The radiology literature is replete with reports of imaging overutilization by self-referring physicians. This issue has waxed and waned over the years, producing a strong case against referring physician ownership of imaging technology, federal statutes designed to curb the abuse (and loopholes to circumvent them), and a steady stream of grumbling from radiologists concerned about turf incursions. The grumbling has grown to an outcry as this phenomenon is felt by radiologists in cities, towns, and rural areas across America.

This is happening as imaging utilization in general is on the rise, a situation not lost on elected officials and policy makers in Washington. Nancy-Ann DeParle, appointed last summer to the Medicare Payment Advisory Commission (MedPAC), advised the National Coalition for Quality in Diagnostic Imaging Services (NCQDIS) board members to prepare for an era of heightened public scrutiny. MedPAC, created by Congress to advise it on Medicare policy issues, recently analyzed Medicare claims data from 1999 through 2002 and discovered that of all four categories of physician services (evaluation and management, imaging, procedures, and tests), imaging led the pack in average annual growth at 9%. The overall annual growth rate for all services was 3.6%.

Imaging is on the rise for many reasons: new and improved technology is providing better information; a lethal medicolegal environment is unforgiving of physician error; and a rapidly evolving menu of new drugs and treatments are providing physicians with the tools to treat what the imaging technology can detect. A radiologist recently told me that the emergency physicians produced by today's medical schools seem not to have the intuitive skills of their predecessors, and, instead, instinctively reach for the imaging order pad. Could it be that we are in the midst of a paradigm change in medicine in which referring physicians dispense with intuition in favor of the power of knowing that imaging can provide?

One can only speculate about how much of this increase in imaging can be attributed to inappropriate studies performed on in-office technology by self-referring physicians. What is known is that more in-office imaging is being performed by self-referring physicians. They have their reasons: financial gain and patient convenience, both of which are compelling.

How many of those besieged down through the ages have had to answer that most difficult question (whose outcome very well could have grave consequences, at least for life as he or she knows it): Shall I fight to the finish or strike a deal? Enter the new models in radiology ventures in which radiologists increasingly are partnering with orthopedists, cardiologists, oncologists, and others in joint ventures. These arrangements make a good deal of sense: the specialist provides the patients and the radiologist provides the readings, and ensures proper care and maintenance of the technology. The risk and the rewards are shared.

As radiology enters into a greater number of partnerships with specialists who want to own the imaging technology, it is incumbent on radiologists to bring some discipline to these arrangements. Radiology has an opportunity to add real value for the patient, the referrer, and the health care system by collaborating with their partners to establish care protocols and examination criteria that will ensure that every examination is appropriate. Without attention to utilization management, radiologists could find themselves in the uncomfortable position of aiding and abetting the burdening of the health care system with unnecessary costs.

Cheryl Proval

cproval@medpubs.com