COST: Getting the Prescription Right for Medical Imaging

Medical imaging, such as CT scans and MRIs, has become synonymous with medical cost growth, and both private insurance and Medicare looking for ways to rein in costs, according to a recent AP article by Linda Johnson.

Citing work done by the Center for Studying Health System Change, the article noted that from 2000 to 2005 the use CT scans in the U.S. rose from 12 scans per 100 people to 22-with each test generating between $500-$1000 in revenue. During that same period, Medicare's spending on imaging services nearly doubled from $6.4 billion to $12.0 billion, accounting for 23 percent of total outpatient hospital payments in 2005, according to MedPAC-Congress's advisory committee on Medicare.

Concerns are not just about the costs, but also the quality and value of the imaging services. Growth in CT scans—which expose the body to much more radiation than X-rays—has led some doctors to conclude that the amount of radiation exposure may actually increase the rates of cancer in future years (subscription required). Insurers have responded to the growth in imaging by requiring precertification before ordering new studies, much to the chagrin of some doctors and radiologists,

The problem is that no one can distinguish necessary from unnecessary imaging and all the financial incentives in medicine are for over-performance of imaging. One-third of medical malpractice suits are for failure to diagnose, so if a doctor has the slightest question about whether a symptom heralds something serious, an imaging study is ordered. The care of an individual patient is highly disorganized because patients are cared for by multiple doctors who rarely know what the other has done. Unless a single doctor is coordinating or managing the care of a patient—which is rare—duplicate studies are commonplace. Another factor is that no one measures the quality of a doctor's practice and without standards of performance who is to know necessary from gratuitous imaging? Even when there are standards for performance, such as in coronary angiography, the evidence is overwhelming that those standards are not followed with any regularity. Furthermore, in an effort to increase income, doctors have increasingly installed imaging units in their office rather than referring patients to radiology facilities for studies, further escalating the problem of unneeded studies.

The only way out of this box is to gather more information on what does and does not work, establish clear standards for the use of imaging, to hold doctors accountable to those standards—such as paying only for a standard workup unless the doctor certifies the need for additional studies in unusual cases—and to hold doctors harmless from medical malpractice suits for failure to diagnose if they follow those standards.