The high cost of precision

There is a natural inclination for doctors to use machines they've bought or have some financial stake in. Studies have shown that doctors with their own equipment are two to seven times more likely to order tests than those who send their patients to other facilities. A recent report by the Government Accounting Office suggested that financial incentives for doctors were a major factor in the rising number of scans.

Madyoon, whose cardiology practice was among the first in California to get a CT scanner, said the main reason to have one is for the convenience of patients.

But since doctors have been suffering as "the dollars and cents are being squeezed out of medical practice, why shouldn't they get their own equipment?" Madyoon asked. "You've got to survive."

A cornerstone of his practice is a controversial type of heart scan known as a CT angiogram, which provides a high-resolution image of coronary arteries using a blast of radiation roughly equivalent to 100 standard chest X-rays.

The scans are much simpler to do than traditional angiograms, which require threading a catheter into arteries, but they are also less accurate.

In just four years since the scans became possible, the number has quickly climbed past 400,000 a year in the U.S.

Although research suggests the scans can rule out heart disease in certain patients, Medicare earlier this year found evidence that the scans improved overall cardiac care to be inconclusive. Cardiologists and radiologists launched a massive protest when Medicare attempted to eliminate most reimbursement, enlisting members of Congress in a successful fight to ensure that government kept paying.

Medicare is now debating how far to go in restricting doctors from referring scanning business to themselves, in part to rein in skyrocketing scanning costs, which have grown to $2.17 billion in 2006, more than double what Medicare paid six years earlier.

Starting next year, it plans to eliminate a common arrangement in which doctors lease blocks of time on somebody else's machine and bill as if they own the equipment.

A bigger fight is brewing over the potential conflict of interest for doctors who own their own machines. It pits cardiologists, orthopedic surgeons and other specialty doctors against radiologists, who rely solely on referrals for their business and resent the invasion of their turf.