Imaging growth halted after 2005: Causes, consequences abound

From the mid-1990s to mid-2000s, advanced imaging grew at a robust clip, surpassing 6 percent per year, and exceeding 20 percent annually in some market segments. Growth of advanced imaging among Medicare beneficiaries started to slow in 2006, and research suggests the slowdown extended to the non-Medicare insured. The expansion of prior authorization, increased cost sharing and other policies fueled the slowdown, according to a study published online July 25 in Health Affairs. The American College of Radiology (ACR) characterized the list of factors cited for the decline as incomplete and emphasized that the drop in imaging use is not without adverse consequences.

David W. Lee, head of health economics and reimbursement for the U.S. and Canada at GE Healthcare in Waukesha, Wis., and Frank Levy, PhD, professor of urban economics at the Massachusetts Institute of Technology in Boston, aimed to answer three questions:

• Did the slowdown in growth of imaging under Medicare persist and extend to the non-Medicare insured?

• What factors caused the slowdown?
• Was the slowdown good or bad for patients?

To analyze the trends in utilization, the authors examined claims data for both the Medicare and non-Medicare patients from 2000 to 2009. For the Medicare population, use of CT grew at an annual rate of 14.3 percent from 2000 to 2005; the growth rate began declining each year after 2005, to the lowest increase of 1.4 percent in 2009. MRI use in Medicare slowed from 14 percent annual growth between 2000 and 2005 to an average of 2.6 percent during 2006 to 2009. The authors noted a parallel slowdown among the commercially-insured nonelderly population.

Lee and Levy cited several factors as fueling the slowdown: prior authorization, increased cost sharing, the Deficit Reduction Act reimbursement changes and fear of radiation.

ACR offered an expanded list in a release, and cited greater use of evidence-based ACR Appropriateness Criteria and electronic physician order entry systems based on these guidelines. The organization explained that  Image Gently and Image Wisely have made providers aware of opportunities to reduce radiation from imaging exams and reduce unnecessary use of scans. ACR also touted the increasing numbers of ACR-accredited imaging facilities, which helps improve quality and reduce duplicate scanning due to poor quality images.

Finally, ACR referred to a study published June 13 in the Journal of the American Medical Association, which showed a similar drop in utilization patterns in integrated healthcare systems, as well as fee-for-service settings, meaning reimbursement has little to do with physician ordering decisions.

How do patients fare?

“Several types of imaging studies that played a prominent role in the overall slowdown in the growth of imaging have been cited in the past as being of potentially lower medical value as well as source of overuse,” wrote Lee and Levy. They referred to MRI of the lumbar spine and MRI of any lower extremity joint as examples of studies of questionable diagnostic value that were most responsible for the utilization slowdown.

ACR countered that reimbursement cuts are forcing imaging providers to reduce services or close. According to the FDA, there are 207 fewer mammography facilities and nearly 1,200 fewer mammography scanners available to American women than in January 2007.  

The organization pointed to studies showing that imaging exams are linked to greater life expectancy, and for many indications, declines in mortality rates. Scans are also safer and less expensive than many of the invasive procedures that they replace, ACR continued. For many serious indications, imaging exams reduce the number of invasive surgeries, unnecessary hospital admissions and length of hospital stays.

Although radiology benefits managers (RBMs) have been used in the private sector for 10 years, there has been no scientific, peer-reviewed research on their safety or impact on administrative costs, ACR said. A Patient Advocate Foundation report found that insurance coverage denials to patients seeking critical imaging services have doubled over the last four years, while 90 percent of the reversed denials for imaging services were actually covered in health plan language.        

“This Health Affairs study further supports the fact that medical imaging scans are being more efficiently used and are not a primary driver of rising healthcare costs. Medicare spends the same amount on imaging services now as in 2003—virtually unheard of in the healthcare arena. This is likely the case among the privately insured as well. Those who contend that imaging is primarily responsible for rising costs are either misinformed or purposefully misinforming others. RBMs deny needed care and intrude on the doctor-patient relationship at critical times. Arbitrary, backward looking limits on care may slow or even reverse gains against cancers and other serious illnesses and deny patients access to potentially lifesaving services. This can’t be allowed to happen,” said Paul Ellenbogen, MD, chair of ACR board of chancellors.

Meanwhile, Lee and Levy highlighted the importance of identifying and reducing nonmedical incentives driving imaging utilization as an important complement to comparative effectiveness research. For example, bundled payments counter nonmedical incentives “by putting an opportunity cost on a procedure’s use,” they wrote.

Ramifications for rads

Weaker demand, coupled with increased efficiencies provided by the transition to digital imaging, resulted in a tighter job market and loss of bargaining power for radiologists. Graduates of radiology fellowship programs are no longer able to command their ideal job description, location and pay, Lee and Levy reported. Compensation for new radiologists has dropped, and the wait for partnership has lengthened. Some hospitals have dropped exclusive contracts with radiology groups, and others have forced radiology practices to drop the right to read all imaging exams, which has enabled cardiologists and urologists to read their imaging exams.