Richard Townley

One of the most contentious subjects facing imaging today is the issue of nonradiologists performing imaging services. Nationwide, utilization of outpatient imaging (particularly MRI and CT) has increased significantly over the last few years. During this time, the percentage of outpatient imaging, particularly for MRI and CT, (and now PET), being done by referring physicians has increased even more.

The driving forces behind the proliferation of this phenomenon include the favorable economics of outpatient imaging and the legal exceptions available to medical specialists under the Stark II regulations. As multi-specialty groups or medical specialty groups increase in size and scope, it is not unusual that they install their own imaging services if the numbers make sense, which, of course, is almost entirely dependent on their ability to self-refer examinations.

In the past, most communities saw outpatient MRI and CT imaging being done by hospitals, local radiologists, and/or entrepreneurs that could not readily control where the patient was referred or the level of utilization. Now, more and more, these same communities see the imaging service providers include physician specialists who have the ability to control which examinations are ordered and where they are performed.

These market forces are not going to let up, as imaging becomes an increasingly critical element in the delivery of high-quality care. These forces are particularly acute as hospitals attempt to develop comprehensive cardiac, vascular, and cancer treatment programs, in which the medical specialist is an important element in the determination of need for the examination and where the patient goes for these high-cost services.

In this environment of increasing levels of self-referred, high-cost PET, MRI, CT, and other imaging studies by medical specialists, there is growing concern by payors and health care stakeholders that the delivery of cost-effective, high-quality imaging services is being compromised by unwarranted utilization and/or substandard technical and professional component services.

Medical specialists, on the other hand, argue that ownership of the technical component and the ability to self-refer within the legal parameters allowed by federal, state, and local statutes help them provide a higher level of quality care to their patients, especially where the marketplace is not doing so.

For the foreseeable future, it appears that the current federal regulatory climate is going to continue. And no knowledgeable person can argue that the current situation is not ripe for exploitation. Accordingly, it is important that steps be taken to help ensure that potential abuses inherent with self-referral are minimized as much as possible. The involvement of nonreferring entities such as radiologists and hospitals in the provision of outpatient services will be a key ingredient in a successful strategy toward that end.

During the past few years, radiologists and hospitals have successfully structured outpatient imaging ventures that provide appropriate levels of technology and professional services to the community, with governance and operating controls that help ensure proper utilization and patient care. More recently, given the realities of the marketplace, radiology groups and hospitals are including referring medical specialists in these ventures. There is recognition that the imaging services sector is expanding dramatically and is sufficient to accommodate each of the parties' respective agendas; but only if each is prepared to put patient care and overall health care community needs first, while adopting a high-quality, cost-effective approach to the delivery of imaging services. These are the type of self-referring entities that provide the appropriate level of safeguards to meet the health care community's quality needs and satisfy payor concerns regarding utilization.

Richard Townley is president and CEO of AGI Healthcare Group, Danville, Calif, an imaging services consulting group.