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!