From the "Duh!" Department...Study finds high utilization rate on scanners owned by self-referring physicians

Image courtesy of http://www.tomgpalmer.com

Diagnostic Imaging magazine online today reviewed this article from the upcoming issue of Radiology. (The link will work if only if you already have online access to the Grey Journal.)

To make a long story and article short, the team from the Institute of Technology Assessment at Massachusetts General Hospital "analyzed more than 526 million claims filed between 1999 and 2003 with an employer-based health insurance plan having about four million members." Dr. G. Scott Gazelle, lead author, took a slightly different approach than some other researchers in this field:

We chose to look at same-specialty referral instead of just self-referral because "self-referral" may represent referral to one's partners or colleagues. This broader definition may have resulted in the inclusion of some physicians with no financial or other relationship with the referring physician and may thus have reduced the magnitude of the observed increase in utilization (ie, if same-specialty–referring physicians without financial relationships did not demonstrate increased utilization of diagnostic imaging, their inclusion would have diluted the effect). Compared with Hillman (4) and Hillman et al (5), who defined self-referring physicians as individuals who charged at least once for an imaging procedure, we categorized referring physicians on the basis of their entire referral history for the condition of concern. Same-specialty referrers must have always referred patients to themselves or to others in the same specialty. Finally, our logistic regression analysis, which controlled for patient age and comorbidity, may provide a more accurate estimate of the effect of same-specialty referral on the utilization of diagnostic imaging procedures.

The bottom line, from DI's review:

The results indicate that physicians who refer their patients to themselves or to others of the same specialty for imaging use imaging 1.12 to 2.29 times more often than physicians who refer their patients to radiologists for imaging.

The study also found that patient age and comorbidity do not explain the increased frequency for self-referred imaging. After controlling the data set for patient age and comorbidity, imaging frequency was 1.196 to 3.228 times greater for the self-referred patients.

The numbers are somewhat lower than those Drs. David Levin and Bruce Hillman, and others have found over the years, perhaps due to the methodology of this particular paper.

Levin criticized the study design for focusing only on the professional component of insurance claims, a tactic he believes misses "carloads" of self-referred cases.

"The numbers in this study are impressive enough on their own, but they significantly underestimate the magnitude of the problem," Levin said. "Policymakers have to realize that if we continue to allow self-referral, costs will skyrocket."

But they already have, Dr. Levin, they already have.

A companion piece in today's DIMAG.com notes another "Duh":

Self-referring physicians are among the first casualties of reductions in Medicare technical payments from the new 2005 Deficit Reduction Act rules implemented in January. Some nonradiologists are shutting down their self-referred imaging businesses, according to Dr. Harvey L. Neiman, executive director of the American College of Radiology.
Neiman spoke Oct. 25 at the 2007 Economics of Diagnostic Imaging National Symposium in Arlington, VA. . .

Estimates on Medicare's cost-savings from the DRA cuts vary from $1.4 billion in first year to as much as $13 billion over a three-year period.

While the DRA cuts were probably not designed to limit self-referral per se, they will have that effect, at least in some cases.

I smell a schism within the ACR. Half of the ACR is rabidly trying to overturn the imaging cuts of DRA, and they don't mention self-referral in polite company so as not to offend their "friends" within AMIC. But here, we have Dr. Neiman speaking very publically about how DRA is helping to curb self-referral. Hmmmmmmmmm. Maybe if we all worked together on this, we might accomplish something. Ya think?

Three Interesting Articles

The recent changes in imaging payment as proposed by CMS have brought about a lot of discussion. Today, three articles pertinent to the discussion were referenced in the "Daily Scan", a newsletter from the RSNA.

The first is excerpted from the Wall Street Journal. Author David Armstrong has often dealt with the self-dealing issue, and in today's Wall Street, he reviews Medicare's apparent targeting of the practice. He notes several projects that have been derailed by the new thinking, such as this:

In February, a group of cardiologists in Gainesville, Ga., announced they were building a diagnostic heart center in an $18 million joint venture with the local hospital. Last month, they said the project was dead. . .

. . ."A lot of people have just called a time out on these deals," says Daniel Mulholland, a Pittsburgh health-care attorney who has advised hospitals on such investments. "The party is over. . ."

The reason? Federal Medicare officials want to crack down on arrangements like the one that was planned in Gainesville, where doctors refer patients to businesses in which they have a financial stake.

