A Conversation with . . . Helene Pavlov, MD, FACR

Not all images are created equal

There’s a growing trend in the world of medical imaging that worries Helene Pavlov, MD, FACR, radiologist-in-chief at Hospital for Special Surgery in New York City. Physicians who own their own imaging equipment – but are not formally trained, board-certified radiologists – are self-referring X-rays, MRIs, and CTs in increasing numbers.

Pavlov wants patients and referring physicians to understand the value of a fellowship-trained radiologist, and she’s calling on the government and radiologists themselves to shed light on this potentially dangerous practice. rt image spoke with Pavlov to learn about this growing trend and what radiologists can do to increase patient awareness.


rt image: With increasingly more images being prescribed in recent years, what trends are you seeing with regard to who acquires and interprets the images?

Helene Pavlov, MD, FACR: Basically what’s happening is that there is an increase in self-referral of CT and MR and other high-cost imaging examinations in private offices and imaging centers – the majority of which are owned or are in partnership with non-radiology physicians. This behavior is driving up the cost of healthcare on the basis of imaging, but you have to question the quality of the imaging that is being done as well as the appropriateness of the studies – are they really needed?


image: Why is this trend growing?

Pavlov: Several reasons. I think imaging is definitely getting better and it is easier to produce a clearer image, so the images – on the surface – seem easier to interpret. That doesn’t necessarily mean the acquisition of the image is simple, but once they have an image, it seems easier for a non-radiologist physician or a less-trained physician to believe that they can interpret it. This is especially the belief if they just want to know something easy, such as, “Is the bone broken?”.

The problem with that thought process is that getting a really clear image is easy, but as the technology gets better, the equipment can actually do much more and provide significantly more information than a clear picture. So, if all they’re looking for is a broken bone or if a ligament is torn, other information that would be very valuable to the patient may be overlooked; information that may be contributory to the pain or the patient’s condition should be considered in the treatment plan. Without appropriate expertise, the doctor interpreting the image may not know to look for a significant finding and the image may not reveal the information because of how the image was acquired.

So what’s actually driving the trend? Non-radiology physicians can buy low-end equipment and rely on their technologists to obtain the images without radiologist supervision. The final image is clear and seems easy to read, and the interpretation is purposely limited to what they are looking for. This practice makes money. As reimbursements for all medical procedures are going down, physicians are looking for ways of making more money.

So the concept is, “I’ll buy an extremity MR, and I’ll make a lot of money.” They’re not necessarily thinking that they’re doing any patient harm. [They’ll say], “I’ll do another study if I need more information, like an ultrasound – there’s no ionizing radiation.” They do not recognize that they might be doing a detriment to the patient by delaying the proper diagnosis and, furthermore, this practice adds to the healthcare burden.

If you’re the patient and you’re in pain, and you’ve had an imaging examination and the physician reporting the study says, “Everything looks fine, Mrs. Smith, there’s no problem,” the patient goes away thinking, “Well at least I don’t have a problem, but I still have my pain.” In fact, they may have a serious problem, but it’s undiagnosed. There’s a delay in treatment until the proper diagnosis can be made, which means the patient has to suffer longer or the problem becomes much more compounded than if it had been detected earlier.


image: What about vendors that are making it more appealing for a private practice to purchase its own equipment? Is that a new trend or has it always been there?

Pavlov: It has always been there, but never to the extent that it is now. Basically, vendors will sell to anyone that has the money to buy the machine. You look at the stock market and these companies are in trouble. They need to sell equipment – that’s how they make their profit. Specifically with ultrasound equipment, because it is less expensive, the vendors emphasize to potential buyers that, “You’re not going to do any damage to the patient; you’re not going to be using ionizing radiation.”

[Untrained physicians] feel as though there’s a magic button that they’ll press that will give them an image, and they will either rely on the sonographer or send it to India or some service and get a low-cost reading, or they’ll read it themselves thinking they’ve got the necessary expertise – which they may or may not have.

Non-radiology physicians do not fall under the scrutiny of the American Board of Radiology, which requires written and oral examinations and verification of four years of training to be a board-certified radiologist. Non-radiology physicians do not get extensive training in imaging and their boards do not test for imaging expertise. Patients and possibly third-party payers are not aware of that.


image: What effect will this practice have on the future of imaging?

Pavlov: I think there will potentially be a rationing of services. Low-yield diagnosis on the initial imaging examination, which may have been inappropriately ordered or performed, will result in patients being forced by their insurance carriers and the approval process to wait for imaging examinations until the problem is worse and the condition is easier to diagnose.

If you need to have an MR, for instance, it won’t be approved by your third-party payer until you’ve suffered for a few weeks longer, or you can’t walk, or you’ve had [physical therapy], etc. as opposed to having the MR earlier after the onset of symptoms when you might be able to start an appropriate rehab program or do outpatient surgery.

