Organized radiology is turning away from the term “self-referral.” While it is not backing away from the claim that nonradiologists are raking in more and more of the imaging dollar by sending patients to themselves, radiology wants to shift the focus off physician income. It wants to put the focus instead on the health care cost increases that occur from overutilization. It is also alleging that there is a certain amount of patient-unfriendly imaging being done by nonradiologists.

Thomas Fletcher, MD, is a Texas radiologist who hopes to convince his state legislature to take a new look at the self-referral-overutilization-quality of health care issue. He will be happy if Texas passes laws that make nonradiologists think twice before they refer patients for imagingon machines that they ownfrom a purely financial motive.

“One of the drivers of cost to health care is physician behavior,” says Fletcher. “It is incumbent on the physician community, before we point the fingers of blame at everyone elsepharmacies, hospitals, administrators to look internally and assess where the cost drivers are in our own behavior.”

Fletcher is a subspecialist in interventional radiology. He is a partner in the Austin Radiological Association, a group practice with about 60 radiologists. Past president of the Texas Radiological Society, where he still serves on the executive committee and board of trustees, he is also an elected member of the council steering committee of the American College of Radiology (ACR).

In discussing self-referral, Fletcher likes to begin from a broad perspective. “Nationally, 15.3% of American people are uninsured; in Texas, 25% of the citizens have no health insurance,” he says. “We are the only industrialized country in the world that does not provide a health care safety net.”

He believes the sheer numbers of health care “disenfranchised”now at about 45 millionwill mandate political action. “I think ultimately we will come to a single payor system,” he says, “but that’s 10 years away. Being a free market person, I don’t see single payor as a panacea. Probably, it will be thrust upon us. But between now and 10 years from now, we have to fix what we can of the problem.”

The part of the problem that radiologists need to be concerned with is what Fletcher calls “inappropriate utilization” of the many modalitiesfrom 64-slice CT to PET to MRI and on down the listthat have come into the imaging armamentarium in a technological surge over the last couple of decades.

“Physicians in control of these powerful technologies are in good faith employing them as they think best, but we don’t have any firm outcome data on whether procedure X or Y benefits the patient,” he says. “What’s occurring in medicine is a wholesale utilization of these techniques without a deeper understanding of what is appropriate. We lack the objective data.”

The lack of data can lead not just to overutilization but possibly to harm to the patient, he says.

“With MRI and CT, we’ve seen a 20% per year utilization increase. With CT you are irradiating people. A woman comes in with belly pain or shortness of breath. You order a CT. A woman’s breast tissue is vulnerable. A CT scan gives you a tissue dose to the breast 10 times the dose from a mammogram. Three CTs is a lifetime of mammo. Get 10 CTs and when do we talk about inducing cancer? We may be causing more harm than good. We may be causing cancer.

“Who’s minding the store?” he asks. “Well, organized radiology is stepping forth and asking as loud as it can about quality and patient safety.”

It is issues like quality and patient safety, Fletcher says, that have made him quit using self-referral as a tag phrase. Like the ACR, he prefers a term like “inappropriate use” that would include self-referral as one of its components. Ignorance is another component, he says, and so is defensive medicine.

Another reason self-referral is losing favor as a tag line in radiologists’ fight against other specialists taking over more and more imaging is that the radiology community now agrees that a lot of self-referral by nonradiologists is perfectly legitimate and good medicine. OB/GYN ultrasound is a favored example.

“The way modern medicine is engineered, you cannot really do away with self-referral,” says Fletcher. “If an obstetrician/gynecologist has an ultrasound machine in his office, that’s self-referral. But that is so woven into the fabric of medicine, how do you outlaw it?”

On the other hand, he suggests, “Just when is obstetrical ultrasound appropriate? That needs to be given top priority in clinical research.” He says the same kinds of questions in other disciplines where self-referral is growing need answers too. The goal for radiology is to curtail overutilization by establishing guidelines that determine appropriateness.


