As the Radiologist in Chief at Hospital for Special Surgery, an orthopedic hospital in New York City, I want to comment on an article that appeared in USA Today. The piece, which was titled, "Imaging at the doctor's: Good thing or transparent ploy?" addressed the concerns of how physicians are installing MRI, CT and other imaging equipment in their office and then performing imaging studies on their patients. This process of self-referring patients helps pay for their equipment and drives significant additional revenue. According to these physicians, the argument for in-office imaging equipment is patient convenience, one stop shopping and instant answers to the clinical question.
The potential problem with self-referred imaging examinations is the increased number of imaging examinations being ordered that may not be clinically required and the unnecessary exposure to ionizing radiation. In June 2008 a Government Accountability Office Report "Rapid Spending Growth and Shift to Physician Offices Indicate Need for CMS to Consider Additional Management Practices" found that advanced imaging (CT and MRI) costs more than doubled from 2000 to 2006. The report concluded the spending rise was linked to in-office imaging, occurring with a concurrent reduction in hospital based (Academic Center) imaging. These additional costs are passed on to the patient consumer in the form of taxes, additional insurance premiums, co-payments or worst of all, limitations to quality imaging services. Self-referral increases the insurance burden and contributes to the escalating health care costs and the spotlight on unnecessary imaging as a prime cause.
Many physicians with in-office imaging equipment do not use the expertise of a trained radiologist to interpret their images. A radiologist is a physician who has specialized in image interpretation with four years of dedicated post medical school training. Additionally, they are trained in appropriate utilization of imaging, image acquisition, how to obtain a quality image with minimal exposure, and how to protocol a CT or MRI to optimize the images to best demonstrate a suspected abnormality. Radiology training in radiation safety, image acquisition and interpretation is much more intensive than the non-radiology physician specialists receive in their few weeks or months of rotating though an X-ray department during their training programs. Radiologists' training is in imaging and their expertise is validated by the certifying examination of the American Board of Radiology. Similar to the physician ordering the imaging examination, it is ideal if the radiologist is sub-specialized with an additional year or two of advanced training in image interpretation associated with a specific field of medicine.
At HSS we frequently see self-referred imaging examinations that were performed at outside imaging centers and doctors' offices. Many of these examinations are of questionable quality and non-diagnostic due to motion, wrong pulse sequences, not specifically protocoled for the suspected condition, may not target the specific area, etc. These poor quality examinations often need to be repeated, adding cost for the insurers and patients, not to mention angst and possible missed opportunities for early diagnosis and treatment.
Collaboration amongst physician specialists and radiologists (imaging specialists) increases speed to diagnosis and provides the best protection and safety in image acquisition. The unbiased opinion of the radiologist should play a key role in helping to identify the right imaging study and an accurate diagnosis early in the course of a disease or condition. Collaboration can help to drive down and control the overall costs of health care. Expert imaging leads to expert diagnosis and less need for repeat imaging and unnecessary additional imaging examinations. All of this equates to improved patient care quality and lower health care costs.
Quality experts in their respective fields increase the potential for earlier diagnosis when clinical presentation and imaging findings are still subtle. In the long term, earlier diagnosis saves money for insurance companies, the patient and overall cost of health care. Patients should ask their doctor who will be supervising and protocoling their imaging examinations. Patients should be informed of the imaging training and expertise of the physicians interpreting their examinations. Radiologists are unbiased experts who are trained to interpret imaging examinations. With fewer barriers to care, like pre-authorization for imaging examinations, patients will be able to go to quality providers earlier in their care. Patients in our health care system require expert sub-specialty trained physicians as is most typically found at academic departments.