Health Affairs: Medicare should halt imaging self-referrals

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Only 15 percent of self-referred high-tech imaging occurs on the same day as the physician's order, calling into question any benefit from self-referral and the higher imaging rates with which it's associated, while leading researchers at the American College of Radiology (ACR) to call for potentially terminating Medicare reimbursements for self-referred high-tech imaging, according to a study published in the December issue of Health Affairs.

Self-referred imaging, in which the physician owns at least part of the equipment with which the patient will be imaged and therefore stands to profit from the imaging order, is currently reimbursed as a "designated" service by Medicare. Self-referred imaging is purported to provide a one-stop service by evaluating, imaging and even commencing treatment all in the same day at the same facility. The practice bodes special benefits in care for elderly Medicare recipients and other patients who may be less likely to return for follow-up visits due to inconvenience.

On the other hand, "[e]mpirical research show[s] that self-referral is associated with much higher use of imaging, compared to referrals to radiologists. This finding has drawn attention because imaging had repeatedly been found to be by far the most rapidly growing component of physician services," noted Jonathan Sunshine, PhD, director of research at ACR, along with co-author Mythreyi Bhargavan, PhD, director of data registries at ACR.

Sunshine and Bhargavan examined the prevalence of one-stop imaging, performing the first investigation into the advantages of self-referred imaging. "There had been very little examination of whether this actually happens, so we decided to look at this claim," Sunshine told Health Imaging News.

The authors analyzed Medicare's 5 percent Research Identifiable Files, which comprise a random sample of 5 percent of all Medicare fee-for-service insurance claims. Sunshine and Bhargavan assessed the files for both 2007 as well as 2006, to ensure that Medicare's 2007 adoption of a different physician identifier system had not affected the recorded rates of imaging. No major differences were observed.

In 2007, 2.2 million self-referred imaging services were received by the 2.6 million Medicare beneficiaries sampled. Of these images, 28 percent were "relatively straightforward" chest or musculoskeletal x-rays, with 74 percent of these patients imaged on the same day as an office visit. "In contrast, only 15.2 percent of high-tech images—nuclear medicine, CT scanning, and magnetic resonance imaging (MRI)—had a same-day office visit," Sunshine and Bhargavan found.

The authors also investigated self-referral for ultrasound, discovering that 34.5 percent of self-referred ultrasound scans were accompanied by same-day office visits, with ultrasound accounting for just fewer than 20 percent of self-referrals.

"Overall, 21.2 percent of patients receiving self-referred imaging services other than chest or musculoskeletal x-rays had an office visit on the same day," wrote Sunshine and Bhargavan.

Nuclear medicine accounted for 47 percent of all self-referred imaging, with patients receiving same-day visits in 14.8 percent of cases. CT totaled just 1.3 percent of self-referred imaging services, with accompanying same-day visits for 26.7 percent of these scans. MR images were taken along with an office visit in 15 percent of scans, but with MRI making for less than 1 percent of self-referrals.

"Overall, less than one-fourth of imaging other than these types of x-rays was accompanied by a same-day office visit. The fraction for high-tech imaging was even lower—approximately 15 percent," highlighted Sunshine and Bhargavan. The authors argued that these low rates indicated that "Policy makers attempting to make the use of imaging more responsible should consider narrowing Medicare's special provision allowing referrals to a physician's own practice so that the provision covers x-rays only.

Sunshine cited studies of smaller scope and similar results to validate the extrapolation of this study's findings to the general population. "Physicians are not schizophrenic," Sunshine contended, "they probably treat patients much the same way whether they've reached their 65th birthday or whether or not they use Medicare as a source of payment ... And the empirical evidence supports this."

The authors acknowledged that their methodology might have led to some inaccuracy in one-stop imaging assessment, though only in overestimating the rates of one-stop imaging. For one, Medicare has only recently begun to crack down on "abusive" leasing, in which imaging practices will share a physician ID code with the referring practice that leases the equipment. This loophole looks on paper like a one-stop visit and imaging exam, but in reality the patient must go to separate practices.

"We have shown that self-referral is seldom a one-stop process (with the exception of relatively straightforward x-rays), although its purported benefits are heavily dependent on its being a one-stop process. Thus, relatively straightforward x-rays are the only form of imaging for which one main benefit of self-referral—one-stop service—seems likely to offset its apparent drawbacks."

Sunshine argued that "from this we come to a fairly straightforward and I would say reasonably obvious policy conclusion, and that is that Medicare generally prohibit financially interested referrals ... The obvious fix is to allow self-referred imaging only for x-rays."

The authors further pointed out that "It is ironic that a major justification for self-referrers' acquiring this expensive equipment is to provide same-day convenience to their patients—but, presumably to keep their costs down, the physicians inconvenience the vast majority of their imaging patients by scheduling scans for a later date."