Doctor Self-Referral: Should You Get That X-Ray or CT Scan?

Doctors make money when they prescribe and perform diagnostic tests. That's a conflict of interest.

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A front-page story in today's Washington Post might give you pause the next time a doctor offers to scan you to determine the source of a health complaint. The story, by Shankar Vedantam, gets to the heart of a financial conflict of interest that's rife in many outpatient medical practices. It's called physician self-referral. That jargony term is just a label for what occurs when a doctor tells you that you need a test or procedure and then offers to sell you—er, perform for you—that same test or procedure.

It happens all the time, and there's nothing intrinsically nefarious about it. In fact, self-referral is often an enormous boon and time-saver for patients. As Vedantam suggests, if you go to a doctor because you've hurt your foot, you'd probably be quite glad to find that she has an X-ray machine in her office and can determine on the spot if you've broken a bone. A doctor without a scanner, and therefore unable to self-refer, would have to prescribe a foot X-ray and send you elsewhere to get it. What would that mean for you? Another appointment, another copayment, and possibly a delayed diagnosis. Chalk one up for self-referral.

There's a darker side to self-referral, however. Diagnostic testing can be a lucrative source of revenue for physicians, which is one motivation for purchasing the often-expensive hardware that makes self-referral an option. Once a doctor buys a scanner, for example, she has every incentive to use it and use it again in order to pay off its cost and, if she's lucky, put some additional money in her pocket. As Vedantam documents in his story—and others, notably Atul Gawande, have also explained—the purchase of a new scanner tends to lead to more scans being prescribed and performed.

Is that a bad thing for patients? Not always, but it certainly can be. For one thing, Vedantam cites a source at the National Cancer Institute who blames up to 1 percent of all cancers nationwide on radiation exposure that patients get from medical imaging. Furthermore, the overuse of medical imaging and other high-tech tools and treatments doesn't necessarily lead to better care, and it often does significantly increase the cost of care, as my colleague Katherine Hobson reported in the August issue of U.S . News & World Report [Cost of Medicine: Are High-Tech Medical Devices and Treatments Always Worth It?].

By the time I'd finished reading Vedantam's story, I'd vowed to myself to think twice the next time a doctor tells me I need a scan and then says, in effect, "Step right this way." If there's a good clinical reason for the scan, I'll agree to it. If not, I won't be shy about declining.

Related:

Facing a CT Scan? Think About Radiation.