To Read or Not to Read

As Shakespeare’s famous Prince of Denmark did, many radiologists I know struggle with choosing between two mutually exclusive paths to fulfillment. In Hamlet’s case, the idea of honorable revenge was countered by fantasies of ending it all. While not as draconian, the choice for radiologists is nevertheless gut wrenching. Should you continue to suffer the slings and arrows of life's outrageous fortune, which brought you the so-called opportunity to read imaging studies conducted increasingly by other specialists with their own newly purchased equipment? Instead, do you stand on principle and ignore the path that leads inexorably to (at least short-term) financial security? It’s a tough choice. Maybe you have kids in college with high tuition bills. Maybe you still have your own student loans to repay. Maybe you have simply become locked into a lifestyle that requires boatloads of cash to keep it going. In any case, walking away from lucrative reading contracts with doctors at the top of the self-referral food chain sounds easier than it might prove to be for many radiologists who would otherwise denounce the practice. Isn’t this just perpetuating the problem of self-referral? Don’t these referring physicians become enabled when their search for radiology contractors is made so easy for them? Aren’t they at the root of the overutilization problem and the resulting Deficit Reduction Act type of reimbursement cuts? Yes, yes, and yes; that’s precisely the definition of a dilemma. It is a predicament presenting a confusing choice between two alternatives. In this case, as with most dilemmas, there is no correct choice—only unpleasant trade-offs. These same problem causers bring business to radiology practices hungry for steady referrals. “Wait a minute, Curtis,” many of you will say. “We need to be principled. We need to protect the sanctity of the profession. We need to keep the imaging where it rightfully belongs. We need to fight this scourge called self-referral once and for all! At all costs, we need to protect and keep the technical-component revenue.” Oops—how did that one get into this list of noble reasons? Perhaps not everyone’s reasons are noble, after all. By focusing on the loss of the technical revenue rather than the larger implications for the medical profession and for the overall viability and integrity of the system, some of these critics provide an easy target for professional societies representing orthopedic surgeons, neurologists, and other specialists. They can and have made the case with the payors and regulators that this self-referral argument is all about economics and that turf issues such as these are best handled within the family of medicine. Indeed, payors have, thus far, bought this argument. On the opposite end of the spectrum are those private-practice radiologists who are just trying to succeed in a free-market economy. The old business maxim advises us to find a need and fill it, and when one realizes that it is a business that is as stake, what is wrong with providing a much-needed service to these specialists, who would, perhaps, otherwise contract with less qualified radiologists? Shouldn’t we be concerned with the quality of the interpretation? Shouldn’t we do the reading anyway, since it is inevitable that someone will provide the service—perhaps someone, in a distant country, who does not have the subspecialty training that you have? It is a business proposition that is difficult to counter and vilify. If it is your business that you want to protect, you can fight self-referral just as you would fight any other competitor. Beware, however, of the consequences of taking on a competitor who also is likely to send you referrals. That is a complex layer added to the dilemma. Nevertheless, you have a right, and certainly an obligation, to protect your business. The real answer is that all health care is local, and all decisions regarding these types of issues are dependent on nuance, the core values and ethics of the practice, the objectives and goals of the practitioner, and on the motivation for doing the deal. If it is clear that the referring physician in question has become accredited, has employed top technical talent, has invested in the best equipment, and has impeccable integrity and credentials, it is hard to make the case that depriving the physician and the patient of your expert interpretation services would somehow be the right thing to do. If the deal is done strictly to make a quick buck and value judgments have not been considered, that is another thing entirely. Essentially, the dilemma continues along its circuitous course. There is self-referral, and there is self-referral. The degree to which it becomes egregious depends entirely on the individual circumstances, the motivations, and the ethics involved, a these can be said to be neither right nor wrong. There is clearly a right way to provide care and a wrong way. We need to focus our attention on those doing it the wrong way. Be careful of using the red-herring argument, though, as it will be suspected that you have ulterior motives. A case in point is a very thoughtful email that I received from a private-practice radiologist in upstate New York. In his response to my column last month on the politics of greed, he outlined the difficulties that his group faces in dealing with some unethical business practices in its market. I love his value proposition, and I believe that his group has it right. He says, “We have chosen to compete based on quality and service, not through inducements. As you say, losing business is less important than losing self-respect. However, you do not mention . . . another, more pernicious example of greed in imaging, all the more so because it is perfectly legal: the rapid proliferation of imaging self-referral by nonradiologist physicians. We have lost far more business to orthopedic surgeons putting inexpensive, secondhand extremity magnets in their offices than we have lost to other outpatient centers. Primary care centers, which formerly only had x-ray in their offices, have added ultrasound and are openly discussing CT . . . the orthopedic surgeons put it best: their society advises them to ‘capture their ancillaries’.” The key here is in the use of inferior technology. It is a quality issue, and one that clearly sets in motion a response that is appropriate given the radiology practice’s commitment to quality. Likewise, it is fairly easy to identify opportunistic self-referral. This is a complicated and nuanced dilemma offering no correct or easy solution. If it is all about the money, then the pathway to success clearly indicates that the free market will benefit the entity willing to work faster and smarter, and to provide the best service and value. It will also benefit the one best positioned to take advantage of any unevenness in the playing field. If it is all about integrity, values, and protection of the core principles to keep the profession as pristine as possible, then one can feel purified by the fact that he or she has walked away from the temptation of current market-driven opportunities to share in the income generated by the referring office’s contribution to potential overutilization of imaging services. Every headache gets a scan and the volume grows exponentially. Where that is the case, the profession needs to put a stake in the ground based on this principle and work collectively to change the laws governing self-referral at the state and federal levels, as has been done in Texas, Arizona, and Maryland. The bottom line is this: not all self-referral is inherently bad, but most of it affects radiology practices in differing ways. When it is clear that the self-referral contributes to overutilization, the argument for its abolition becomes clearer. The argument has not been made (and will not be made) based on economic impact to individual radiology practices because that argument will find no sympathetic ear, as long as the focus remains on which specialty is winning financially. Should you read for self-referring practices? I would ask this: What is most important to you for the long term? How do you view your contribution to the profession and to society? What are the core values with which you conduct your life? Can you create change as a participant more than you can as an observer? Can you safely say that if you were given the opportunity to stack the deck in your own favor, you would transcend temptation and do the right thing? Then make a decision in your life and move forward in your course of action with a clear conscience—and beware of the poison-tipped sword