In recent years, many physicians have become wealthy by investing in magnetic resonance imaging, or MRI, facilities, surgery centers and diagnostic sites -- and then sending their patients to them. A recent McKinsey & Co. study pegged doctors' profits from this practice, known as self-referral, at $8 billion a year.

His assessment of the new CMS proposals:

. . . tough new restrictions proposed by the federal Medicare authority. . .would essentially ban Medicare payments for many self-referred services. In unusually blunt language, the Centers for Medicare & Medicaid Services said the self-referral arrangements are "creating incentives for overutilization and corrupting medical decision-making."

What else is there to say? Well, a few graphs from the article tell much of the story. See any trend?

It goes with what I have been saying for a while. Imaging spending is skyrocketing, having doubled in the last several years. Of this, Armstrong notes that $8 Billion goes to self-referral, although other sources have pegged this at $16 Billion. He does note that the glaring loophole known as the in-office exception remains in place.

The second article comes from Capitol Hill, via thehill.com's Jeffrey Young. It seems that our friends at the big imaging companies are starting to worry about their bottom line, and are lobbying the White House to turn things around.

GE Health President and Chief Executive Joseph Hogan and other imaging company officials gathered at the White House Monday for an audience with presidential advisers to press their case that their industry is being asked to bear an unfair burden as Congress and the administration look to rein in Medicare spending.

Lawmakers have set their sights on imaging spending in particular based on evidence that spending doubled in the first five years of the decade.Trade groups representing the companies are engaged in a push against additional regulations and legislation that they say will threaten Medicare patients’ access to the innovative, but expensive, technology.

Sound familiar? It should. . .

“We acknowledge there’s a growth in the sector. We don’t necessarily agree you can equate that growth as bad,” said Amy Jensen Cunniffe, director of government relations for the Advanced Medical Technology Association (AdvaMed).

AdvaMed is one of three trade groups leading the charge against the imaging cuts, along with the National Electrical Manufacturers Association’s Medical Imaging and Technology Alliance division, and the Access to Medical Imaging Coalition, which includes industry, physician and patient groups.

Yes, they are working side-by-side with NEMA and AMIC. All three are still pushing the same agenda suggesting that cutting back on machine expenditures will limit patient access to sophisticated scans. I have yet to hear that DRA-2005 has harmed or significantly inconvenienced even one little old lady. Some self-dealers and enterpreneurs, maybe. And of course GE and Siemens. But not Granny.

The final article of the treo is from the AP newswires, and it may be the most ominous of the bunch. "Health care premiums rise 6.1 percent," writes Emily Fredrix.

The increasing cost of health insurance is putting coverage out of reach for many small to midsize companies and their workers, even though the rise in premiums this year was the lowest increase in eight years. Since 2001, the cost of premiums has gone up 78 percent, far outpacing a 19 percent increase in wages and 17 percent jump in inflationaccording to a survey released Tuesday by the Kaiser Family Foundation, a health care research group that annually tracks the cost of health insurance.

"There's no scientific tipping point that you can point to at which health insurance becomes unaffordable," said Drew Altman, the foundation's president and CEO. "But it does seem like we've crossed a threshold where health insurance is increasingly unaffordable for medium-sized employers, particularly smaller employers and average people this year."

We have been treating the healthcare money pool as endless, that another dollar can always be printed to cover this cost or that. I think we have just discovered the bottom of the pool, as we rush headlong toward it after a high-dive.

As an aside, I am certainly not letting the insurance companies off the hook. They have a lot of questions to answer on how we got where we are, while they add considerable wealth to their coffers. My son has a chronic disease, and recently generated a $14,000 bill for diagnostic procedures. Because our company hadn't made a "good deal" with our provider, I'm going to pay at least $4,000 of this out of pocket. I can afford it, thank Heavens, but what about someone who can't? And this is with paying a rather high premium for group coverage.

The hemorrhaging and wasting of money cannot go on, and CMS is in the lead to staunch the bleeding. I'm not going to anoint them as saints just yet, however, as their ambitions are not necessarily to keep things honest, but in the words of the Monty Python Blackmail Sketch: "No, no, sir, it's alright, we don't morally censor, we just want the money." They have observed the huge flow of cash into imaging, and they are going to tap it. Nothing personal.

