Imaging Utilization’s Wild Ride

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 - Rollercoaster

Radiology is on the defensive. Medical imaging, once heralded for its capability to enhance the accuracy of a diagnosis, is now looked upon with some measure of skepticism from policymakers focused on reducing costs through across-the-board cuts. How will utilization trends evolve? What practice management developments will follow?

The last decade saw an explosion in advanced imaging use, and with healthcare costs overburdening the economy, this growth ignited political headwinds. Now, with CT and MRI use plateauing, the future of imaging utilization could look very different from today. Although data and interpretations can be contradictory, a few practice management developments offer insight into a future with an emphasis on appropriate use of imaging. Consider:

A decision support initiative in Minnesota increased the rate of imaging that met appropriateness criteria from 79 to 89 percent, while reducing overall imaging utilization.

The first statewide image archive is being built in Maine, and aims to reduce repeat studies and save providers an estimated $6 million over seven years in data storage and transport costs.

A renewed emphasis on educating physicians and staff on costs and radiation risks associated with imaging resulted in a more than 20 percent reduction of imaging orders at one California medical center.

The blame game

More than 70 million CT scans are performed each year in the U.S. MRI and nuclear medicine also play large roles in diagnostic imaging in ways that couldn’t have been conceived of in the early days of imaging.

But are physicians relying on imaging too much? The question emerged over the last decade as advanced imaging utilization rates began their rapid climb. Among Medicare beneficiaries, use of CT grew at an annual rate of 14.3 percent from 2000 to 2005 and MRI use grew at a 14 percent annual growth rate over the same period, according to a study published in the August 2012 issue of Health Affairs. Parallel trends were seen among the commercially insured nonelderly population.

More than just an increase in imaging use, there are many signs that a substantial portion of the tests being ordered are not appropriate. The U.S. has failed to curb excessive testing, according to a study and accompanying editorial published online Nov. 19, 2012, in Archives of Internal Medicine, which pointed to high rates of repeat exams. According to the study, 55 percent of Medicare beneficiaries who underwent echocardiography between 2004 and 2006 had a second test within three years, suggesting some physicians routinely repeat diagnostic tests. Imaging stress tests, chest CT, cystoscopies and endoscopies all had moderately high repeat rates.

Self-referral is another area where signs point to at least a portion of imaging being ordered inappropriately. When a physician who orders an imaging study owns, leases or otherwise has some financial stake in an imaging system, the number of imaging studies ordered increases. This suggests financial incentives rather than clinical necessity may be partially responsible for driving use. The Government Accountability Office (GAO) found that in 2010, providers who self-referred made 400,000 more referrals for advanced imaging services than they would have had they not been self-referring. These extra studies cost Medicare approximately $109 million in 2010.

Political pushback

 - CT Volumes: Before and After the DRA

The rise in imaging use caught the eye of policymakers during the mid-2000s. Healthcare expenses were dragging on the economy, and imaging was among the fastest growing components of medicine in terms of cost. Lawmakers needed a target. They designed a slew of reimbursement cuts to radiology to de-incentivize the overuse of imaging services. The Deficit Reduction Act (DRA), multiple procedure payment reductions, practice expense revaluation and the bundling of procedural codes all combined to take a bite out of the budget.

Whether these efforts were successful depends largely on perspective. Speaking at the 2012 meeting of the Radiological Society of North America (RSNA), Vijay M. Rao, MD, of Thomas Jefferson University in Philadelphia, said that while the DRA was designed to reduce incentives for self-referral by cutting the technical component payment for imaging, she and colleagues found that the number of self-referred studies actually increased to offset the payment cuts. After implementation of the DRA in 2007, radiologists saw a 10 percent drop in MRI volumes and a 37 percent drop in payments.