Self-referral in neuroradiology.

The diagnosis of spinal meningiomas and schwannomas by my-elography. Enlargement radiography without special apparatus other than a very fine focal spot. S elf-referral in radiology is a complex and contentious topic that has received a great deal of attention recently. In addition to radiologists, others expressing concern about this phenomenon are Congress, the Centers for Medicare and Medicaid Services (CMS) and other payers, state legislatures, consumers, journalists, and so forth. We know who cares about the problem, but here is the key question: Why do they care and what can be done to limit the ill effects of self-referral and still maintain the benefits that are purported by its proponents to accrue to patients and the health system as a whole from this pattern of practice? 1-10 The case for self-referral rests on 3 principal arguments: First, access, convenience, and coordination of care are touted; second, expertise is invoked; and third, economic efficiency is asserted. These can be taken in turn. The argument regarding access is relevant to the lower technology modalities such as plain films and sonography, which are frequently provided at the time of a patient visit in primary care, orthopedic, and obstetrics and gynecology practices. The data show rather convincingly that same-day service is not often the case with respect to CT and MR imaging studies, those of most interest to the neuroscience and investor community. With respect to access, there are no well-conducted studies, to my knowledge, that support the notion that an inadequate supply of scanners in underserved communities results in the installation of imaging instruments by clinical neuroscience physicians. To the contrary, the data suggest that the safety-net payers are under-represented in practices that are organized on principles of self-referral. The argument based on improved coordination of care falls flat when one considers that increased imaging occurs in self-referring practices after the installation of the referring physician by the owned or leased instrument and that patients imaged in a physician-owned facility are more likely to undergo invasive treatment rather than conservative management of back pain, for example. Self-referral may facilitate more expensive and aggressive treatments than are well-grounded in a rigorous evidence base. Some advocates of self-referral practice models imply that the expertise of clinical physicians in the neurosciences is superior to that of radiologists. Again the data do not support this hypothesis. Some consider investigation of the question to be absurd because the …