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Some Facts On Rapid Imaging GrowthAlthough their paper solely addresses imaging growth in a particular health maintenance organization (HMO), Rebecca Smith-Bindman and colleagues (Nov/Dec 08) suggest that legislation focused on self-referral will not sufficiently limit the drivers of rapid imaging growth nationwide. They state, without supporting data, that imaging growth in HMO systems "closely parallel[s]" that in fee-for-service systems. They suggest that self-referral is therefore not a primary driver of escalating overall imaging costs. Neither the scope of their paper nor the published results support these claims. Self-referral, by which providers refer patients to imaging centers or equipment they own, presents a significant conflict of interest and has been identified by private insurers and government agencies as a primary driver of spiraling costs. There is no financial incentive for ordering physicians to increase imaging utilization unless they self-refer. Government Accountability Office (GAO) reports and published research document that imaging skyrockets when providers directly profit from ordering scans.1 As much as half of self-referred imaging may be unnecessary and may cost the health care system up to $16 billion annually.2 Self-referred imaging also presents significant quality and safety issues for patients. The Medicare Payment Advisory Commission (MedPAC) cited a major insurer study that found that 78 percent of nonradiologist imaging facilities had at least one serious deficiency—many of which could have "tragic" consequences.3 Also, the National Council on Radiation Protection and Measurements cited self-referral as a primary driver of a fivefold increase in Americans’ exposure to radiation over the past twenty years.4 Imaging is increasingly replacing more invasive procedures—enhancing and extending the lives of patients. Any imaging policy should curb growth in inappropriate imaging, not imaging that has clearly benefited patients. Efforts to discourage self-referral are the most direct and sensible way to reach this goal.
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