The volume of advanced imaging services delivered to Medicare beneficiaries decreased in 2009 for the first time in 11 years, potentially signaling the end of the era of rapid growth in medical imaging volume, according to a study conducted by The Moran Company. The dip in volume could spell reduced access to advanced imaging and may drive healthcare costs higher.

The study, released Feb. 9 by the Access to Medical Imaging Coalition (AMIC), a coalition of physician, patient and imaging manufacturer groups, found that while the volume of advanced imaging services decreased by 0.1 percent, the amount of overall imaging services declined by 7.1 percent.

“The analysis found that Medicare spending for advanced imaging services increased by less than half the spending growth for physician services overall,” said Don Moran, president of The Moran Company, a healthcare consulting firm based in Washington D.C. “With a 1.2 percent increase in spending for advanced imaging compared with 2.6 percent for services overall, imaging was one of the slowest growing segments of the physician fee schedule in 2009.” Imaging spending remains below 2006 levels.

Moran’s analysis of Medicare claims data from 1999 through 2009 examined both the spending and volume of advanced imaging services – specifically CT, MRI and nuclear medicine including PET – as well as overall imaging services, including mammography. The new findings are comparable to a 2008 analysis of Medicare claims data that showed a 19.2 percent reduction in Medicare spending on advanced imaging from 2006 to 2007 and revealed a significantly reduced volume growth rate of only 1.9 percent, which was less than the overall rate of physician-payment growth.

End of an era
“It’s pretty clear that the era of rapid growth in medical imaging has come to end,” observed Moran. Although the last decade has been characterized by substantial growth in imaging services, growth flattened mid-decade. “Since 2005, we’ve seen marked deceleration in the growth of imaging generally and advanced imaging in particular.

Much of the concern [about imaging volume and spending] has been predicated on the assumption of rapid growth. At this point, advanced imaging is growing at half the rate of growth of medicine in general, and it is becoming a declining share of overall Medicare spending,” reported Moran.

While imaging growth slows, underlying diagnostic needs remain relatively constant. “This decline is significant,” stated John A. Patti, MD, chair of the American College of Radiology board of chancellors. “The incidence and prevalence of disease has not declined and the Medicare population is increasing.”

The trend could ultimately drive healthcare costs higher. “One of the tremendous benefits of advanced imaging is that it has obviated the need for more costly and invasive diagnostic evaluation, [which is behind] the rise in imaging volumes over the last decade. This reversal suggests Medicare recipients may not be receiving the benefit of exams and thus early diagnosis, which may have negative downstream effects on the health of aging citizens and [overall] costs if disease is discovered in advanced stages,” said Patti.

Stuart Seidis, MD, associate director of cardiology at Washington Hospital Center in Washington D.C., added, “The fact that imaging has been and will continue to be a substantial portion of the Medicare budget does not mean that the public is getting poor value for its money.”

That’s because increased spending on imaging may result in lower spending in other areas. For example, increasing utilization of myocardial perfusion imaging has resulted in a dramatic reduction in invasive cardiac catheterizations, said Seidis.

However, “the decline in volume of critical screening services suggests that access issues are at hand,” said Tim Trysla, executive director of AMIC.

Modality trends
Moran’s analysis sliced and diced the data by modality to reveal:

• MR volume decreased by 1.2 percent from 2008 to 2009 while spending increased 0.8 percent in the same time frame;
• Although volume and spending for CT services have been increasing from 1999 to 2009, spending started to decrease in 2007 with implementation of the Deficit Reduction Act;
• The 2008 to 2009 rate of growth for CT procedures was nearly half that of the previous year (2.6 percent to 1.6 percent); and
• From 2008 to 2009, total mammography volume decreased by 0.3 percent compared to a 2.8 percent compound annual growth rate for the 10 year period.

Wading into the future
Patti and Seidis referred to the importance of appropriate use criteria in the imaging process and welcomed the emphasis on appropriate use in the Medicare Imaging Demonstration project, which will assess the impact that decision support systems used by physician practices have on the appropriateness and utilization of advanced medical imaging services ordered for beneficiaries in original fee-for-service Medicare.

However, the overall fiscal situation portends an ongoing challenge; the Patient Protection and Affordable Care Act (PPACA) calls for another $3 billion in spending cuts.