Radiologists pull out the long knives

Radiologists get awfully worked up when other specialists (like cardiologists and orthopedists) get into the lucrative advanced imaging business. In the past it really hasn’t mattered that much because there’s been plenty of imaging work to go around and the pie continued to balloon.

Now that cost control and radiation exposure are firmly on the table, the radiology community is nervous that the overall pie might stop growing or even shrink. When that happens they want to grab a bigger slice. They sure don’t want others using up the financial or radiation budget!

The latest salvo is fired by American College of Radiology researchers Jonathan Sunshine and Mythreyi Bhargavan in the December issue of Health Affairs (The Practice of Imaging Self-Referral Doesn’t Produce Much One-Stop Service). They attack (non-radiologist) physicians who refer patients for imaging tests in facilities owned or leased by the physicians themselves. Such “self-referral” is allowed by Medicare because it purportedly provides advantages to patients, including same day service.

Sunshine and Bhargavan repeat previous critiques of self-referral –including that such policies leads to a lot more use of imaging, higher costs and higher radiation doses– then hone in on their principal line of attack: that self-referral does not actually lead to same-day service, at least for CT and MRI scans.

The evidence as presented by the authors is fairly compelling, and they really go for the jugular in interpreting their findings and making policy recommendations. In particular:

  • In the “study limitations” section –where authors typically explain why their results may need to be tempered in some way, these authors point out that their findings “may seriously overestimate the extent to which self-referral is truly a one-stop process.” A key reason is “abusive” practices –providers lying on their bills about the location of services. In other words, they want us to think the problem is even worse than they’ve shown!
  • The authors cite profit-maximization as a motive for self-referring physicians, who claim their pricey MRI and CT  machines are used for same-day service while actually booking ahead to maximize utilization
  • The authors want Medicare to limit the self-referrals to x-rays, which are low cost and low profit, and disallow it for advanced imaging such as MRI and CT
  • They go even further by suggesting other self-referral exemptions not related to imaging –including physical therapy, lab tests, and durable medical equipment– should be examined, too, to see whether they also lead to overuse and other “undesirable effects” like high pricing and “cream skimming” of easy to treat, well insured patients

The authors may be completely correct in their analysis and recommendations but the results are so transparently self-serving to the ACR membership that they bear independent scrutiny.

I got my biggest chuckle out of the last suggestion (to look at areas other than imaging). The only reason that’s in there is to try to attract others to the radiologists’ side. But radiologists are famously friendless among their clinical colleagues and it will take a lot more than this suggestion to bring others around. Nice try though!

December 14, 2010

7 thoughts on “Radiologists pull out the long knives”

  1. In the end, I’m not sure what your stance is here. Are you saying that self-referral is, in fact, okay? Or that you agree with the message but not the medium? You accuse Jonathan and Mythreyi of being self-serving to the field of radiology, but it seems like you, to some extent, defend the non-radiologists for, in effect, being EXTREMELY self-serving. Their goal was not to prove that this is bad for patients — in fact, that has already been soundly proven – but to try to make this phenomenon better known. So yes, they are trying to “attract others to the radiologists’ side,” but keep in mind the motivations of each party here. Radiologists are actually trying to SHRINK THE PIE. Yes, trying to take more of that pie, but, because overuse of imaging is bad for patients and bad for our national health care system in general, they are trying to DECREASE growth in imaging.

    Think about this very carefully — in what other field in medicine is the representative body of that field actively trying to decrease work? Do you think a cardiologist would ever argue that there should be interventional procedures? Would a urologist ever recommend we cut back on prostate biopsies, even in the face of evidence that we over-diagnose and over-treat prostate cancer? Radiologists are unique in this respect.

    So, again, what is your point? Yes, the article was self-serving. But should radiologists simply sit by the wayside while specialty after specialty abuses the health care system and its patients to pad their own pockets? While perfectly capable professionals, who spend years training in the field and learning about the effects of radiation on individuals and the population, watch others try to unfairly steal their work?

    Also, thank you so much for noting that radiologists are “famously friendless.” It is so comforting to know, as a radiology resident, that I’m entering a field that will leave me lonely, distressed, and broke thanks to the perpetuation of such untrue and harmful stereotypes.

