The New York Times’ ethicist Randy Cohen opined on Sunday that a physician should not refer a patient to a radiology center in which he has an ownership interest (and should certainly always be up front in informing patients of the conflict). Cohen concerns himself with the ethics, and doesn’t mention the ultimate cost to our health care system of physician self referral.
I did a review of this topic a few years ago. Some relevant facts:
- Imaging self referral associated with increased imaging utilization by factor of 1.7 to 7.7 (Hillman BJ, Olson GT,
, et al. Physicians’ utilization and charges for outpatient diagnostic imaging in a Medicare population. JAMA 1992;268:2050-4;Hillman BJ, Joseph CA, Mabry MR, Sunshine JH, Kennedy SD, Noether M. Frequency and costs of diagnostic imaging in office practice—a comparison of self-referring and radiologist-referring physicians. N Engl J Med 1990;323:1604-8.) Griffith PE
-The GAO estimated that self referral is associated with increased imaging utilization by factor of 1.95 and 5.13 (Referrals to physician-owned imaging facilities warrant HCFA’s scrutiny: report to the Chairman, Subcommittee on Health, Committee on Ways and Means, House of Representatives. GAO/HEHS-95-2.
: U.S. General Accounting Office; 1994.) Washington, DC
- Financial incentives led to physicians in a primary care practice increasing their imaging ordering by 16% (Hemenway D, Killen A, Cashman SB, Parks CL, Bicknell WJ. Physicians’ response to financial incentives. Evidence from a for-profit ambulatory care center. N Engl J Med 1990;322:1059-63.)
- In the late 1990s, most of the increase in noninvasive imaging was for tests read by nonradiologists (Maitino AJ,
, Parker L, Rao VM, Sunshine JH. Practice patterns by radiologists and nonradiologists in noninvasive diagnostic imaging utilization among the Medicare population between 1993 and 1999. Radiology. 2003;228:795-801) Levin DC
Cohen quotes Katie Watson, a Northwestern professor, who says “I trust my physicians…t.o be human beings, which means they’re vulnerable to subconscious influences and incentives just like the rest of us.”
Clearly, having physicians earn higher income when they recommend tests performed at facilities that they own is troubling. It’s also expensive.