My sense is that in the future, because of the current abuse of self-referred imaging examinations and in an effort to control healthcare costs, patients’ accessibility to imaging studies will be controlled. Patients not dependent on third-party billing will pay out of pocket or out of network [for an exam]. Overall, it’s not the ideal way of distributing equal and fair and appropriate healthcare. If third-party payers try to control the proliferation of self-referral and the related cost by reducing reimbursements, then physicians will just order more studies to offset their losses.

Ideally, a quality study should be obtained and interpreted properly the first time when the findings may be more subtle, so the examination doesn’t have to be repeated. Patients should get the imaging examination and interpretation needed – not by self-referral, but by appropriateness based on the doctor and the radiologist discussing the patient’s condition and determining the required imaging needs.

Radiologists are physicians and are consultants to the other physicians. Radiologists are knowledgeable about all the imaging modalities and can best determine the appropriate imaging examination – MR or CT, etc. – for the patient’s condition. Under this scenario, the correct study would get done in a timely manner for the patient and is interpreted by an unbiased radiologist who is not going to benefit by saying, “I’m not really sure what’s going on. However, I think if I operate or take a look with a scope . . .”

Non-radiologists also self-refer this way for their own additional imaging studies as well, saying, “We already have an MR, let’s get a CT or an ultrasound – let’s get some other imaging study.” What they do not say is, “I have the equipment, and I can get more information and better satisfy my bottom line.”


image: What about the use of teleradiology as an option?

Pavlov: Teleradiology is used in two ways. Teleradiology can be excellent. For instance, we do teleradiology for private offices and imaging centers that will send us specific examinations to interpret, based on our being board-certified radiologists with a specific subspecialty, such as dedicated spine, dedicated shoulder, etc. Part of a good teleradiology service is also providing oversight for the acquisition of those images, assuring that they are of optimal quality. If we can’t interpret the study because it is of suboptimal quality, we inform the physician.

On the other hand, other imaging centers that, in order to get reimbursed, need a radiologist to interpret [the image] will send the image to other countries or to the least expensive radiologist to provide the interpretation. Most of these arrangements work on volume, so the speed of each interpretation, not the quality, is rewarded. The qualifications of the interpreting physician is a question. Are they trained in America? Are they subspecialized for the condition that they’re interpreting? These are the questions that need to be answered. There are some teleradiology services that do screen for that, but not all.


image: What can radiologists do to discourage physicians from imaging without a radiologist’s support?

Pavlov: Radiologists have a responsibility; their reports must add value to the referring physicians and the patients. They have to be able to provide information in that interpretation or in the image acquisition that actually helps the referring physician and helps the patient. Referring physicians need to be taught to recognize quality and recognize that there is value in having a radiologist interpret the examination.

There also needs to be recognition by third-party payers, by Congress, and by our politicians that radiologists are physicians, and that radiologists are unbiased in their interpretation, and they are truly patient advocates. I think it’s important for that information to be out there, because it is not widely recognized.


image: Are there any governing bodies that could step in on behalf of patients and radiologists?

Pavlov: The ACR [American College of Radiology] has a campaign to put a “Face on Radiology” to help patients become more aware that radiologists are physicians and the role the radiologist has in patient care. Right now, the only time a patient may be aware of the radiologist is when they see the radiologist’s name on a bill. [Except] if the radiologist is doing an ultrasound examination or you’re doing an interventional study, the patients and the radiologists directly interact. I think patients need to know about the valuable consulting role of radiologists.

Referring physicians usually make it seem to their patients that they are interpreting the X-ray or imaging study – which helps promote a good doctor-patient relationship. However, we need to get them to say to their patients, “I reviewed this with the radiologist, and we’re all in agreement.” When you’re watching a medical show on television or a hospital scene in a movie, you need to see a radiologist interpreting the X-rays and MRs. You never see that. You never see a radiologist working, actually helping patients and the referring physician. A multifront approach is needed.


image: By law, radiologists can’t self-refer. Why isn’t it the same for physicians?

Pavlov: I wish I knew. Radiologists do not self-refer as a mechanism to prevent unnecessary examinations and control costs. Non-radiology physicians should have the same restrictions. The non-radiologist physicians use the argument that they provide imaging service for patient convenience; for example, they have an X-ray machine right in their office and can take the X-ray and determine if the bone is broken. And they probably can. But they may not interpret that there is other damage that they’re not looking for or are unaware of what an unfamiliar pattern on the image may indicate.

I see this as [needing] extensive lobbying from radiology groups and third-party payers. The ACR and radiologists need to step up to the plate.

— Stephanie Twining