July 2004

Meeting on 07/20/04
MGH, Robbins A Room

In attendance:

Jill Saunders, Brent Townsend, Peter Chiou, Kevin Roscoe, Erik Nelson, Aradhana Venkatesan, Seth Hardy, Josh Rosebrook & Bruce Stewart


  1. Introduction to ACR & MRS
  2. Self Referral: Aradhana Venkatesan
  3. MMS/AMA Update: Josh Rosebrook
  4. August Social
  5. Membership Committee: Josh Rosebrook
  6. Next Meeting

I. Introduction to ACR & MRS
Josh gave a brief overview of the mission of the MRS and the ACR for the multiple new attendees at the meeting.


II. Self Referral: Aradhana Venkatesan
Battling Self Referral is the number one legislative priority of the ACR. Aradhana discussed a recent NY Times Op-Ed by Dr. David Levin on July 6, 2004 which nicely outlined the case against physician self-referral for the lay public. Aradhana also analyzed the letter of response published the following day by Dr. Michael J Wolk, the President of the American College of Cardiology. The Op-Ed piece, Wolk’s letter as well as Aradhana’s response are included below.


III. MMS/AMA Update: Josh Rosebrook
Josh discussed some of the resolutions by the MMS/AMA including simplifying MA Licensing procedure, increasing reimbursements for mammography, and procedural competency.


IV. August Social
Plans are progressing for the annual August social at a venue other than “The Rack.” Josh visited “Jillian’s” and reported that it has been recently renovated and seemed an appropriate venue for the social. Due to distance concerns, “The Milky Way” is no longer being considered, and the HMS meeting rooms were deemed too sterile. If for some reason “Jillian’s” does not work out, “Boston’s Greatest Bar” and “The Pour House” were also proposed as possibilities. The current proposed dates for the social include Thursday, August 12th, 19th, or 26th.


V. Membership Committee: Josh Rosebrook
Josh briefly discussed the ACRís Membership committee, and the initiatives to increase involvement with other state chapters.


VI. Next Meeting
The next MRS event will be the August Social with current proposed dates including: August 12th, 19th, or 26th.


Respectfully submitted by
Bruce Stewart


July 6, 2004
Me and My M.R.I.

RYN MAWR, Pa. – With health care costs rising so rapidly, the last thing we need is a trend that makes them rise even faster. Yet that is what is happening in doctors’ offices around the country: to increase their incomes, more and more doctors are installing M.R.I. scanners and other medical imaging equipment in their offices and scanning patients themselves instead of referring them to a radiologist.

The result is that more and more scans are being done, and insurers and patients are being charged more. Both Medicare and commercial insurers like Blue Cross have noted that imaging is growing more rapidly nationwide than any other physician service.

If you are a patient who needs an X-ray, an ultrasound, magnetic resonance imaging, CAT scan, or nuclear scan, there are two ways you can get it. Your doctor can refer you to a radiologist, who has spent four to five years learning how to interpret those images. Or your doctor can buy viagra online for a scanner and do your scan himself – a practice known as self-referral. Although this might seem more convenient for a patient, self-referral creates cost and quality problems.

A number of studies have shown that self-referring doctors order imaging tests far more frequently than doctors who refer their patients to a radiologist. Self-referring doctors have to cover the costs of purchasing and operating their imaging equipment and to make some profit as well.

This creates an irresistible urge to order as many imaging tests as possible – including many that aren’t really medically necessary. A recently published study showed that between 1993 and 1999, virtually all of the increase in Medicare use of imaging and the resulting costs were attributable to nonradiologist doctors who operate their own imaging equipment and are usually in a position to self-refer.

Quality also suffers in these cases. Research has shown that nonradiologist physicians don’t do nearly as well as radiologists at interpreting imaging tests. This is hardly surprising, since they get little or no formal training in image interpretation during their residencies.

