Monday, March 9, 2009

Can the U.S. Put The Medical Imaging Genie Back into the Bottle?

You can’t put the genie back into the bottle.

Popular Idiom

Can the U.S. put the medical imaging genie back into the bottle?

I’m not optimistic. We are a technology–oriented nation; medical imaging –CT, MRI, Nuclear medicine, including PET – are superior technologies; and the public and physicians have embraced medical imaging as the new standard of care.

Don’t take my word. Look at the numbers.

• From 2000 to 2006, Medicare expenditure for these imaging services rose from $3.6 billion to $7.6 billion (17% a year).

• The rate of imaging growth exceeded be far that of other service physicians billed Medicare over that period – culmulative change for imaging 70%, all diagnostic tests 53%. All physician services 45%, major services 25%, evaluation and management services, 24%.

• Nationally, some 7000 sites now offer MRI services.

• Internationally, the U.S. offers many more MRIs per million persons than any other country- US 26.5. Switzerland 14.0, Germany 7.7, Netherlands 6.6, Canada 6.2, United Kingdom 5.6, France 5.3, and Australia 4.9.

These numbers raise legitimate concerns that imaging is being overused, that non-radiologists are purchasing imaging equipment, that some imaging equipment is outdated and used inappopriately, that patients are being exposed unnecessarily to excess radiation, that physicians refer patients to facilities they own.

Consequently, Congress has imposed spending caps on outpatient payments for these imaging tests with these differences in rates.

Lumbar spine without contrast material – $557 to $429, 24.6% reduction.
Joints of lower limbs with contrast material - $520 to $413, 21% reduction.
a. Brain with and without contract material, $1023 to i$611, 40% reduction.

• CT
Pelvis with contrast material - $327 to $391, 6.6 % reduction.
Thorax with contrast material - $342 to $310, 9.4% reduction.
Thorax without contrast material - $290 to $245, 15.3% reduction.

• 3.D multiple heart images- $532 to $473. 11.3% reduction

What Does This All Mean?

Basically, it means that government and private health plans have been unable to contain the fee-for-service incentives for imaging technologies and subdue the profit incentives that propel their use.

Some of these incentives not only involve profit, but also include patient expectations that imaging has become an expected standard of outpatient care, that physicians hesitate to act without imaging diagnostic confirmation, that failure to perform imaging make become a malpractice issue. Imaging has become an integral part of coordinated and defensive medicine.

Therefore, without leverage to implement effective utilization constraints, policymakers and private insurers, after these short term fee reductions, are seriously considering “restructuring: or “replacing” fee-for-service” payments with a more “rational approach” which will probably involve bundled-payments to a single entity made up of hospitals and physicians.


Organized medicine will certainly react negatively to bundling since they consider outpatient imaging services and hospital episodes of care as separate and often unrelated to hospital activities. Procedures physicians perform in their offices and outpatient imaging centers may bear little relationship to what occurs in the hospital. In other words, outpatient imaging and hospital services have yet to be “integrated.”

Putting the imaging genie back into the bottle,

After in routine practice it reaches full throttle,

is not nearly as easy as it seems.

Once imaging becomes expected in the fee-for-service scheme.

It becomes routine and irreplacable in the practice model.

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