Harvey Neiman, MD

But just how bad is self-referral that results in overutilization or inappropriate use? That is not an easy question to answer, particularly if some, perhaps a major portion, of self-referral is viewed as legitimate even by the radiology community.

In its report to Congress in June of this year, the Medicare Payment Advisory Commission (MedPAC) cited its own analysis of Medicare Part B data from 2002. The MedPAC analysis found that radiologists did 48% of all reimbursed Medicare imaging, meaning that nonradiologists billed for the remaining 52%. Among those nonradiology billings, cardiologists had by far the largest piece of the pie at 23% of the imaging total.

According to MedPAC, another 7% was done by independent diagnostic testing facilities (IDTFs); 5% by internists; 6% by surgeons of various specialties; 4% by “other” medical practitioners; and the remaining 7% by another group of lumped “others” that included portable x-ray suppliers, nuclear medicine, and multispecialty clinics. These figures do not reflect radiologists’ involvement in imaging, since radiologists may have been paid to interpret images for which other specialties or entities did the billing, particularly IDTFs.

The MedPAC study did not pinpoint amounts of self-referral but it did confirm the way imaging is slipping from radiologists’ grasp. Other studies have shown a similar pattern.

According to data provided by the ACR, nonradiologists performing their own imaging are two to seven times more likely to order imaging procedures than are treating physicians with no stake in the radiology practice to which they are referring. Self-referring physicians order as much as 54% more imaging for their patients than do physicians without a financial interest in the imaging they order, the ACR data indicates.


In a big-picture bit of research using 2002 Medicare data, the ACR attempted to determine how radiology would be impacted if radiologists “won back” imaging lost to nonradiologists or, conversely, if radiologists “lost” all imaging to nonradiologists in other clinical specialties. That study, which remains unpublished, found If radiologists “won back” all imaging services to Medicare beneficiaries, then the radiologists’ workloads (measured in professional component relative value units) would increase by as much as 86%, and the total number of procedures relative to their workloads would increase by as much as 61%.

Breaking this workload data down into its component modalities, the study found that for ultrasound the procedures would increase by 29% and the PC-RVUs by 37%. Similar tallies for interventional radiology were 5% volume and 28% workload. For nuclear medicine, it was 6% volume and 9% workload; for x-ray, 19% and 8%; for MRI, 1% and 2%; for CT, 1% and 1%, and for mammography, 1% and zero.

  • The study also analyzed how much of these “won back” gains would come from categories of competing specialists. This data showed cardiologists were by far the main competitors. Workload gains from cardiologists for ultrasound were 17% for procedure volume and 23% for workload PC-RVUs. For IR, the gain from cardiology was only 3% in volume but 22% in workload. All other gains charted, including those involving other clinical specialties, were in the single digits.
  • Computing volume and workload gains by body part, the study found nervous system workload would increase by 2.8% and volume by 2.5%. Vascular imaging would increase by 10.9% in PC-RVUs and 5.2% in volume. Cardiac imaging would increase the most, 56.7% in workload and 27.8% in volume. Other body part tallies were too small to be broken out in the report.

The report also attempted to compute how much Medicare imaging radiologists would “lose” if nonradiologists captured it.

  • Organizing this “loss” data by modality, the study found radiologists would suffer workload losses of 31% in CT, x-ray 22%, MRI 13%, IR 12%, ultrasound 9%, nuclear medicine 7%, and mammography 5% if nonradiologists captured these imaging segments.
  • Tellingly, the study also compared radiology “wins” and “losses” using 1995 data to compare to the 2002 data. The comparison showed that radiologists are losing more and more imaging to nonradiologists. “In 1995, the role of nonradiologists in radiology was 72% as large as the role of radiologists (measured in PC-RVUs). By 2002, it was 86% as large,” the study says.


David Levin, MD

David Levin, MD, is former chairman of the Department of Radiology at Thomas Jefferson University Hospital in Philadelphia. He now serves as national medical director for HealthHelp Inc, a Houston-based radiology management services company.

