Neurologists say that they’ve been involved in medical imaging since its beginnings and that self-referral is intricately tied to good medicine. Some radiologists adamantly disagree. Is there a middle ground?

Over the last several years, “self-referral” has become a credited cause for the rapid growth in medical imaging, and an increasingly maligned trend. Researchers and professionals within and outside radiology are blasting the practice of self-referral as ethically flawed, and the root of many of health care’s financial woes.

In the area of neurology, however, the acceptance of this view is causing great concern. Those neurologists who include imaging services within their practices, or support the right to do so, call into question the vilification of self-referral. They argue that long historical ties between neurology and imaging make for a cohesive and natural partnership, and that self-referral is intricately tied with good medicine. And they claim that today’s radiology realities demand that neurologists step up into imaging roles.

In a time when costs are king, and the medical profession is hurting, is there room for both radiology and neurology in the field of imaging?

Self-Referral Concern and Confusion

Imaging as a whole is in an unprecedented place of importance in health care today. The advent of powerful and specialized technology like CT and MRI has revolutionized every area of medicine. For this and other reasons, utilization is up to record levels. A study by Georgetown economist Jean Mitchell in the May 2008 issue of Medical Care examined private insurance reimbursement trends across California from 2000 to 2004. She found imaging utilization shot up during this time period, by almost 400% for PET scans and more than 50% for MRI and CT scans. Radiologist Rebecca Smith-Bindman conducted a similar study for Washington State, published in a 2008 issue of Health Affairs. Over the years 1997 through 2006, the study showed CT imaging increased 14% per year and MRI increased 26% per year. Over the 10-year period studied, ultrasound increased by nearly 40%, CT doubled, and MRI nearly tripled.

Increased utilization makes sense. Technology is more widely available. Patients and physicians demand imaging to round out their care. Reimbursements are favorable. But increasingly, the idea of increased utilization is decried as a detriment to the system. What’s the problem? Increased utilization can mean increasing radiation exposure for patients. It can mean higher insurance premiums for patients. And overall, it has meant skyrocketing health care costs. Smith-Bindman notes between 2000 and 2006, spending for imaging services more than doubled from $6.6 billion to $13.7 billion, an average annual growth rate twice the overall rate of growth in physician fee schedule services. The majority of the growth occurred for advanced imaging, including CT and MRI. But the biggest problem of all may be the potential for abuse of the system.

“With existing and proposed reimbursement reductions, physicians are all looking for other sources of income,” said Barry D. Pressman, MD, FACR, chair of the S. Mark Taper Foundation Imaging Center and Department, and chief of neuroradiology and head and neck radiology at Cedars-Sinai Medical Center, Los Angeles. “Imaging is an area that everyone sees as a potential benefit. The risk is this: if people are benefiting by volume, they might take some advantage. They might take leeway with what is and what is not appropriate in the patient’s care. As a result, the patient suffers, but also society suffers as a result of unnecessary increased health care expenditures.”

Therein lies the major problem of self-referral. Defined as physicians referring patients for ancillary services to their medical facility, or one in which a financial interest is held, self-referral is disallowed under the Stark II regulations created in 1993. But exceptions and loopholes mean physician group practices can self-refer under certain criteria and hospitals are exempt.

In the last decade, articles, studies, and reports are crediting self-referral as a major source for the rapid growth of medical imaging. But what’s the real story? Attempts to definitively explore the issue, not to mention find a solution, are caught up in a ceaseless back and forth: Proponents of self-referral see financial opportunity combined with better, more convenient care for patients, while opponents see financial abuse and substandard service. And so the debate rages, and patients are stuck in the middle.

Neurology and Self-Referral

Neurology is placed squarely in the midst of this debate. Many of those articles and reports blaming self-referral for increased utilization call out neurology as one of several offending fields.

