing to download them to aersonal digital assistant (there is currently a $200 chargeor this to nonmembers). As we suggested previously [4],he ACR could contract with journals in primary carend certain other medical specialties to publish one of theore commonly applicable Appropriateness Criteria in

ach issue of those journals. Such measures would dem-nstrate the ACR’s commitment to trying to help reduceverutilization.

Hillman [23] recently discussed other initiatives thathould be undertaken by radiologists as part of the solu-ion to the self-referral problem in imaging. He empha-ized the importance of multicenter clinical trials, such ashe ACR Imaging Network, in defining best practices inadiology, as well as the need for research relating out-omes to both self-referral and referral to radiologists.

e agree with his viewpoint.In summary, it is clear that doing something about

elf-referral in diagnostic imaging is an idea whose timeas come. Reform would be in the best interests of pa-ients, hospitals, payers, and employers. This is not aopeless task; something can be done about it. The var-

ous approaches discussed here could substantially limithis expensive and wasteful practice. We recognize thathis is a controversial subject and that the plan outlinedbove is an aggressive one, and we wish to emphasize thathese ideas do not necessarily represent the viewpoint ofhe ACR or any other organization. Physicians in otherpecialties and organizations such as the American Med-cal Association would likely oppose all or parts of thelan. The ACR itself may choose not to endorse it.owever, we also wish to point out that most of these

pproaches have been tried already in one venue or an-ther and have been helpful. We hope that this arti-le provokes thought and discussion on what is obviouslydifficult issue. We also hope readers will contact usith further ideas or experiences of their own, at

avid.levin@mail.tju.edu or vijay.rao@jefferson.edu.

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