Key Points From Some of the Available Evidence on Appropriate Utilization


Key Points From Some of the Available Evidence on Self-Referral

There is a fair amount of available literature on self-referral beginning in 1965 when Childs and Hunter examined the influence of nonmedical factors on the use of diagnostic x-ray (Childs AW, Hunter ED. Non-medical factors influencing use of diagnostic x-ray by physicians. Medical Care. 1972; X, no 4: 323-335). However, a few studies in particular are recommended for review rather than reading the cumulative research available.

Specifically, the following article provides an empiric review of the literature and outlines much of the existing evidence regarding the impact of self-referral on quality, cost, utilization, etc.

  1. Kouri BE, Parsons RG, Alpert HR. Physician self-referral for diagnostic imaging: review of the empiric literature. AJR Am J Roentgenol. 2002;179:843-850.

Some key points from this empiric review are:

  • "Non radiologists performing their own imaging are at least 1.7-7.7 times as likely to order imaging than those non-self referring physicians in the same specialty who see patients with the same problems.
  • "Imaging increased up to 54% when a patient was sent to a facility in which a physician had a financial interest.
  • "Deficiencies, such as image quality or patient safety are up to 10 times as common among non-radiologists as among radiologists."

Of course, there are the Bruce Hillman articles, which were quite groundbreaking for their time:

  1. Hillman BJ, Joseph BA, Mabry MR, Sunshine JH, Kennedy SD, Noether, M. Frequency and costs of diagnostic imaging in office practice: a comparison of self-referring and radiologist-referring physicians. N Engl J Med. 1990;332:1604-1608.
This is one of the early studies on self-referral for diagnostic imaging. It shows the much higher utilization and cost that result from self-referral. Utilization by self-referring physicians was 4 to 4.5 times as high, depending on the patient's health condition, as physicians who refer their patients to radiologists for imaging. Charges were 4.4 to 7.5 times as high.
  1. Hillman BJ, Olson GT, Griffith PE, et al. Physicians' utilization and charges for outpatient diagnostic imaging in a medicare population. JAMA. 1992;268:2055-2059.
This is a subsequent article by the same research team. It dealt with a broader range of health conditions and included the full range of imaging. The results are the same: Self-referral produces much higher utilization, 1.1 to 7.7 times as high, depending on the health condition being studied, and therefore much higher costs. Costs were 1.6 to 6.2 times as high as for non–self-referrers.

Levin, Roa, and Maitino have done extensive research on the subject of utilization and self-referral. Following are a few specific citations:

  1. Maitino AJ, Levin DC, Parker RL, Rao VJ, Sunshine JH. Practice patterns of radiologists and nonradiologists in utilization of diagnostic imaging among the Medicare population. Radiology. 2003; 228, no 3: 795-801.
Noninvasive imaging procedures performed by radiologists decreased from 73.0% in 1993 to 67.4% in 1999. Maitino, Levin, Parker, Rao, and Sunshine's analysis showed an overall decrease of approximately 4% in the utilization rate (per 100,000 beneficiaries) of noninvasive diagnostic imaging for radiologists and an increase of approximately 25% in the utilization rate for nonradiologists.
  1. Levin DC, Parker L, Intenzo CM, Sunshine JH. Recent rapid increase in utilization of radionuclide myocardial perfusion imaging and related procedures: 1996-1998 practice patterns. Radiology. 2002;222:144-148.
This analysis showed differences in MPI utilization rates between cardiologists and radiologists (including nuclear medicine physicians) across a 2-year timeframe and revealed significant differences in the use of the 2 add-on services by cardiologists as compared to radiologists, particularly in the office setting. Levin et al found that MPI utilization rates (per 100,000 Medicare beneficiaries) increased a total of 19.1% from 1996 to 1998. MPI utilization by cardiologists increased by 36.3%, radiologists' utilization increased by 3.7%, and utilization by "other physicians" increased by 18.6%. Evaluation of utilization rates in the private office setting showed a 282% increase in the use of add-on services among cardiologists compared to a 117% increase among radiologists. This is significant, as inferences could be made that self-referring physicians in the office setting unnecessarily order additional services.

Levin is also publishing a series of articles on self-referral in the Journal of the American College of Radiology (JACR), which are recommended for review as well.

  1. Levin DC, Rao, VM. Turf wars in radiology: the over utilization of imaging resulting from self-referral. Journal of the American College of Radiology (JACR). 2004;1:169-172.

There are 2 articles published in the literature which may be interesting, as they detail 2 different examples where a private payer implemented privileging programs or quality standards with success, resulting in cost savings and improved quality.

  1. Moskowitz H, Sunshine J, Grossman D, et al. The effect of imaging guidelines on the number and quality of outpatient radiographic examinations. AJR Am J Roentgenol. 2000;175:9-15.
This study of the quality issue found that high percentages of nonradiologists' offices had serious quality deficiencies. It also demonstrates that large savings were achieved by no longer allowing physicians to bill for imaging services outside their field of specialty expertise. This project was carried out for a managed care organization in the Northeast.
  1. Verrilli MS, Bloch SM, Rousseau M, Crozier MM, Yecies SB. Design of a privileging program for diagnostic imaging: costs and implications for a larger insurer in Massachusetts. Radiology. 1998;208:385-392.
This study of the quality issue found that, except for radiologists and cardiologists, high percentages of facilities did not pass a quality inspection. This project was carried out for Blue Cross and Blue Shield of Massachusetts. Large savings are estimated from no longer allowing physicians to bill for imaging procedures outside their field of specialty expertise.

The following earlier study on quality may also be of interest:

  1. Edmiston RB, Levin DC. Film quality assessment varies among specialties. Diagnostic Imaging. 1992:37-39.
This is an early article on the quality issue. It shows that some nonradiologists (internists, general and family practitioners, etc) do very poor imaging. This study was a project of Blue Cross and Blue Shield of Pennsylvania.

More recently, Health Affairs published an article on financial pressures and physician entrepreneurialism, which basically indicates that a primary physician strategy to increase income often includes investment in imaging and laboratory services.

  1. Pham HH, Devers KJ, May JH, Berenson R. Financial pressures spur physician entrepreneurialism. Health Affairs. 2004; 23, no 2: 70-81.

Following are other articles and studies that may be of interest:

  1. Aronovitz LG. Referrals to physician-owned imaging facilities warrant HCFA's scrutiny: General Accounting Office report to the U.S. House of Representatives. Washington, DC: General Accounting Office; 1994:5 Publication GAO/HEHS–95-2.
  2. Sunshine JH, Bansal S, Evans RG. Radiology performed by non-radiologists in the United States: who does what? AJR Am J Roentgenol. 1993;161:419-429.