Levin and fellow researchers Vijay Rao, MD, current radiology chair at Jefferson, Andrea Maitano, MS, and Larry Parker, PhD, conducted their own analysis of Medicare Part B data and found a pattern similar to MedPAC’s, showing cardiologists were second to radiologists in performing the highest number of imaging examinations.

“The payments from 1998 to 2002 went up by 65% to radiologists,” Levin says, “but to cardiologists they went up by 105%. The utilization rate of ultrasound between 1993 and 2001 by radiologists was up 25%, but among cardiologists it went up by 87%.”

Levin’s team also analyzed the increase in utilization of stress nuclear cardiac scans, a procedure that is routinely done by both radiologists and cardiologists. “When radiologists do them, it means a cardiologist or another doctor has made a referral,” Levin notes. “When cardiologists do them, it’s a self-referral situation.”

In an earlier study on 1996 to 1998 data, Levin’s team found stress nuclear cardiac scans by radiologists rose 4%, but those by cardiologists rose 36% during the time span. Looking at the same stress nuclear cardiac scan Medicare data for 1998 to 2002, Levin says, “We found that the overall utilization rate increase for all specialties was 42%, but among radiologists it was up only 2%, and for cardiologists it was up 78%. If this represented a shift in volume between cardiologists and radiologists, you could say it was just competition, but the overall utilization rate increased 42%. All of that increase is attributable to cardiologists.”

He adds, “The cardiologists would like you to believe they used this scan to substitute for cardiac catheterization, but during those same years cardiac catheterization was up 20% among cardiologists. The huge jump in stress nuclear cardiac scans is not a substitute for cardiac catheterization. There is no medical reason why this should be happening. Cardiologists who self-refer are driving this utilization through the roof.”

In another bit of data, Levin says orthopedic surgeons had much higher utilization increases for MRI, although the orthopedic volumes were far smaller than radiology volumes. “Between 1997 and 2002,” he says, “the payments to radiologists for MR went up by 99%. The payments for MR to orthopedic surgeons went up by 599%.”


Nobody wants to fault OEMs (original equipment manufacturers) for pursuing sales on behalf of their stockholders. Nonetheless, the push by OEMs to move equipment into clinicians’ offices is viewed as part of the reason that nonradiology imaging is proliferating.

“The physician who owns the equipment gets the technical reimbursement,” Levin says. “There’s plenty of profit, and that’s still self-referral. If the manufacturers weren’t pushing that equipment on these other doctors, a lot of this wouldn’t have happened.”

William Thorwarth, Jr, MD

William Thorwarth, Jr, MD, FACR, is a North Carolina radiologist with a long history in the ACR. He is a former ACR president and a former head of its economics commission.

Thorwarth says in his view self-referral has become “progressively severe.” And he thinks manufacturers are partly responsible. He also says OEMs are hurting themselves in the long run by pumping too much imaging equipment into the hands of clinicians that may not use it appropriately.

“The vendors need to realize they have a responsibility,” he says, citing the example of a nose and throat clinic near him that was just sold a CT scanner. “I don’t know who’s pushing the buttons [on the scanner],” he says. “I find that unconscionable that a company would do that. They may be putting ionizing radiation into the wrong hands.”

But Thorwarth says the biggest problem with the proliferation of imaging equipment and its use by nonradiologists is that “there is no oversight organization and quality control is on a voluntary basis.”

Moreover, he says, payors have been blaming radiologists for skyrocketing imaging expenses without recognizing the differentiation in the imaging done by nonradiologists.

“The problem is there is no difference in the reimbursement arena between a 15-year-old ultrasound machine used by someone with no training and someone with a new machine and a certified sonographer performing the exam,” he says. “This makes it easier for a physician to augment income, but there is no assurance of examination and patient care quality.”