I once had great respect for the equipment companies, who invest zillions of dollars to build the latest and greatest of scanners. We all benefit from this, especially our patients. But does this end necessarily justify the means of selling an excess of scanning capacity by pushing machines in venues where they really aren't required? I have to think not. But it's pretty clear that this party is about over, and the question will shortly become moot. Especially if Hillary wins, and Rush Limbaugh says there is an 80% chance of that.

The First Salvo Is Fired...Self-Dealing in Medical Imaging: Call for Action

The Battle of Fort Sumter, the beginning of the Civil War

Image courtesy of http://www.civilwarhome.com

Dr. Murray Reicher is well-known in PACS circles as the founder of DR Systems and their famous Catapult technologist workstation. Dr. Reicher has made his mark on imaging.

In a guest editorial in the Journal of the American College of Radiology (JACR, the Blue Journal), Dr. Reicher takes aim squarely at self-referral:

I have great concern over the possible destruction of my profession caused by self-dealing in medical imaging. Self-dealing occurs when a referring doctor makes money, directly or indirectly, simply by referring a patient for a medical imaging procedure, especially by gaining a financial benefit from the technical component of the procedure. . .Do you care about the future of the medical imaging field? Are you appalled by doctors who refer on the basis of personal economic gain? Do you realize that this practice not only threatens your profession but impairs the health care of your community and sucks resources away from legitimate health care providers and hospitals?

Wow. Pretty powerful stuff. Dr. Reicher goes on to provide us with a battle cry of sorts:

No machine fee for self-dealing in medical imaging.

This position is written in plain language because nonphysicians must understand it. The statement means that no referrer should make money, directly or indirectly, through ownership or lease, from the technical component associated with a medical imaging examination.

Dr. Reicher goes on to explain why the practice should bother you:

As a result of these legal loopholes (Stark in-office exception, etc), this practice of referring patients to self-owned or leased imaging equipment has again become rampant. Self-dealing radically raises costs . . . and subjects patients to unnecessary procedures. Technical and professional quality is lowered when radiologists are not directly involved. . . Opponents of legislative or private restrictions on self-dealing see self-referred medical imaging as an opportunity for physicians to add an income source in their own offices. They cloud the issue with demands for more study and statistics. Statistics can show us how much self-dealing is costing us but can never prove that it’s ethical, because it isn’t.

In medical imaging, first, we had no rules against self-dealing. Then, we adopted rules with loopholes. Surprise: the greedy and unethical minority of physicians have jumped through the loopholes, and if we don’t close them, the reputation of all health care providers will suffer. The truth will come out, eventually.

Italics are mine. Basically, this is what people have been saying all along concering the DRA-2005 fight. But that situation took a markedly tangential course when non-self-referring radiology-owned operations were tainted with the same tar-brush. I cannot help but think that this was a result of the ACR's incomplete job of educating Congress about self-referral. Maybe they should have brought Dr. Reicher with them to the various hearings.

Dr. Reicher goes on to dismiss many of the arguments out there that support self-referral/self-dealing. First, he makes it clear that this is not a "turf" issue, which is how the ACR managed to lose the interest of Congress:

To most people, even doctors, the discussion of professional turf isn’t relevant, and nobody feels qualified to make turf judgments. But most people can understand that when your doctor collects a technical component or “machine fee” just for ordering an examination, your doctor has lost the ability to independently advise you with regard to the right test or the right facility.

He notes that it is indeed not a matter of radiologists protecting our turf, since they stand to make a significant amount of money by reading the self-referred scans.

Dr. Reicher then very accurately points out that self-referral is anticompetitive:

In fact, the practice of self-dealing exposes patients and payers to a monopolistic, anticompetitive practice. When orthopedic surgeons send patients to scanners they lease, neither the patients nor their referring doctors select the facility on the basis of normal competitive merit; the doctors do not ask which facility in the region has the best technology, the best professionals, the best pricing, or the best service. Instead, they send the patients to the facilities with which they have business agreements that provide them a profit’s interest in the fees. Restricting the anticompetitive practice of self-dealing in fact favors competition.

So, what do we do about this lovely situation? Dr. Reicher gives us several approaches. He advocates asking the ACR to help fight this battle. Personally, I still harbor grave doubts about their ability, and even their willingness to do so after they have "hooked-up" (love the kids' phraseology) with every outfit that promotes self-referral under the guise of AMIC. What else can we do? Talk to vendors, and tell them:

. . .that if they support self-dealing, they don’t support you, and you won’t support them. Referring doctors who have purchased medical imaging equipment for their offices to self-deal in medical imaging via the “in-office” Stark safe-harbor clause have sales representatives from equipment vendors whispering in their ears, supported with beautiful color collateral materials and spreadsheets. If you want vendors to stop this behavior, you must show them that biting the radiology hand that feeds them is bad business.

