The Riddle of Self-Referral

Take a peek at what's in store for self-referral in medical imaging.riddle of self referral

Most radiologists have an understanding of self-referral and its negative impact on medical imaging and interpretation in the United States.

However, self-referrers often argue that referring patients to their imaging facilities ensures timely and convenient care and that those who oppose this practice are merely protecting their own turf. Regardless, health-policy research has shown a significant increase in the number and frequency of imaging referrals to a facility in which a physician has a financial interest.1-3 Research also indicates that most patients do not receive more timely and convenient same-day service in a self-referral facility versus an independent imaging center.4-6

In response to concerns about self-referrals, Congress passed the so-called Stark Law (Section 1877 of the Social Security Act), a series of legislative enactments designed to restrict self-referral and named after principal sponsor, Rep. Fortney "Pete" Stark (D-Calif.). The law prohibits a physician from referring Medicare and Medicaid patients to an imaging facility in which the physician or the physician's immediate family member(s) have a financial interest. Unfortunately, Congress succumbed to the self-referral lobby and provided some exceptions to this prohibition — including the in-office ancillary services exception (IOASE). This exception permits self-referral if the imaging is supervised and billed by the physician or his or her group and if the facility is in the same building as the physician's or group's practice or in a centralized facility run exclusively by the group.

So, how does a loophole this large restrict self-referral and ensure appropriate medical care? In short, it doesn't. The IOASE was a political compromise designed to assuage the concerns of the self-referrers. And for nearly two decades, this uneasy truce was considered to be good enough despite the steadily growing cost of medical imaging. But when the economy took a downward turn, money, rather than patient care or even turf, became the focus.

When the federal government began to look for quick ways to cut medical costs, medical imaging was an obvious target. However, rather than looking at the source of overspending, which was primarily imaging by nonradiologists, the government attempted to cut all nonhospital imaging. This resulted in cuts to the technical component in physician offices and Independent Diagnostic Testing Facilities as well as reductions for same-day and contiguous-parts imaging, and both MedPAC and CMS are now suggesting further cuts.

At the same time, due to a handful of errors at separate, unrelated imaging facilities, radiation exposure became a public concern, which somewhat shifted the government's focus to patient safety. Politicians, physicians, and patient advocacy groups all looked for ways to reduce exposure, and dose registries and elimination of unnecessary imaging rapidly became the solutions of choice.

As a result of these two imperatives — patient/voter concerns and the desperate need for money — Congress and state legislatures may now be willing to focus on the primary source of inappropriate and expensive medical imaging that often exposes patients to unnecessary and excessive radiation — physician self-referral.

Despite the concerns about radiation dose, taking an all-or-non approach to reimbursement cuts does not work because self-referrers can simply increase volume to make up for the drop in reimbursement. Adding cuts for all groups will eventually reduce imaging by those who do not self-refer — imaging that is appropriate and necessary — and it is patients who will suffer.

Legislators also need to see that overexposure to medical radiation is most often due to imaging by physicians who do not have sufficient training in radiation safety, such as those who use radiation-intensive modalities such as fluoroscopy or CT to excess when another modality may be more appropriate. When the regulators begin to focus on the qualifications of those ordering the studies, they'll be able to control volume, and they will also discover that the conflict of interest inherent in self-referral cannot be avoided.

Even the United States Department of Health and Human Services Office of Inspector General (OIG) should begin to look at whether self-referred studies are medically necessary. The OIG has begun to do so in advanced-imaging modalities such as MRI. Then, billing the government for medically unnecessary studies constitutes a false claim, a type of fraud and would result in significant penalties.

In summary, the current situation may present the radiology community with the chance to help Congress and others revisit the self-referral issue from a different perspective, and perhaps to arrive at a different conclusion. First and foremost, the repeal of the IOASE is necessary to ensure that only essential and appropriate imaging, performed at the lowest functional exposure levels, can guarantee safe and affordable patient care.

1. Kouri BE, Parsons RG, and Alpert HR. “Physician Self-Referral for Diagnostic Imaging: Review of the Empiric Literature,” AJR 2004;179:843–850.
2. Gazelle GS, Halpern EF, Ryan HS, Tramontano AC. “Utilization of Diagnostic Medical Imaging: Comparison of Radiologist Referral Versus Same-Specialty Referral,” Radiology 2007;245(2):517–522.
3. Levin DC, Rao VM. “Turf Wars in Radiology: The Overutilization of Imaging Resulting From Self-Referral,” JACR 2004;1:169–172.
4. Mitchell JM. “Trends for Advanced Imaging Procedures: Evidence From Individuals With Private Insurance Coverage in California,” Medical Care. 2008;46(5):460–466.
5. Ramsey KK, Paxton BE, Stinnett SS, et al. “Self-Referral in Medical Imaging: A Meta-Analysis of the Literature,” JACR 2011;8:469–476.
6. Hughs D, Bhargavan M, Sunshine JH. “Imaging self-referral associated with higher costs and limited impact on duration of illness,” Health Affairs 2010; 29(12): 2244-2251.

By Bill Shields, J.D., LL.M., CAE and Tom Hoffman, J.D., CAE
Bill Shields, J.D., LL.M., CAE (This email address is being protected from spambots. You need JavaScript enabled to view it.), is ACR general counsel.
Tom Hoffman, J.D., CAE (This email address is being protected from spambots. You need JavaScript enabled to view it.), is ACR associate general counsel.

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