In his own practice, Thorwarth says, “We see a lot of follow-up second opinions chasing a sort of pseudo-lesion. You have a lot of false positives chasing something that’s not there to begin with because of inexperienced people. That’s a common pattern.”


Nearly everyone in radiology agrees that the self-referral problem is real and growing. Not everyone agrees on what to do about it. A lot of people are trying hard to do something, getting the message out to legislators and payors and patients too. This effort has provoked a response.

Nonradiology clinicians who do imaging in their offices are not sitting quietly watching the radiology community assail them. They are fighting back. The American Medical Association (AMA) has passed a resolution opposing any strengthening of self-referral legislation. The American College of Cardiology (ACC) is mounting public relations and lobbying efforts to achieve the same purpose (see box at left). And they are using the same argument radiology uses, that what is at stake is good patient care.

The resolution passed by the AMA in June reads in part: “There is value to having imaging interpretations performed by a physician who has a full knowledge of his/her patient’s medical history… . Additional restrictions on physician ownership and referral of imaging services will force patients to go elsewhere for diagnostic testing and will disrupt the important continuity of care.”

For its part, the American College of Radiology is seeking to offer training and accreditation that will assure quality imaging and interpretation. Its programs are not just for radiologists; other specialists can seek ACR training and certification too.

“We have created a number of guides for physicians to use in their image ordering patterns,” says ACR executive director Harvey L. Neiman, MD. “We are also trying to accredit and to make sure that imaging users are quality trained. We are looking at accreditation programs for facilities… . We think radiologists are leaders on appropriate utilization, but we want to get away from the knee-jerk response of saying that all self-referral is automatically bad. Some nonradiologists do good studies and use the technology appropriately.”

But as Neiman describes it, politically at least, the ACR is in something of a holding pattern.

“We are working with a variety of sources, whether private payor or government agency,” Neiman says. “We are listening to our specialists and subspecialists to try to understand their viewpoints. We are listening and learning and talking to a whole lot of people.”

Neiman says the ACR shares the concern in radiology that higher imaging costs will simply goad payors into seeking across the board cuts in reimbursements.

“Our concern is that all of imaging not be tarred by looking in some cursory fashion at the fact that costs are going up and therefore the quickie answer is to reimburse less. We are trying to look at it more carefully. Where utilization is appropriate, we don’t have a problem. Where the patient is not getting the value, we think that needs to be looked at.”

But the issue is complex, and having acknowledged the legitimacy of self-referral in many cases, radiology must frame its requests to legislators carefully.

“I don’t want to say that we are targeting any one approach as to what is best for the patient and therefore radiology as well,” Neiman says. “A whole variety of approaches are being studied, and we are not ready to take a stand. We have not committed to strategy or tactics. We are not lobbying for changes in self-referral laws. We have not introduced any bills or asked anybody to introduce them for us. We have not approached any Congressman about changing legislation.”

Neiman says the ACR’s stance that “imaging is best done by those trained to do it” does “probably” bring it into conflict with other physician organizations, but he calls the AMA’s self-referral resolution “a premature reaction… . A more thoughtful approach would have been to come and talk to us. It was unnecessary and counterproductive.”


Cherrill Farnsworth

While the ACR is moving carefully, some in radiology are pushing more aggressively for controls on self-referral and inappropriate utilization.

Cherrill Farnsworth is CEO and chairman of HealthHelp Inc, a radiology management services company. She is also the founding executive director of the National Coalition for Quality Diagnostic Imaging Services (NCQDIS), a political action committee that represents more than 2,400 imaging centers and imaging departments. NCQDIS has hired a public relations firm that has gotten self-referral concerns written up in several national newspapers. It has hired a Washington, DC law firm to lobby on its behalf.

“The radiologist is the faceless doctor,” says Farnsworth. “The patients don’t know who is reading their studies.”

