Regulations Are Stripping Away Your Access to Proper Diagnosis and Treatment

As a specialist who has been practicing musculoskeletal radiology for more than 25 years, I find the recent policy proposal of The National Quality Forum ("National Voluntary Counselors Standards for Outpatient Imaging Efficiency") to be somewhat concerning. I've reached out to senior ranking officials who are responsible for these standards to ask for an explanation behind the newly proposed policy requiring physical therapy (PT) prior to obtaining an MR of the lumbar spine for "Low Back Pain" and/or providing enhanced reimbursement for the MR examination contingent on this criterion. This decision, if it is instituted, will seriously handicap patient care and negatively affect the radiologist's relationship with the patient and the referring physician.

This mandate will potentially cause patients to have increased pain and injury from the PT if being performed for an inadequately or inaccurately diagnosed symptom. The PT appointments and follow up visits with specialists will further prolong a patient's time away from work and will further delay obtaining an accurate diagnosis and initiation of appropriate PT and/or intervention.

The vast majority of the lumbar spine MRs are done with the diagnosis of "Low Back Pain" and there is no constraint or reimbursement risk borne by the ordering physician. The policy, therefore, positions nonradiology, self-referring physicians who own in-office MR equipment and control their own (self) referrals to order PT, indicated or not, prior to their ordering their in-office MR in order to assure that they will be reimbursed at the enhanced rate.

To further insure a healthy bottom line, self-referring physicians will quickly incorporate PT services (if they have not already done so) along with their in-office imaging equipment, all, in the name of patient convenience. From a patients' perspective, it will be much easier to get the MR in this "nonradiology physician in-office setting" than from a Board Certified Radiologist. This is unfortunate, for non-radiology physicians (e.g. orthopaedic surgeons, emergency doctors and cardiologists, etc.) have inferior and less regulated imaging training compared to radiologists for both image acquisition and interpretation. Also, there is no quality assurance or validation of the level of imaging expertise of a nonradiology physician.

Patients unfortunately do not always appreciate the benefits that they receive from a study performed and interpreted under the supervision of a radiologist. The radiologist, having no control over the ordering patterns of referring physicians, will be at a significant competitive disadvantage from nonradiology, self-referring physicians. This disadvantage flows to the patient as the radiologist has specific training in image interpretation from which the patient would benefit. Judy Burleson, director of Metrics of the American College of Radiology (ACR), at a recent AHRA meeting stated that the ACR has similar concerns.

This proposed policy, if instituted, will result in the ordering of more PT and more MR. This statement is based on observed documented behavior. It has been reported (1) that a decrease in reimbursements results in the ordering of more self-referred (nonradiology ordered) MR examinations and does not yield cost savings. This proposed policy, if instituted, will neither cut costs nor facilitate optimal patient care.

If you are concerned about the quality of your ongoing level of care, and/or if you plan to visit your local physician about lower back pain, reach out to The National Quality Forum ( and ask them about the rationale behind this initiative.

1. Levin, DC, Rao,VM, Parker L, Frangos, AJ The Disproportionate Effects of the Deficit Reduction Act of 2005 on Radiologist' Private Office MRI and CT Practices Compared with those of Other Physicians. J Am Coll Radiol 2009;6:620-625