What you should know about doctors and self-referral fees

The Question

I'm a patient of a cardiologist who was asked me to make an appointment for a nuclear cardiology stress test, even though my last test was six months ago. I'm stable and have had no change in symptoms. The secretary let it slip that the cardiology group now owns this clinic. I am uncomfortable booking the scan so quickly after the last one and feel it is a conflict of interest. Can doctors self-refer tests to clinics they own and hence financially benefit by ordering more, possibly unnecessary, tests? I live in Ontario.

The Answer

Doctors can refer patients for tests to clinics they own and there is a worry that physicians may order more than needed. However, it will soon be less lucrative to do so in Ontario: The provincial government has moved to cut self-referral fees in half starting July 1. Seven other provinces already regulate self-referrals.

According to Gordon Guyatt, Distinguished Professor of medicine at McMaster University in Hamilton, the medical literature is "extremely consistent that when there is the opportunity for self-referral, more tests get ordered." He described you as being an "extremely astute patient who got it right."

Even so, there can be reasons for another test being ordered so soon after the initial one.

As a matter of course, cardiologists look at test results to ensure they have been done properly, according to Jim Swan, a cardiologist who practices in several Ontario cities. They follow appropriateness guidelines which meet current international standards and do their best to reduce patient exposure to radiation, he noted . A test is sometimes re-ordered when the original was done on older equipment, and there are legitimate concerns about the initial report's accuracy.

"If the patient has concerns about the appropriateness of the test, all imaging physicians, including cardiologists always welcome an open discussion with the patient so that we can make sure that the correct test is ordered on the correct patient at the correct time in the correct place," wrote Dr. Swan in an e-mail.

By cutting the self-referral fee, it may help prevent unnecessary testing and overexposure to radiation. But it may pose an inconvenience to patients. Ideally, you would want to get a necessary test done right then and there when in the specialist's office. Though the cardiologist may choose to do the test for half-price when the new rules take effect, more likely you will get referred to another clinic or back to your family physician to arrange testing elsewhere.

This is a highly politicized issue, where the government is trying to get its fiscal house in order and stamp out unnecessary testing, causing all cardiologists to undergo a massive change in the way they are remunerated.

What is paramount for you, as a patient, is to find out whether you need the second test. I suggest you ask why it's being ordered. The cardiologist should be able to justify it.

The Patient Navigator is a column that answers reader questions on how to navigate our health-care system. Send your questions to patient@globeandmail.com.