Imagine you are a patient sitting in the office of a cardiologist, oncologist or orthopedist. Your doctor tells you that you need a CT scan, and schedules you for this imaging exam.
Are you fully capable of asking about alternative tests? Do you ask about imaging facilities that may provide the same exam at a lower price with better technology or higher professional expertise? Of course not. You reasonably assume your doctor has your best interests at heart. But that is not quite the case when your doctor makes money as a result of the referral. When the doctor has a direct or indirect financial interest in referring to a particular medical imaging device or facility, and is essentially self-dealing in medical imaging referrals, the patients best care may not even come into play at all.
Self-dealing in medical imaging wastes healthcare resources, subjects patients to the morbidity of unnecessary procedures, sometimes results in omission of necessary measures and places physicians in ethical conflict with their own patients. So how can a nation struggling to make intelligent healthcare decisions be dumb enough to tolerate such self-dealing? To understand the answer, one must understand the insidious development and reasons for such self-dealing.
In the 80s and early 90s, physicians often formed financial joint ventures to purchase medical imaging equipment. But because of rampant overutilization, subsequent federal and some state legislation placed severe restrictions on such financial arrangements. Loopholes remained, however, enabling physicians to own medical imaging equipment in their own offices, or to lease defined time periods on imaging equipment owned by hospitals and imaging centers. In recent years, such self-ownership and leasing agreements burgeoned, and have contributed to the rapid rise in medical imaging costs.
Self-dealing in medical imaging may take many forms, but the two most common are:
In either instance, the referrer makes money with every referral, whether the physician is even involved in reading the exam. In both cases, the physicians lose money unless they refer a sufficient number of exams to overcome the investment or lease costs.
Proponents of self-dealing in medical imaging defend the entrepreneurial rights of physicians. They propose that increase competition in medical imaging will drive down prices in a competitive economy. However, the reality is that self-dealing is anti-competitive. When a physician refers a patient to a device he owns or leases, the normal competitive forces, such as price, service and technological superiority are taken completely out of play.
Proponents of self-dealing ask why radiologists and hospitals should be the only ones that can own medical imaging equipment. My response: Any physician can invest in medical imaging in many waysby investing in companies that produce equipment, by investing in for-profit hospitals and by investing in publicly traded imaging center businesses. These types of investments seem reasonable because the referring doctor cant materially impact his own investment through his referrals. One might also justify physician self-dealing in medical imaging when the immediate disposition of the patient requires in-office imaging, such as in obstetrical ultrasound or orthopedic radiography. However, it seems preposterous to provide physicians the unique entrepreneurial right to invest in imaging equipment in situations where their own referrals drive their immediate profits.
The first and foremost solution is to restructure payments to physicians, particularly those in primary care, so that they can make an honest living without resorting to entrepreneurial schemes. Simply put, pay doctors to take care of patients, and dont pay them for any self-dealing arrangements.
The second reasonable solution, whether imposed by public policy or private payers, would be to require full financial disclosure to both the patient and payer prior to authorization of medical imaging procedures. Im not referring to a placard in a doctors office that says: We are proud to own the MRI next door. I refer to a real disclosure, such as: We make money when we refer you to USA MRI, so you cannot depend on us to reasonably advise you as to whether tests in this facility are really needed, or whether there is another nearby facility that does a better or less-expensive job.
The third solution would be to stop paying the technical component for self-referred procedures. Without financial incentive, this hopefully transient and sad episode in the history of healthcare will disappear.
Murray Reicher is a practicing radiologist, co-chief executive of Imaging Healthcare Specialists, San Diego, and chairman of DR Systems, a San Diego-based provider of medical imaging information and image management systems.