New data show self-interpretation is especially common among smaller practices and certain specialties, raising questions about training and potential conflicts of interest.
A new Harvey L. Neiman Health Policy Institute study investigated whether office-based providers are more likely to refer imaging to a radiologist or to self-refer and interpret the ordered imaging studies themselves. The study found that 43.6% of office-based studies were interpreted by the ordering provider, and 58.5% were interpreted within the ordering provider’s practice.
Rates of self-interpretation varied by the specialty of the ordering provider and the imaging modality. This study, published in the American Journal of Roentgenology, was based on over 1.6 million office-based imaging claims for Medicare fee-for-service beneficiaries in 2022 that were ordered by non-radiologists.
Self-Interpretation Rates Vary by Modality and Specialty
By modality and across all specialties, the study found that the self-interpretation rate for office-based imaging was 50.4% for radiography and fluoroscopy, 52.0% for ultrasound, 39.5% for nuclear medicine, 5.3% for CT, and 6.1% for MR. Self-interpretation by specialty was 19.9% for primary care physicians, 75.7% for orthopedic/sports medicine physicians, and 30.5% for non-physician practitioners.
Practice size was another important determinant of self-interpretation rates, which were substantially less in the largest practices (500+ providers) than the smallest practices (1-9 providers): 24.2% vs 48.9%, respectively.
Access to Radiologists May Curb Self-Interpretation
“Whether or not there was a radiologist in the ordering provider’s practice was highly correlated with self-interpretation of imaging by the ordering provider,” says Eric Christensen, PhD, research director at the Neiman Health Policy Institute, in a release. “If there was a radiologist in the practice, the odds of self-interpretation [were] about one-half compared with practices without a radiologist on staff. Conversely, the odds of within-practice interpretation were generally two to three times higher if there was a radiologist in the practice.
“Ongoing healthcare consolidation, which is creating larger, multispecialty practices, may serve to reduce imaging self-interpretation by increasing access to a within-practice radiologist. Such centralization of radiology services may encourage referral of imaging interpretation to the within-practice radiologist in lieu of potential self-interpretation.”
Training Gaps and Policy Questions Remain
The results raise potential implications for patient care quality, according to Vijay Rao, MD, senior vice president of enterprise radiology at Jefferson Health and professor of radiology at Thomas Jefferson University. “Non-radiologist specialties, aside from cardiology, lack the rigorous and comprehensive training in imaging interpretation that occurs during the four years of a radiology residency program,” Rao says in a release. “Some specialties may provide targeted training in imaging interpretation that is narrow in scope, such as in ultrasound for emergency medicine or obstetrics/gynecology. The large differences between radiologists and non-radiologists in interpretation training could lead to differences in diagnostic accuracy.”
Rao continues, “At present, there is little restriction on imaging interpretation by non-radiologists and concerns of financial conflicts of interest related to self-referral contributed to the passage of the federal Stark law in the 1990s, intended to curb the practice of self-referral. However, the law’s in-office ancillary exception greatly weakens its ability to restrict imaging self-referral. Hence, our results highlight a need to revisit the in-office ancillary exception policy to impact the potential financial incentives that lead to self-referral.”
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