Sadly, I don't think there would be any vendors left to deal with if we cut off those who pushed this agenda. Still, it doesn't hurt to make them squirm a little.

Perhaps the most effective approach is that of educating the payers, and somehow forcing physicians to disclose their financial conflicts of interest. How about this for a consent form?

Attention All Patients: We make money whenever we refer you for MRI (or PET, or CT) to the following facilities: _____. As a result, you cannot trust us to impartially consider when we send you to these facilities if the tests are really needed, if there are tests better suited for your problem, if there is a more qualified facility or imaging specialist in the area, or if competing facilities offer better pricing. Because we make money by referring you to the facilities we own or lease, you should consider the need for a second opinion from an independent provider before undergoing the test. We are required to provide you with a list of competing facilities in this community that may offer safer, more accurate, or less expensive medical imaging. They are _____.

I'm not holding my breath waiting to see that one out in public. There is a huge problem with this facet of the situation. Patients trust their doctors implicitly and explicitly. This is certainly a good thing, especially for those of us who grew up watching Marcus Welby, M.D. Is it right to point out to the patients that their trust in some cases is misplaced? Are we interfering in the doctor-patient relationship, one which I once thought sacred (before getting out into the real medical world) when we point out that their beloved doc just might be taking advantage of their trust and ignorance? I honestly don't know. On those rare occasions when I have broached the subject, I mainly get the response, "Oh, I trust my doctor. If he/she says I need a scan, I'll do it anywhere he/she suggests. It's so convenient to have the scan done in his/her office!" Maybe a little brainwashing, maybe a little hostage mentality. Either way, there is probably more of an uphill educational struggle on this front than you might think.

Perhaps the hardest pill for many radiologists to swallow is the fact that they are collaborators in this practice. The self-dealers ask them to read their scans, and they are happy to do so. After all, they reason, if they don't, someone else will. They might as well keep the otherwise lost revenue, and provide the patients the best of care. Right? Dr. Reicher answers:

I owe it to my community to behave in a trustworthy manner. Businesses that maintain the respect of their customers are the most successful in the long run. The “secret” of self-dealing is ultimately going to be widely understood by the public. If you are a collaborator, you are going to be seriously embarrassed at the least, and potentially personally liable.

Gulp. Not much I can say to that, is there?

There have been several objective articles before this, discussing the costs of self-referral. However, I have never before seen such a passionately-written article on the topic, one which calls a spade a spade, in this case blatantly declaring self-referral unethical. All I can say is, "BRAVO!" The problem is, sadly, I don't think too many folks are listening just yet. But, maybe that will change, and I hope that happens before Hillary uses this sort of information to justify destroying the American Health Care system.

Rife Machines, Travel Scams, Self-Referral, and Imaging Kickbacks

I just came back from a whirlwind visit to one of my relatives stricken with cancer. I am happy to report that she is doing well, with a clean PET/CT scan after 9 months of chemotherapy. Now, here's the bad news. My relative and her husband proudly announced that they had purchased a "Rife Machine," and this was the reason she had done so well. I'll let you Google the term to find out the details of this particular alternative medicine scam, but suffice it to say, it is supposed to zap the bacteria that "cause" cancer by sending a radio wave tuned to the exact "frequency" of the bacterium through the body. If you do take the time to Google, you will notice that the sites promoting this scam outnumber those exposing it by about 100 to 1. The Internet and human nature at their finest. Here is a good article debunking the outrageous claims. Check out this one as well. Anyway, in response I said, mostly under my breath, "It probably won't hurt you, and that's the best I can say for it." My relative then turned to me angrily and said, "I suppose you think it needs years of testing? You've been brainwashed by the medical establishment!" At that point, I changed the subject, knowing that I would not win this argument. I don't think I'm the one who was brainwashed at all.