  2. Thanks for the comment, AHK.

    The point of the post is that ACR is being completely self-serving and before we accept their findings and conclusions we’ll need independent validation.

    I don’t really believe radiologists are trying to shrink the pie. Rather they realize the pie is going to stop growing and want to make sure to elbow any competitors out of the way in order to grab whatever’s left. In addition, radiologists are worried that other specialties are giving imaging a bad name and may accelerate the decline in imaging volume growth or reimbursement rates.

    For the record I’m against self-referral.

    Radiologists aren’t that popular among their colleagues because they are perceived to get paid a lot without working that hard. That’s made worse by the tendency of radiologists (not all of them)to provide only mediocre service to physicians who are referring to them. For example, the radiologist may hang out in their dark room rather than interacting directly with PCPs.

    That means when it’s time for providers as a whole to consider ways to cut costs, they don’t and won’t hesitate to look into ways to squeeze radiologists.

  3. Thanks for the response, David. Unfortunately, I don’t think anyone will do “independent validation” on this, which is why the ACR feels compelled to.

    But do you doubt the actual results of the study? As long as there is no obvious flaw in the study’s methodology, I can’t see discounting it solely on the basis of the people who did it. If we waited for “independent validators” to perform every study in medicine…well, lets just say we’d still be putting leeches on wounds and performing frontal lobotomies. ANY study has to have some sort of self-serving purpose.

    I think what you’re referring to with this particular study is that, when radiologists are the self-serving ones, their reputation precedes them and no one gives them the benefit of the doubt. I can’t argue that there are some radiologists playing into the stereotypes you’ve outlined above, but the EXACT PURPOSE of studies such as this is to show everyone, “Look! We’re not just in it for the money! We legitimately care about patients and are willing to do the research to show that what we’ve been saying all along is, in fact, true.” It’s unfortunate it’s not being viewed that way, and is instead being viewed as a bunch of sniveling, anti-social eggheads locked in a dark room playing with gold doubloons. (As a corollary, don’t bloggers get the reputation of being degenerates living in their mom’s basement? Just kidding.)

    And you’re right, radiologists need to do a better job of marketing themselves, and that begins with showing PCPs and other referrers we’re interested in the clinical aspects of patient care, and we really want to integrate in their care. An uphill battle, to be sure, but hopefully the legitimate threats to our field that you discuss will spur us to do better.

    In response to radiologists “elbowing competitors out of the way,” well, you’re RIGHT, but don’t we have a purely legitimate reason for elbowing them out? It’s not just this study, but many studies have shown self-referral is bad, and this just confirms that the one argument FOR it is probably bogus. So should we just wait for someone to elbow everyone out for us? We both know that will never happen. We’re protecting our turf…but in my mind we’re completely justified in doing so. We’ve done plenty of legwork, and it would be nice to just say “let’s let everyone else prove us wrong,” but if we did that, we’d have no more pie. Such is the paradox of the modern-day radiologist, I guess. Damned if we fight, damned if we don’t.

    In case it wasn’t glaringly obvious by my long-winded comments, as someone going into the field, I AM scared that we’re going to be heavily targeted by government, providers, etc as a cost-cutting opportunity. I just wish it wasn’t going to be such an uphill battle, but I love what I’m training to do, I believe that I truly help patients, and I feel the trouble is worth it.

    Sorry for the rant. Thanks for inspiring great discussion on important topics.

  4. ACR research self-serving? Maybe true, but much research is self-serving, in some fashion. Should we question research by dermatologist when the reseearch demonstrates that a dermatologic procedure has benefit? Since most research is done by people whose promotions depend upon its publication, that creates an incentive for embellishment, if not fabrication. Thus, we look for duplication or corroboration of results.
    In the case of the ACR research, it basically corroborates and extends not only what has been shown many times in many venues; it confirms what common sense dictates: that doctors are human and subject to economic incentives and vulnerable to conflicts of interest.
    More common sense: How would you feel if the govt policy were to abandon the bidding process and, instead, let each defense contractor make its products and bill the Treasury for whatever supplies and services it performed, at its sole discretion. And what if the contrctor’s procurement officer were compensated onthe basis of the services he performed. Do you think he might drive up his procurement?

  5. Pingback: Radiologist: Commoditize thyself | Health Blog

Leave a Reply

Your email address will not be published. Required fields are marked *