Radiologists would do a pretty poor job if they tried to deliver babies or operate on brain tumors, and by the same token, doctors in other fields often make mistakes when they try to practice radiology without benefit of training. Imaging centers belonging to nonradiologist doctors may be substandard as well. A large health care insurance plan in one western state recently conducted inspections of 462 offices that provided imaging. More than one-third of the offices run by nonradiologists failed; of the offices of radiologists, only 1 percent failed.

At this point, you might be asking, “Aren’t there laws that prevent doctors from doing things they aren’t fully trained to do?” Surprisingly, the answer is no. Doctors with state licenses can provide any medical service they want in that state, regardless of whether they’ve had training for it. Federal laws prevent doctors from referring patients to an outside imaging center in which they have a financial interest, but a loophole allows installation of the equipment in their own offices.

Some states have begun instituting restrictions. Maryland now prevents doctors other than radiologists from putting CAT or M.R.I. scanners in their offices. It remains to be seen whether other states will adopt similar measures. A federal law similar to, or even broader than, the one in Maryland would greatly assist Medicare in reining in its imaging costs. Another approach would be to require inspection and accreditation programs for all doctors’ offices that provide any type of imaging (a federal program of this type already exists for mammography but not for any other type of imaging). There are other possible remedies as well.

I practiced radiology for 35 years before retiring in 2002. And I now work part time as national medical director of HealthHelp, a company which manages the use of diagnostic imaging for health insurance carriers. I have great respect for my colleagues, and I sympathize with those who feel the need to bring in more revenue so they can cover the ever-rising costs of malpractice insurance, personnel, rent and other items. But self-referral in imaging is neither good patient care nor good medical economics.

David C. Levin is the former chairman of the department of radiology at Thomas Jefferson University Hospital in Philadelphia.

NYTimes, July 7

To the Editor:
David C. Levin, a retired radiologist, implies that nonradiologists are not qualified to interpret imaging studies for their patients (“Me and My M.R.I.,” Op-Ed, July 6). In fact, cardiologists are the physicians best prepared to interpret cardiovascular images. Cardiologists spend years gaining the necessary knowledge about the organ system and disease state for which cardiovascular images are obtained. It is necessary to understand the heart, and how it functions, to interpret cardiac imaging studies properly. In addition, imaging is integrated into cardiologists’ training and clinical decision-making. This allows the cardiovascular specialist to perform imaging services selectively, keeping the patient’s full medical history in mind. Sending patients from office to office for imaging services can be costly, time-consuming and unnecessary. It is time for Dr. Levin to start working with the greater medical community to make patients’ lives easier and healthier.

President, American College of Cardiology
New York, July 7, 2004

Aradhana’s Response:

Not only bitter, but heavy handed and inappropriately self serving, for someone who is in such a prominent leadership position. Who would disagree that cardiologists spend years gaining knowledge about cardiac organ system and disease states; does that make them qualified to protocol and interpret studies across multiple modalities, (to which they may or may not have exposure as fellows), and assess the images’ quality AND be attentive to patients’ and personnels’ radiation doses?

He states “cardiologists spend years gaining…knowledge about the organ system…for which cardiovascular images are obtained. It is necessary to understand the heart, and how it functions, to interpret cardiac imaging studies properly.”† If he is trying to imply that cardiologists have subspecialized clinical knowledge of cardiac disease, I’ll buy that. If he is trying to make the leap that they understand imaging as well as radiologists who are also “spending years” gaining the knowledge about imaging per se, he is oversimplifying the radiologists job entirely.

“Imaging is integrated into cardiologists’ training and clinical decision-making. This allows the cardiovascular specialist to perform imaging services selectively…” Based on the stats in Levin’s article, quite the opposite is occuring. Where are Dr. Wolk’s countering statistics?

Finally, he states that “sending patients from office to office for imaging services† can be costly, time-consuming and unnecessary,” and as Levin’s article points out, (with actual statistics to back him up), this is definitely the case. Particularly when the patients are being sent for imaging services by the self referring physician.

An appropriate counter-response to Dr. Wolk would be one either from Dr. Levin or from the ACR leadership…