There is a flaw in human nature that allows us to suspend rationality, to believe in whatever it is we want to believe at the moment. Sadly, there are people (I use the term loosely) with deficiencies of another sort that exploit the window of opportunity afforded by these lapses. This practice is not limited to health-care. My sick relative's husband, in the discomfort that followed the above exchange, went on to describe his latest money-making discovery, YTB Travel. To make a long story short, this is a multi-level marketing operation, like Amway, which sells travel-agencies. Well, to be more accurate, it sells websites that use the Travelocity engine to book travel. But the kicker is that each individual sucker, I mean client, can sell the program himself to other suckers, I mean clients, and the business they generate yields a commission for everyone in the chain above. Which means that the guys who are at the top of this pyramid scheme make big bucks, and the newly-joined make nothing. Oh, by the way, initiation into this little club is $500, and there is a $49 monthly fee. So, for $1100 the first year, you get a portal to Travelocity with your name on it. Whoopie. I went to half-a-dozen random YTB sites, and they are all absolutely identical. I even wrote to their owners, and received only one response, saying how good YTB was to him, and basically assuming that I would join up under his banner. You see, in the end, this is indeed nothing more than the same old pyramid operation with Dot.Com dressing. I'm anticipating a number of hateful emails from YTP devotees, but don't just take my word for it. Check this report from the BBB. A pyramid operation it is, folks. There's one born every minute, as old P.T. Barnum used to say.

Doctors are certainly not immune to any of these scams, and I am ashamed to say that there are real M.D.'s out there selling Rife machines, and probably owning YTB scam sites as well. Somehow, docs have become, well, indoctrinated with the idea that they know everything, that they can be experts at everything, and perhaps most unfortunately, that society owes them everything. You have read about self-referral, and that is a sad illustration of how far physicians will go to preserve the income some feel they deserve. One theory about imaging self-referral by clinicians is that since regulation and so forth have cut into their incomes, they are justified in "branching out" into other fields beyond their area of expertise to recover this income that was "theirs". One of these clinicians, Alan Boyar, M.D., admits as such in this AuntMinnie.com posting:

I was compelled to add these services because unlike radiology, office procedures are reimbursed significantly below cost and it is not possible to keep a private office open in So Cal with current rates. Before I closed, I'm in New Mexico now, I figured I really needed $85 an office visit to stay open and insurance was paying $48, EKG complete is only $28 dollars whereas my derm colleges are getting $60 to freeze a wart! My CA practice had turned into an expensive hobby and the AMA and societies didn't negotiate better rates for us.

I'm sure that's all true, and it is a very sad state of affairs indeed. Now, in Alan's case, he isn't forcing anyone to the best of my knowledge to have their hair depilated or their wart removed, or to be scanned in his Electron Beam CT emporium. But the basis of the downfall of medicine is contained in his statement. What I'm doing doesn't pay well anymore, so I'm going to start doing things beyond my scope of practice to bolster my income. I'll wager that Alan has no intention of going back and doing a Derm residency. Or a Radiology residency for that matter. He just wants the money to compensate him for his losses in primary care. Noble thought.

As noted above, docs are not immune to the cessation of rational thought when it comes to making money. I love to cite the "scanner lease" arrangements that have become so popular. These are loosely camouflaged kickback arrangements, and they are considered by most to be just at the borderline of legality. Basically, I own a scanner, and you "lease" time on it for a set fee, then turn around and bill for the scan at a higher rate than the leasing cost. Thus you make money on every scan you order. I had an internist describe this very scenario with great glee, thinking he had discovered something new and wonderful. When I told him what he was really doing, he turned white as a sheet, and asked me, "Why didn't they tell me that?" Why, indeed...

Regulators, legislators, insurers, and everyone else who is sick and tired of the financial hemorrage are all starting to wake up to what is happening, and the results are not going to be pretty. There is currently a case in Illinois where a leasing scheme is under litigation for violating the kickback statutes:

The MRIs were performed at the radiology centers, though the financial arrangement made it appear that the doctors were in charge of the equipment and billed the services as their own, the suit said. The attorney general's office alleged that the centers concocted "sham 'lease' agreements" to benefit the doctors, who then referred patients to the centers, sometimes for unnecessary tests."Illinois has a clear policy against kickbacks, and making payments to doctors for referral of patients is illegal, no matter how those payments are disguised," Atty. Gen. Lisa Madigan said in a statement. "Our investigation revealed evidence showing that this practice occurs among doctors and radiology centers in Illinois. This is an illegal practice that must stop."