NCQDIS wants to change that. “Some of us don’t have the ability to stand by and watch the radiology industry go by the wayside, and that’s what we’re facing,” Farnsworth says. “The radiology community does not seem to be very aware of the problem. We want to be in front of the government first, before we see the cuts in reimbursement for radiology that would cause diagnostic imaging centers to fail… . This self-referral issue is so big that it could really be critical to the specialty’s future, completely critical.”

Among those agencies that NCQDIS has been presenting to is MedPAC. In its latest report, MedPAC outlined but did not recommend a number of steps to control imaging purchasing. The MedPAC alternatives reflect proposals that are coming from various sources, including NCQDIS. Among them:

  • Coding edits to be used during claims review to detect improper billings or adjust payments, especially unbundling of services and billing for mutually exclusive services.
  • Safety standards for imaging equipment that might entail periodic inspections of facilities and assessment of staff qualifications.
  • Physician privileging programs that would restrict payment for some imaging services to certain specialists, such as radiologists and cardiologists. “One effect of privileging is that it can reduce repeats of imaging studies,” the MedPac report says.

As far as Congress is concerned, action on self-referral, if there is to be any, is geared for 2005.

For years Rep Fortney (Pete) Stark (D-Calif) has promoted legislation to curtail self-referral. The Stark laws that earlier outlawed many kinds of physician self-referral bear his name. But nothing is pending on Stark’s calendar at the moment.

“We’re not promising anything about what’s going to happen next year,” says an aide. “You can say from Stark’s office right now it’s an open book as to what the next Congress will do with regard to this issue. We have nothing proposed. No Medicare cuts have been proposed. You have to look at Medicare as a whole, and no one has started to look at that yet.”


That leaves Texas as one example of what is being tried on the state level.

“The DC government really watches Texas as a bellwether,” says Farnsworth, whose company is headquartered in Texas. She says the Texas legislature has proposed a bill that would require ownership of imaging equipment to be reported to the state. Physicians who owned MRI and CT scanners would not be paid for their scans unless they had completed residencies in the technology, Farnsworth says. State courts upheld a similar law in Maryland, she says.

The Texas legislature early next year will also be presented with a study now being done to assess the impact of self-referral on overutilization. The Texas Radiological Society’s Thomas Fletcher is monitoring that effort. The study will look at state employer health plan data and focus on utilization of imaging, says Fletcher.

“We will then go to the Texas legislature and let the legislature decide if there is significant overutilization. We will let the democratic process decide what is the greatest good for the greatest number.”

Fletcher says he agrees with others that legislation, accreditation, and provider guidelines are ways to attack self-referral, but to those he would add a system of physician profiling so that payors and patients could get access to information about their doctors.

“As consumers, we’re entitled to know what’s behind the black box of the physician,” he says. “For too long, we have assumed all physicians are equal just because they all have a license. One of the parameters you might measure is referral pattern. If you have a doctor where every patient gets a CT scan, then we have an outlier. That doctor is overordering.”

Such profiling would not be an invasion of privacy, Fletcher insists. “We wouldn’t be violating HIPAA (Health Information Portability and Accountability Act) laws. Why would physicians be afraid? If you’re good, you’re good.”


As often happens, the private sector is not waiting for legislation to control self-referral.

Bruce Perkins is senior VP for national contracting at Humana Inc, one of the nation’s largest health insurance providers with nearly 6 million members.

Humana has hired HealthHelp Inc to provide what Perkins calls a “concierge service” to help direct patients to imaging centers where co-pays are smallest.

By directing patients to less expensive locations for imaging, Humana also saves, Perkins says. “If a procedure is $500 or $1,000 and the customer’s out-of-pocket is 20%, they are reducing our expenses as well [by choosing the less expensive option].” But he emphasizes, “We’re in the guidance business here, we don’t steer or mandate.”

Perkins says it is difficult for Humana to differentiate how much of the higher imaging utilization it is seeing is because of self-referral or whether the higher use is simply “commensurate with the burden of illness in our population.”

He says Humana is considering requirements that doctors be made aware of a patient’s imaging history before examinations are ordered.

