Imaging Self-Referral Drives Unnecessary MRI Scanning for Patients

Medical imaging self-referral leads to higher utilization and unnecessary imaging examinations.

“Our study was the first to examine one of the most common advanced outpatient imaging studies ordered in the United States today: orthopedic knee MRI,” said Matthew P. Lungren, MD, codirector of the interventional radiology translational research lab at Duke University Medical Center (Durham, NC, USA). “In our work, we were able not only to evaluate the outcome of the knee MRI examinations ordered by physicians with financial interest in the imaging equipment, but to compare this to another matched referral physician group that had no financial stake in the imaging equipment.”

From 2004 through 2010, the number of self-referred MRI services increased by more than 80%, compared with an increase of 12% for non-self-referred MRI services. Similarly, the growth rate of costs for self-referred MRI services was also higher than for non-self-referred MRI services, according to the US Government Accountability Office. It is estimated that in 2010, providers who self-referred made as many as 400,000 more referrals for advanced imaging services than they would have if they were not self-referring, costing Medicare about USD 109 million.

For the study, researchers reviewed 700 consecutive diagnostic knee scans from 667 patients to determine if ownership of MRI equipment by ordering physicians affected the probability of positive findings, and they assessed the pathology rates as a metric for comparison of utilization. The scans had been interpreted by one radiology practice between January and April 2009 and referred by two separate physician groups serving the same geographic community. The first group had financial interest in the MRI equipment used (FI group), and the second had no financial interest in the equipment used (NFI group).

For each group, the research team studied the percentage of negative exams and the frequency of each type of abnormalities found on positive exams. The results showed that among the 700 MRI scans (350 per group) there was no substantial discrepancy in the number of abnormalities per positive scan between the two groups. However, the researchers found that knee MRI exams ordered by the FI group were 33% more likely to be negative, indicating a significantly higher number of potentially unnecessary exams. Of the 205 negative exams, 117 belonged to the FI group, compared to 88 for the NFI group. In the FI group, 33% of patients referred for exams had negative scan results, compared to 25% of the NFI group.

“This occurred despite otherwise highly similar pathology, demographics, and referring physician characteristics between the two groups,” Dr. Lungren said. “These findings suggest that there is a different threshold for ordering MRI examinations which may be due to financial incentive.”

Dr. Lungren noted that self-referral has been shown to be an important driver of rising medical costs, and that this study has revealed powerful evidence of greater use of high-tech imaging when physicians can financially benefit. “This increase in unnecessary costs is of paramount importance in the current national conversation regarding health care cost and implementation,” he said.

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Duke University Medical Center