I truly anticipate more and more litigation and ultimately prosecution of this sort of thing. And this will extend to self-referral as well. We put our trust in our physicians, and that should not require a suspension of rationality. But some docs stretch this trust, if not violate it completely, by ordering tests that serve little purpose beyond padding their wallets. I guess I'm from the Marcus Welby school where doctors were good people who made housecalls, didn't testify against each other, and didn't worry about fees. Sadly, ol' Doc Welby is long gone, and his sidekick (James Brolin) is married to Barbra Streisand and is deeply involved in liberal causes.

I don't know how to return us back to the day when docs could be trusted to do the right thing, and not the lucrative thing. Some on AuntMinnie have seriously proposed that the government prop up the primary care docs so they aren't tempted to dabble in imaging and hair-removal. Personally, I think the government and insurers need to examine the increased revenue produced by self-referral mills, stop the bleeding, and retroactively penalize those gluttons who ruined the system. As for faith, one of the Rife-machine articles sums it up well:

Much of the frequency medicine practised today descends from Royal Rife, who did his research in the early 1930s. Rife identified the virus that caused all cancers (!), which he named “BX”. As this was before the invention of the electron microscope, Rife invented an optical microscope with a claimed magnification of 17,000x. A perusal of the web sites of Olympus, Nikon and Zeiss shows that the best theoretical magnification claimed today is about 1,400x, although practically it is about 1,250x. (Zeiss use an appropriate slogan to promote their microscopes: “Limited only by the laws of physics”.) The secrets of Rife’s microscope are lost, presumably suppressed by orthodox optical companies, but his method of curing cancer lives on.
Rife’s 1931 demonstration of the microscope involved creating a non-filterable form of the typhoid bacillus, which appeared as small moving turquoise dots in a static background. Scientists looked through Rife’s microscope and also saw these blue dots. Some astronomers once looked through Lowell’s telescope and saw canals on Mars; some scientists once saw evidence of the refraction of N-rays in Blondlot’s laboratory; some scientists were once convinced that deuterium could fuse at room temperature within the crystal matrix of palladium. All of them were mistaken. The difference between the last three delusions and Rife is that almost nobody believes them any more. The other difference is that a belief in Mars canals or cold fusion cannot kill anyone. A belief in a false cure for cancer can.

Ordering unnecessary scans probably won't kill anyone either, although the radiation exposure could add up eventually. But American Medicine is tarnished by the practice. In the self-referral scam, docs are the culprits; in the leasing scam, docs are the victims as well. But the patients are never at the top of the pyramid, and that is where they should be, lest we forget. My relatives with the Rife machine have made me very aware that a good segment of the population doesn't trust physicians or conventional medicine. They think they are a cabal organized for their own self-preservation, and the patient be damned, that organized medicine is the pyramid operation, designed to separate them from their money. They think the doctors would let a relative die rather than lose money on a simple "cure". With the behavior I'm seeing out there, I'm not sure I can blame them for their misbelief.

Americans For Responsible Imaging

Have you had a CAT scan in your doctor's office? How about an MRI or a PET? Did your doctor talk you out of going to the hospital for your test? Have you had multiple scans in your doctor's office?

Some doctors who own imaging equipment in their offices are abusing the American Healthcare system, extracting up to $16 Billion per year in unnecessary scanning revenue. Studies show that doctors who profit from scaning in their offices order from two to eight times as many exams as they would otherwise. This practice is hurting all of us by sending healthcare costs and insurance premiums spiraling out of control.

You can make a difference. Insist on having your study done in a hospital or an independent imaging center, where no one profits from self-referral. It's your life, your body, and your money.

Intel's Barrett blames broken health care system for U.S. job exodus

You don't think the American Healthcare system is in trouble? Read this from the chairman of Intel. It isn't very pretty. Here is some of what he said:

"Every job that can be moved out of the United States will be moved out ... because of health care costs,'' which averaged more than $6,000 per person in 2004, Barrett said..."The (health care) system is out of control, it's unstable, it's basically bankrupt, it gets worse each year and all we do is tinker around the edges when what we need are major fixes,'' Barrett said, adding that health care costs make it increasingly difficult for U.S. companies to compete with rivals abroad.

Barrett was more interested in seeing computerized stuff in hospitals than in stopping unnecessary scanning, but the problem is still obvious. Something has to be done before we lose the greatest healthcare system in the world!

A Good Article

Here is a very good article on the subject of self-referral:

http://www.imagingeconomics.com/issues/articles/2004-11_01.asp

All you have to do is "Google" the words "imaging" and "self-referral" and you will find many more!