Addressing Overutilization
2005 Moreton Lecture
David C. Levin, MD
If radiologists are going to successfully deal with the issue of overutilization of imaging services, they must be conversant with the evidence on self-referral so they can effectively participate in the ongoing debate with other clinicians, third-party payers, and policy makers.
Such was the key message delivered by ACR Fellow David C. Levin, MD, in the Moreton Lecture to a capacity audience during this year's Annual Meeting and Chapter Leadership Conference. In his presentation, titled "Overutilization of Diagnostic Imaging Through Self-Referral: What You Need to Know About It and What You Can Do About It," Levin stressed that his comments were not meant to impugn other physicians.
"They simply cannot be expected to perform well in trying to practice a specialty in which they have not been fully trained," he noted.
Levin's comments were supplemented with data from MedPAC and the Blue Cross Blue Shield Association, demonstrating the rapid growth in imaging services and the fact that self-referral by nonradiologist physicians in their offices "is a major driver of this trend." Moreover, Levin was quick to point out that these organizations, and others, "are very concerned about the cost implications."
This exponential increase in self-referral, he continued, has resulted in 3 major adverse consequences for both the health care system and the patient population: (1) overutilization of imaging services, (2) errors in interpretation, and (3) inadequate technical quality.
Levin, former chair of the Department of Radiology at Thomas Jefferson University Hospital in Philadelphia, presented revealing data produced by himself and his colleagues at the Jefferson Center for Research on Utilization of Imaging Services to support his position. According to the data, between 1993 and 2002 the noninvasive diagnostic imaging utilization rate per 1,000 Medicare beneficiaries rose only 7% among radiologists. By comparison, the same rate rose 49% among nonradiologists and 141% among cardiologists.
He proceeded to present evidence demonstrating interpretive errors and inadequate technical quality when imaging services are performed by nonradiologist physicians.
"Side-by-side comparisons of radiologists and nonradiologists reading plain radiographs have shown that radiologists are consistently more accurate," Levin emphasized.
As for technical quality, Levin cited several audits by third-party payers that revealed a high incidence of unsatisfactory quality among imaging facilities operated by nonradiologist physicians.
While these self-referral statistics paint a bleak picture of the state of diagnostic imaging, Levin was quick to point out that awareness of the problem is increasing among the health care community and "there are reasons to hope that solutions may be on the way" as a result of recent news media reports on the issue.
"MedPAC has issued a recommendation that standards be imposed on all physicians who perform or interpret imaging studies on Medicare patients," Levin said. "The state of Maryland has already restricted nonradiologists from putting CT, MR, or radiation therapy equipment in their offices, and several other states are considering similar measures."
In fact, he continued, Highmark Blue Cross Blue Shield of western Pennsylvania has instituted new privileging guidelines making it much more difficult for nonradiologists to operate MR or CT units in their offices.
Levin briefed the audience on the ACR's recent initiative to develop training standards for "designated physician images" and related options that are available to help curtail the increase in self-referral for diagnostic imaging.
"I urge each of you here today to familiarize yourself with these possible solutions and be strongly supportive of these efforts, even though it might cause you some pain," Levin concluded.