Radiology certainly has a long laundry list of woes. In 2008, nearly a half billion radiology procedures are expected to be performed, but at the same time concerns are mounting in the industry over waste, fraud, and patient radiation dose levels. Radiology management services provider MedSolutions points out that high tech, high price imaging costs are growing even faster than pharmacy drug expenditures, and that low-tech imaging representing one of the most fertile areas for abuse.
“Waste is expensive, with unnecessary imaging estimated to cost the country billions, possibly even as high as $10 billion annually,” said Gregg P. Allen, MD, executive vice president and chief medical officer of MedSolutions. “When these procedures are warranted by patient condition, they are among the best diagnostic tools available. But procedures that are simply ordered as a result of patient demand, physician uncertainty, or lack of information” can lead to “unwarranted studies, with attendant unnecessary costs, and in some cases risk to the patients involved.”
Others waste culprits, according to Allen, include defensive medicine, use of imaging studies in place of the physical exam, multiple and repeat screening studies, lack of knowledge regarding the appropriate imaging study, increasing tendencies toward aggressive surveillance and treatment of incurable diseases, and direct-to-consumer marketing.
“Fraud and abuse, on the other hand, encompass a wide range of improper billing practices that include misrepresenting or overcharging with respect to services delivered,” he added. “Both generate unnecessary costs to the insurer, but fraud generally involves a willful act, whereas abuse typically involves actions which are inconsistent with acceptable business and medical practices.”
Allen believes that self referral leads to abuse since there is a clear incentive for physicians to perform imaging studies when the practice will benefit financially. However, instances of in-office imaging continue to grow. Studies indicate that physicians self-refer patients to owned equipment as much as four times more often when compared to practices without in-office equipment ownership.
Patients often pay the price for radiology abuses in numerous ways, including the potential for unnecessary exposure to radiation.
MedSolutions believes that radiology management firms, and some health insurers are helping elleviate these problems by instituting management programs that address these problems. Managed care decision makers are recognizing that radiology spending now accounts for about 10 percent of every healthcare dollar.
“Payers need viable strategies to minimize physician self-referrals, impose credentialing criteria, initiate independent activities to assess providers’ competency to perform diagnostic imaging services, and institute pre-authorization programs for non-emergency outpatient CT, MRI and certain other diagnostic imaging studies,” said Allen.