For example, in the February 2008 Journal of the American College of Radiology, David Levin, MD, department of radiology, Thomas Jefferson University Hospital, Philadelphia, found from 2000 to 2005, private-office MRI examinations performed by radiologists increased by 83% while private-office MRI examinations performed by nonradiologist physicians increased by 254%. The nonradiologic specialties most actively involved in performing MRI included neurology (63,363 Medicare studies in 2005) and neurosurgery (20,712 studies). Levin’s implication is that self-referral accounts for the majority of this increased utilization, an implication echoed by many in the radiology field.

As a result, neurologists are concerned about their increasing role as a target for self-referral opponents and that their side of the story is subsumed in rhetoric. Central to that story is an essential question that often gets ignored: Is self-referral really a problem?

“The notion of self-referral as something bad is disingenuous and limited,” said Mircea Morariu, MD, neurologist at Florida Neurologic Center, Delray Beach. Morariu pursued a fellowship in neuroimaging as a student, and now acts as primary MRI and CT reader for his practice and for other specialized imaging centers. “There are so many aspects of medicine that rely on self-referral. A pain management doctor recommends an epidural for a patient, and he administers it. A spine surgeon recommends surgery, and she conducts it. Even in neurology, it’s accepted for a clinician to recommend and then perform an EEG. But when it comes to MRI and CT, suddenly it’s inappropriate? If a neurologist is trained in these areas, it makes absolute sense for them to fold it into the practice.”

Self-referral aids medicine, neurologists say. Regarding the idea that self-referral and increased utilization are tied, neurologists agree that imaging is at an all-time high. But they disagree with the central supposition that self-referral is necessarily to blame, or that the growth in imaging is caused by anything other than need.

“There are two sides to the story,” said Adnan I. Qureshi, MD, professor of neurology, neurosurgery, and radiology at the University of Minnesota Medical Center, Minneapolis. “On the one hand, we have the argument that self-referral increases utilization. But on the other hand, the data does not conclusively demonstrate such a trend. Self-referral is a necessary method of streamlining the patient management process and maintaining continuity of care, which is essential to patient care.”

The neurologist argument for self-referral starts with these ideas, and then focuses on the history of the field. Neurologists have been at the forefront of medical imaging since its beginnings in the early 20th century. A neurologist, William Oldendorf, one of the founders of the American Society of Neurology (ASN), was the first to describe an early precursor to modern CT scanners in 1961. As far back as 1975, the American Neurological Association declared the unbreakable ties between imaging and neurology, resolving that “neurologists must be intimately involved with planning, implementation, and execution of programs designed to teach these new techniques to physicians, technicians, and students.” Organized neuroimaging was born, and today the American Society of Neuroimaging is at the forefront of administering neuroimaging certifications in MRI, CT, and neurosonology; nearly 1,000 neurologists have been certified in neuroimaging this way.

Based on these long ties, the extensive training and certification available, their deep knowledge of structure and function, and their personal relationships with patients, neurologists feel they are in a unique position. They should be the authority on determining when images are needed and interpreting the findings of imaging studies. As a side benefit, they should receive any financial benefit that may result.

“It comes down to responsibility,” Morariu said. “My job doesn’t end when I finish an imaging report. I also have to use that report as clinical information to take care of my patient. It’s critical for the study to be interpreted properly, so that I have the best quality information to take care of my patient. That’s why I look at the images myself.”

The status quo, however, boxes neurologists out of this natural position. MRI and CT are predominantly done by general radiologists, particularly in hospitals. Neurologists say patient care suffers as a result.

“Some general radiologists may have the training and background in neurological images,” said Leon Prockop, MD, neurologist at the University of South Florida. “But they’re billing for the professional, interpretative component of the MRI without the full level of expertise they should have, and without the responsibility for the patient’s care and outcome. That’s a needless waste of time, effort, and money.”

More and more, many radiologists agree with this notion that general radiologists are in a position they shouldn’t be. In an essay for the Journal of the American College of Radiology, Stanford University radiologist Scott Atlas made the case for subspecialization within radiology as the key to the profession’s survival, questioning whether general radiologists could “understand more about imaging studies of the brain than a neurologist or neurosurgeon who sees these patients and their imaging studies all day long.”