“We are concerned about the rate of [imaging] escalation in both frequency and unit cost. We are concerned about appropriateness and patient safety. It’s well documented that multiple radiation exposures is not the best thing… .In the payor space you’ve got a pretty robust [imaging] history on the patient, which the varying providers may not have… . It is important for physicians who are referring folks for radiology exams to be thoughtful.”

Perkins says, however, that Humana would never decrease imaging reimbursements across the board. Price points are determined and then offered to radiologists, he adds.

John Donahue, MBA

“Radiologists are not sending us the message that they are upset with our fees. We’ve had no substantial turnover in the category of radiology service providers, so we believe our reimbursement is fair.”

Companies that manage imaging services are also acting to police inappropriate or excessive utilization.

John J. Donahue, MBA, is president and CEO of National Imaging Associates (NIA), Inc, a New Jersey-based radiology services management company that serves 30 health plans in 30 states with a combined patient population of about 15 million.

“They delegate fully to us anything to do with radiology except the billing,” Donahue says.

NIA already has in place controls like those being discussed for Medicare.

“We have a very comprehensive radiology provider assessment program,” Donahue says. “We also overlay a prior consultation requirement for any advanced study. We apply our own algorithm logic and then check the eligibility. If the imaging order is not appropriate, a radiologist will come online and talk to the referring doctor, and we will either approve or deny the order.”

He says in some states there are pockets where more imaging equipment is needed. In other states, like Florida, he says, there are too many machines.

“They are on every corner, and that has resulted in a feeding frenzy through self-referral and inappropriate clinical ordering practices,” he says. “We have clients in Florida who have had upwards of 30% cost increases year over year; with our intervention, we have brought that trend flat.”

Generally speaking, he says, there has been “a meteoric proliferation of new imaging equipment being purchased and set up by physicians who have the ability to refer to themselves. It’s across all specialties. It’s becoming so rampant that we see imaging among specialists you would not expect, like urologists buying MR and CT. It’s a big business out there.”

But Donahue says imaging by nonradiologists is often skilled and that situations have to be judged on a case by case basis. He agrees though that tougher self-referral laws are needed. But he says the private sector can do a lot of the policing.

“There are certain rights and certain wrongs. Where it’s getting out of control we have to band together. We need to do it ourselves. We don’t need government to do it.”

Leasing: Magnet for Rent

As physician self-referral of imaging has proliferated, it has come under attack from the radiology community. But now, in a new form of what may amount to self-referral, radiologists themselves are actually joining with referring clinicians to put money in those clinicians’ pockets from imaging procedures. Is it legal? Nobody has challenged it yet, apparently.

This new wrinkle is the leasing of imaging equipment by radiologists-either as imaging time or as a specified number of procedures-to referring physicians who will then use their own billing numbers to get reimbursed for the procedures.

The radiologist leases the equipment and interprets the examination. The referring physician collects the technical fee and possibly the professional fee at a higher rate of return than he pays the radiologist to provide the imaging equipment, shoot the images, and interpret. The actual arrangement is specified in the lease contract.

Leonard Berlin, MD, FACR, has been investigating this leasing phenomenon. He thinks it is a practice that hurts radiology and all of medicine. He calls it a fee shift and implies that it amounts to fee splitting.

“Fee splitting is illegal, fee shifting is not. Are they one and the same? I ask the rhetorical question and leave the observer to decide.”

Berlin says that a radiology group or a hospital could own the leased equipment. Various entities could complete the lease arrangement, but the radiologist would have some involvement.

“The way it works,” says Berlin, “is that the referring physician leases time or leases cases. They say, ‘Give me an hour every day, or give me 10 to 11 every day or 2 to 4 three days a week. I will send patients during that time. You supply everything. I will pay you a flat sum’-pick a figure, $800 an hour-‘I’ll send you two patients. I will bill their insurance company $1,500 apiece.'”

In this example the referring physician would collect $3,000 for an $800 outlay.

