The authors looked at 733,459 episodes of care involving 470,530 unique patients age 65 or older. Federal rules prohibit physicians from referring patients to a facility in which the doctor has a financial interest, but those rules exempt some ancillary services, including imaging, if they are delivered in a physician's office. Conditions evaluated ranged from back pain, headache, digestive neoplasms, heart disease, extremity fractures, dislocations, and respiratory disease.
With some exceptions when the test ordered was an X-ray, Hughes wrote, "Physician self-referral for imaging is not associated with significant benefits for patients in either illness duration or healthcare costs," they concluded.
For example, when physicians self-referred patients with sinusitus for X-rays in their offices, there was a 7.8% shorter duration of episode and 3.6% higher cost. "This amounts to 1.3 illness-free days gained at a cost of $3.92."
"Medicare's current exemption for self-referred imaging should be narrowed so that it includes only X-rays, not other forms of imaging," the authors conclude. "To the extent that state laws or private payers permit self-referral for imaging, they would also do well to follow this policy."
Hughes' finding is consistent with a 2005 report by the Medicare Payment Advisory Commission, which looked at 22 medical condition—imaging combinations for Medicare beneficiaries in six major U.S. markets. "Med-PAC found that self-referring physicians had higher ratios of observed-to-expected spending on imaging than doctors who did not self-refer."
In a second article, Sunshine and Bhargavan went further. They said that despite physician contentions that self-referral imaging provides same day-service, and thus convenience for patients, in fact that is only true for 74% of x-rays. When ordering self-referral for more advanced procedures such as computed tomography and magnetic resonance imaging, only 15% of those tests are offered on the same day.
"Policymakers attempting to make the use of imaging more responsible should consider narrowing Medicare's special provision allowing referrals to a physician's own practice so that the provision covers x-rays only," they wrote.