April 01, 2009
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The costs of diagnostic imaging: On our radar for 2009

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The number of CT scans and MRIs being ordered have increased significantly over the past 7 years. This data has been confirmed by Centers for Medicare & Medicaid (CMS) studies and indicate that Medicare-funded imaging doubled between 2000 and 2006. A study released last year by the Government Accountability Office (GAO) noted that more than 95 million scans are performed each year, with Medicare picking up $14 billion of the $100 billion annual tab.

Other data from the GAO study show that between 2000 and 2006, Medicare spending on CT scans, MRIs and PET scans rose 17% per year; a rate much faster than seen in ultrasound, X-rays and other standard imaging procedures.

“Skyrocketing” costs

In a recent article in Journal of Health Affairs, Rebecca Smith-Bindman from University of California San Francisco, the documents similar increases. In addition to MRIs and CT scans increasing in the past 5 years, PET scans have been reported to have tripled between 2001 and 2005. The government and health care insurance companies are looking for ways to rein in these escalating costs, which some describe as “skyrocketing.”

Efforts to control costs will require setting-specific indications for each scan and probably increase the use of authorizations. There obviously are a significant number of scans being done to assure the patients and in response to patient requests. It is estimated that 20% to 50% of the scans performed are not necessary for patient management. However, a counterpoint to overuse is the issue of professional liability for a missed or delayed diagnosis.

Douglas W. Jackson, MD
Douglas W. Jackson

We walk this tightrope on a regular basis in our practices. Frequently, the patient has an injury and asks, “Will I need surgery or will physical therapy, activity modification and time be all that is necessary?” The patient wants to know so he or she can plan their life around the injury. Most people can ill afford to wait 2 or 3 months and then find out that he or she will need surgery.

Radiology benefits managers

Radiology benefits managers (RBMs) are in place to better control the escalating costs of scans. In the future, they may stand between you and your patients reviewing the indications for every scan you order. Their point-of-view will be that advanced imaging scans should only be used when there is a clear indication of need — a guideline — and documentation in your request as to how it will benefit the patient. They will need to be convinced that every scan is necessary and why, much the way you once presented on rounds to your attending.

Sometimes this will be achieved by submitting well-documented office notes, but often they will wish to speak with you in person. This may lead to phone-tag delays and further imposition on your time. The RBMs only work during certain hours and we are expected to comply and respond within their schedules. Part of their delay technique is to suggest that you try alternatives to see if the symptoms persist, or to simply deny the request based on their interpretation of published references. They may even request you submit medical references to support your recommendations.

If the scan is deemed unnecessary, there is an appeals process and it may involve more then one level of review. The time required for appeals and further appeals can result in more time-consuming procedures.

At a certain point, on rare occasion, I tell the patient that he or she needs to get involved with their carrier because I have done all I am going to do to try and justify my request.

Emerging technology

This is an example of a problem we now have and will face more often in the future: Technology is emerging faster than the indications for its use and its role in medicine are established. This means placing in perspective and not underestimating the value of negative studies in some cases for both the patient’s and physician’s benefit.

The GAO report comments on the prospective nature of private plan authorization compared to the retrospective safeguards employed by the CMS. The GAO wrote, “To address the rapid growth in Medicare Part B spending on imaging services, we recommend that CMS examine the feasibility of expanding its payment safeguard mechanisms by adding more front-end approaches to managing imaging services, such as using privileging and prior authorization.”

It quotes a Department of Health and Human Services recommendation that, “… Medicare contractors, through post-payment claim review have identified imaging services as an area that poses high risk to the Medicare Trust Fund and are continuing to conduct ongoing medical review and provider education in this area.”

The American College of Radiology reacted by issuing a statement saying while they share many of the GAO’s concerns regarding the cost, quality and safety of imaging services, they do not “support GAO’s recommendations for prior authorization by radiology benefits managers, as this process would take medical decisions out of the hands of doctors, may delay or deny lifesaving imaging care to those who need it, and would likely result in longer waiting times for patients to receive care.”

Physician ownership

As a possible area of significant savings in health care cost, the physician ownership of imaging centers is coming under scrutiny. Payers are enthusiastically waiting for utilization figures of physicians who own scanners in comparison to those who do not.

In addition to the science, there are politics involved in restricting certain physician ownership. Hospital associations feel they should own the scanners, and the national radiology association has lobbied to have only radiologists own and interpret scans. Legislation and regulations of the ownership of imaging equipment continue to be lobbied for on the national and state level.

The GAO report stated, “Our analysis of the 6-year data showed certain trends linking spending growth to the provision of imaging services in physician offices.”

The report noted that during the 6-year time period, Medicare spending on imaging services performed in office rose from 58% to 64%, and in 2006 spending per beneficiary was extremely varied across state lines — from $62 in Vermont to $472 in Florida.

“Together these trends raise concerns about whether Medicare’s physician payment policies embody financial incentives for physicians to overuse imaging services,” the GAO wrote.

One thing that appears will continue is decreasing reimbursements as a means of restricting the utilization of scans. It appears that in 2009 there will be increasing attempts to limit the escalation of imaging costs in medicine and possibly further remove important medical decision-making from the physician.

Douglas W. Jackson, MD
Chief Medical Editor

Reference:
  • Smith-Bindman R, Miglioretti LR, Larson EB. Rising use of diagnostic medical imaging in a large integrated health system. Health Affairs. 2008;27(6):1491-1502.