“That is technically legal at this point in time,” Berlin says. “The lawyers draw up a lease agreement and it’s under the radar. It’s a practice that has been going on for the last 3 or 4 years. Who’s going to challenge it? As far as I know, it’s never been challenged.”

Because it provides the referring physician with a financial incentive to do imaging, Berlin thinks the leasing phenomenon is bad for patients, bad for payors, and bad for radiology.

“If people feel that they have to do it,” he says, “I’m not about to criticize my colleagues. I don’t think any radiologist loves it, but in many cases they feel forced to do it.

“I hope that the law is changed,” he adds. “I’m in favor of changing the law, but if the law doesn’t change, maybe even I will have to go into a leasing arrangement someday. It may be that we will all have to accept it. But I think it represents a crack in the profession. I think it does. It certainly lessens our autonomy.”

Resolved: To Protect Self-Referral

Both the American Medical Association (AMA) and the American College of Cardiology (ACC) appear willing to do battle with radiologists over physician self-referral. At stake they say is not only a nonradiologist’s right to do imaging but proper patient care. Rebecca Patchin, MD, is an anesthesiologist and pain specialist in an independent practice in Riverside, Calif. She treats spine patients as part of her practice. Patchin is also one of 16 members of the AMA’s board of trustees.

In June, the AMA issued a resolution advocating protection of current self-referral rules that allow in-office imaging by a doctor for his or her patients.

“RESOLVED, That our AMA work collaboratively with state medical societies and specialty societies to actively oppose any and all federal and state legislative and regulatory efforts to repeal the in-office ancillary exception to physician self-referral laws, including as they apply to imaging services,” the resolution concludes.

Patchin says the resolution (AMA Resolution 235) is a “reaffirmation” of existing policy that is spelled out in AMA Policy Statement E-8.032 “Conflict of Interest: Health Facility Ownership by a Physician.”

Patchin says the issue is not whether nonradiologists are competing with radiologists to do imaging procedures. The issue, she says, is patient care.

“Physicians should be able to own these ancillary services and use them for patients,” Patchin says. “When I see a patient with low back pain, I can get an x-ray of the low back right in my center. It keeps the patients from having to leave, get the imaging, go through a registration, then if the condition is serious, drive back and present the x-ray. It’s the patient convenience that is so helpful.”

Patchin says whether radiologists are losing professional stature as nonradiology imaging proliferates is not at issue.

“The AMA doesn’t have an opinion on loss of stature,” she says. “The roles of many specialties are evolving in medicine. As science and technology have changed, other things have changed. Medicine is in a constant state of change as we discover new technologies.”


The same sort of patient care argument is used at the ACC. Recently, an informal group calling itself Physicians for Patient-Centered Imaging (PPCI) has been organized to carry the message to Congress.

Camille Bonta, who is director of legislative policy for the ACC, says PPCI was organized to “educate both the public and lawmakers about the value of in-office imaging.

“We are meeting with the same people that radiology is meeting with,” Bonta says. “They put the physician community in a position where it can’t allow those claims to go unanswered. We can’t allow the radiology community to communicate half truths on the issue of safety and the quality of imaging that is performed in physicians’ offices.”

Sheila Strand is the ACC’s director of communications. “At issue here is the appropriate use of imaging,” she says. “The term overutilization implies that imaging is being ordered that is not appropriate. We don’t agree with that statement.”

Again, she says, the real issue is patient care. “Especially for the fragile cardiac patient, it’s imperative to have an in-office ability. We really can’t dismiss the value to that patient of having imaging potential in the office.”

Strand argues that changing treatment paradigms are altering the way imaging is used. “Now we are monitoring outcomes. Is the treatment working? The best way to find out is to take an image…. Radiologists are implying that multi-specialists order tests with no medical necessity, and we don’t believe that’s true. We believe most cardiologists are ordering tests that are appropriate and medically necessary.

George Wiley is a contributing writer for Decisions in Axis Imaging News.