To Read or Not to Read

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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