Ordering Patterns for High-Tech Imaging:
Defining Self-Referral across Specialties
Susan Nedza, MD, MBA, FACEP, Chief Medical Officer, AIM Specialty Health cmo@aimspecialtyhealth.com.
Dr. Nedza is an Adjunct Associate Professor at the Feinberg School of Medicine of Northwestern University. She has served as a
member of panels at the Institute of Medicine (IOM), the Agency for Healthcare Research and Quality (AHRQ), The Joint
Commission (TJC) and most recently at the Office of the National Coordinator for Health Information Technology (ONC). She has
given numerous national and international lectures and has published peer-reviewed articles, as well as authored textbook chapters
in the area of health policy, quality and patient safety.
Objective
The objective of this study was to examine imaging utilization patterns across different medical
specialties. High-tech imaging was defined as computed tomography (CT), magnetic resonance imaging
(MRI), nuclear cardiology, positron emission tomography (PET) and echocardiography. Metrics studied
were volume distribution across specialties and use rates per patients. The accumulated data was used
to compare Self-Referral to Non-Self-Referral practice patterns. Self-referral providers were defined as
entities where the ordering provider Tax ID Number (TIN) and rendering provider TIN were the same. A
Rendering Provider was identified as an office based physician specialty (excludes radiologists and
hospital-based specialists).
Scope
Data regarding requests for prior-authorization of high tech imaging exams was reviewed. The
commercially-insured population across Indiana, Kentucky, Missouri, Ohio and Wisconsin were evaluated
for the 12-month period between January 2012 and December 2012.
Results
We found that self-referring physicians ordered 27% of high tech imaging studies. Cardiology was
identified as the specialty with the highest rate of technology ownership with 46% of cardiac imaging
requested by self-referral physicians. When oncology and neurology were excluded from analysis, selfreferral providers ordered fewer studies per patient than non-self-referral providers. With respect
orthopedic surgeons, analysis showed little variation in ordering patterns between self-referral and nonself-referral providers in the same state. In addition, the utilization rate for high-tech imaging by
orthopedic surgery providers was comparable to that of other specialties.
Conclusions
Findings suggest that having appropriateness criteria programs for imaging can impact ordering patterns
of self-referral providers. While the specific reason is uncertain, it is likely that the educational component
of imaging management/precertification programs may positively influence physician behavior. Such
participating providers tend to be better informed of evidence-based appropriate use of high-tech imaging
when compared to other providers in the study.
AIM Specialty Health is a national leader in specialty benefits management helping health plans ensure their members receive
appropriate, safe and affordable care. For more than 35 million members covered across 50 states, D.C. and US territories, AIM’s
mission is to promote the quality of clinical services including radiology, cardiology, oncology, specialty drugs and sleep medicine.
AIM is a wholly owned subsidiary of WellPoint, Inc. (WLP).