Turf skirmishes between radiologists and other specialties erupted into full-scale war at last week's annual meeting of the Radiological Society of North America in Chicago, with several studies pointing the finger at self-referring nonradiologists as the culprits for exponential growth in imaging procedures.
The self-referrals, which take advantage of a glaring loophole in the Stark laws prohibiting such practices, threaten to "bankrupt" the healthcare system, said David Levin, professor and chairman emeritus of the radiology department at Thomas Jefferson University Hospital in Philadelphia. Levin was the author or co-author of five papers presented at the RSNA meeting that examined skyrocketing utilization rates in noninvasive diagnostic imaging procedures.
"Self-referral by nonradiologist physicians (especially cardiologists) in their offices is a major driver of the rapidly increasing utilization and costs of diagnostic imaging in our healthcare system," Levin said.
The studies took aim at entrepreneurial orthopedic surgeons, who are putting magnetic resonance imaging machines in their offices, and cardiologists, who have practically co-opted nuclear stress tests. Another major battle between cardiologists and radiologists is brewing now that 64-slice CT scanners designed to accommodate the high-resolution, lightning-fast exam times required for coronary artery images are ready for use (Dec. 1, 2003, p. 28). Making an economic and clinical case against the practices, Levin argued that self-referring physicians are compromising quality and increasing costs to the healthcare system.
From 1997 to 2002, orthopedists snatched Medicare reimbursement for magnetic resonance imaging services at six times the rate (599%) of radiologists (99%), while cardiologists boosted the utilization rates of in-office stress tests by 78% during the same period, compared to 2% among radiologists, according to Levin.
Levin's studies built on earlier reports showing that radiologists have been losing ground in recent years to other specialties (Dec. 8, 2003, p. 16). Although the data don't show whether the individual tests were unnecessary, there were no trends that occurred from 1997 to 2002 that would explain the disparity, which leads to the conclusion that orthopedic surgeons and cardiologists are simply motivated "to increase their revenues," Levin said.
The practice also is hurting hospitals, which are losing patients to private offices, he said. One of Levin's studies determined that the proportion of noninvasive diagnostic imaging performed in hospitals fell during the five-year period to 28.4% from 33.6%, while imaging at private offices climbed to 32.6% from 28.1%.
The American College of Cardiology quickly responded in a news release that Levin and his radiology colleagues have "oversimplified the growth in imaging services" and that the "real story is that the loss of market share is a key factor driving the radiologists' campaign." Physicians from nonradiologic specialties have banded together as Physicians for Patient-Centered Imaging "to set the record straight," according to the news release. At deadline, a spokeswoman for the American College of Cardiology had not responded to a request for an interview.
Levin said it was "baloney" to suggest private, office-based imaging services are more convenient for patients, and he denied that the radiologists are fearful of competition and lost market share. "Radiologists have more than enough business," he said. Radiologists' "complaints are they have too much work to do."
Nevertheless, the trend is enough of a concern that the American College of Radiology has taken the lead in lobbying for change. James Borgstede, chairman of the ACR's board of chancellors, said he worries that when they finally get fed up with 50% increases in annual utilization rates, payers will institute across-the-board cuts. If that happens, office-based practices would increase utilization even more to capture the lost revenue, which would prompt additional across-the-board cuts until "it drove everyone out of the imaging market," he said. "With the field growing so much, we're killing the goose that's laying the golden egg," Borgstede said.
As a result, the ACR is working with payers to establish standards that would regulate the equipment and practitioners for high-cost imaging services-CT, MRI and PET-in much the same way that the federal government regulates mammography, Borgstede said. Highmark Blue Cross and Blue Shield launched a program along the same lines last summer, and last week the ACR and UnitedHealth Group announced a collaboration that supports the ACR's "appropriateness criteria."
The Highmark program, now in its first phase, is focused on credentialing radiologists and other physicians that perform imaging services outside the hospital setting as a condition for Highmark reimbursement. Highmark, which pays more than $500 million per year for outpatient imaging services, reported it has seen its payments for advanced imaging services increase more than 20% annually for the past three years.
"We're concerned on two fronts: With our members undergoing more and more repeat scans, we are concerned about the quality of the equipment and the quality of the staffing at some of these outpatient imaging centers and ultimately the impact on cost," said Michael Weinstein, a Highmark spokesman.
Outside the educational sessions at the RSNA meeting, vendors were showing off their newest 64-slice CT scanners and reporting huge interest by cardiologists. Scott Schubert, global product manager of CT for GE Healthcare, noted that when the company held an educational symposium on CT last October, 90% of the attendees were radiologists. At the same symposium this year, 60% of the attendees were cardiologists, he said.
But vendors are staying out of the fray between specialties.
"It's a political issue," said Paul Smit, senior vice president of strategy and business development for Philips Medical Systems. "If you look at leading hospitals, they have gone beyond the turf battle to focus on patients. Our business is not about deciding who will make money but how to get (the technology) to the patients."