Specialization is a fine notion, say neurologists, but the reality is one of impossible numbers. There simply are not enough neuroradiologists to serve the entire country, meaning many hospitals and rural areas must rely on general radiologists. In these cases especially, neurologists know far more about neuropathology, neuroanatomy, and clinical differential diagnosis, and can improve patient care by reading the images.

The argument for neurologist self-referral, then, is about providing patients the best quality of care. It’s about relying on those with the expertise and experience, allowing specialists with the proper training and certification to practice their discipline. And it’s also about saving costs in the long run.

The Radiologist Take

The neurology argument for self-referral is compelling. But neuroradiologists see multiple areas of fault, all centering on experience and expertise.

“There is simply no situation in which a neurologist is better trained in imaging than a radiologist,” Levin said. “Neuroradiologists have their residency and fellowship concentrated in neuroimaging. Neurologists do not have this background. Even in hospitals where general radiologists read the neuro scans, they have had 4 months of neuroradiology training in residency, and the potential for additional training in their fourth year. Neurologists are great at what they do, and are fine physicians. But they are not properly trained in neuroimaging.”

A neurologist’s expertise in their area can ensure phenomenal patient care in nearly all aspects of care. But when it comes to imaging, nothing will replace the skill and objectivity of a radiologist, they say.

“Neurologists have taken the position that since it is their field, they can better interpret the imaging on their patients,” Pressman said. “My experience is that this is not the case. Unless they were reading images all day, everyday, neurologists don’t have the database of cases in their mind to make the tough calls. Additionally, the MRI and CT are very complex instruments. Understanding the physics of the machines, utilizing them correctly, and keeping up with all the changes are difficult enough for me, let alone a neurologist who must also be expert in neurological care. That is why subspecialties like neuroradiology are so important today.”

While neurologists also suggest that their personal relationship with patients is a strong reason they should keep imaging in house, neuroradiologists say this can actually weaken interpretation. A neurologist who conducts a thorough exam might suspect MS, and therefore look only for signs of the disease in the film. Neuroradiologists can remain objective, look at all four corners, and ensure nothing is missed.

A Middle Ground?

And so the debate continues. While each side presents their valid issues and supporting evidence, stubbornness sets in. Anxiety about remaining financially solvent seeps in. Formal organizations join the fray: The AMA opposes efforts to further restrict self-referral, and the major organizations within neurology have echoed the AMA position. At the same time, the ACR supports federal and state legislation designed to inhibit self-referral, opposing self-referral as a financial arrangement that improperly affects a physician’s medical judgment on how they should treat a patient.

Each side blames the other for impure motives and goals. And occasionally it feels as if the issue has become a down and dirty turf war. Is there a middle ground? Can radiology and neurology coexist in a compromise, one that benefits clinicians and patients?

“There’s always a middle ground,” Qureshi said. “In this case perhaps the middle ground is that all qualified individuals should be able to read and interpret images, independent of background and without arbitrary lines drawn. For the best solution, we can look to examples in other fields that have weathered similar storms. Their experiences can help us cut through this debate, and develop a plan that provides patients with the best care by maximizing utilization of expertise.”

In the end, new laws and regulations may solve the problem, as insurance increasingly favors certified administrators of images, and neurologists are finding it harder and harder to apply for and obtain that certification and credentialing. But no matter what happens, both neurologists and radiologists caution that we must keep a sense of what is at stake in this argument. We must find that middle ground and remember what this entire argument is for, or we risk losing our central focus as good clinicians.

“This can’t just be a turf war,” Pressman said. “That cannot be the central point or it minimizes this debate, taking away what really matters. We have to keep the patient in mind, or this simply becomes a pointless and ultimately detrimental argument. The primary issue is to ensure that the patient is getting the optimal care.”

Amy Lillard is a freelance writer for Axis Imaging News.