JACR: Self-referrals cost billions in potentially unnecessary exams
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With healthcare costs in the U.S. topping $2.1 trillion in 2006, and growing at a rate outpacing gross domestic product (GDP), medical imaging has become a high-profile target for cuts, singled out by the U.S. Department of Health and Human Services, the Medicare Payment Advisory Commission and President Barack Obama.
Until recently, medical imaging constituted the fastest growing component of medical expenditures, though recent studies indicate a dramatic slowdown. Still, scrutiny over unnecessary imaging continues, especially regarding self-referring physicians, who, studies indicate, may be more likely to order such exams, explained Ramsey K. Kilani, MD, and co-authors from Duke University Medical Center in Durham, N.C.
“Self-referred imaging is defined as 1) physicians (or nonphysician providers) who are not radiologists directing their patients to their own on-site imaging services or 2) the referral of patients to outside facilities in which the referring physicians have financial interest,” noted Kilani and colleagues.
The authors performed a meta-analysis of studies examining self-referral in an attempt to calculate the frequency of self-referred imaging and its cost to Americans, based on statistics provided by the Government Accountability Office (GAO). Five studies covering nearly 77 million episodes of care were included in the analysis.
Self-referring physicians were found to be 2.5 times more likely to order imaging studies than radiologists. Overall, 60 percent of imaging procedures were estimated to be self-referred.
Based on 2006 GAO figures, the “theoretical [cost] associated” with self-referred studies was $3.6 billion. “This level of spending on potentially unnecessary medical imaging is concerning in light of the growing emphasis on reducing health care expenditures,” argued Kilani and colleagues. Applying several sets of GAO data, the authors estimated the Medicare costs of utilization “over the expected rate for physicians without financial incentive to be on the order of billions of dollars annually.”
Kilani et al also pointed out that the proportion of physicians billing for in-office imaging more than doubled between 2000 and 2006, making 2008 Medicare fee-for-service payments to nonradiologists higher than to radiologists.
The authors attempted to preempt arguments that self-referral offers patients greater convenience or better outcomes, referencing one study which found that only 15 percent of self-referred CTs and MRIs were performed on the same day as the order. Meanwhile, another study revealed that illnesses for which patients received self-referred imaging did not show improved outcomes, but did result in higher costs, Kilani and colleagues wrote.
The authors emphasized the need for improved documentation requirements for Medicare providers in order to more accurately estimate the cost of self-referral. Nonetheless, they concluded, “Addressing the potential costs of medical imaging self-referral may be one way to address the seemingly unsustainable growth of medical imaging spending.”