Download The Value of Diagnostic Medical Imaging

INVITED COMMENTARY
The Value of Diagnostic Medical Imaging
Don Bradley, Kendall E. Bradley
Diagnostic medical imaging has clear clinical utility, but it
also imposes significant costs on the health care system.
This commentary reviews the factors that drive the cost of
medical imaging, discusses current interventions, and suggests possible future courses of action.
R
adiologic and other diagnostic medical imaging has
evolved at a rapid pace over the past 120 years, beginning with Röntgen’s discovery of x-rays in 1895 and continuing through further advances in more recent decades: the
clinical use of nuclear medicine in the 1950s; the growth
in the 1970s of innovative diagnostic imaging modalities
including ultrasound, computed tomography (CT), nuclear
magnetic resonance imaging (MRI), and position emission
tomography (PET); and digitalization of radiographic images
in the 1980s [1-3]. More recently, PET/CT has become available, providing both metabolic and anatomic insights.
These modalities have had a significant positive impact
on diagnostic capability, but they are also expensive. The
cost of medical imaging—especially that of sophisticated
imaging studies—has grown faster than overall inflation of
medical costs; it has also grown faster than overall inflation
of gross domestic product growth or worker wages [4, 5].
To know whether this expense is worthwhile, we need to
know whether medical imaging improves health outcomes
and whether the value of those improvements exceeds the
economic costs. But answering the question “How valuable
is imaging?” depends on one’s perspective, and any assessment requires an analysis of the quality, effectiveness, efficiency, safety, diagnosis, setting, patient population, and
ownership of each diagnostic modality [6-8].
Diagnostic medical imaging costs in North Carolina—
driven in large part by MRI, CT, and PET—have accelerated
rapidly as the number of imaging machines has increased
from the mid-1980s to the present. Internal data collected
by Blue Cross and Blue Shield of North Carolina (BCBSNC)
show that diagnostic medical imaging accounted for
9.7%–11.5% of total per-member-per-month medical
expenses from 2005 through 2013, and advanced imaging (CT, MRI, and PET) accounted for more than 50% of
diagnostic medical imaging costs during that time period.
These figures are consistent with national data, which
show that diagnostic medical imaging accounts for 10% of
all US health care costs [9].
The 2013 State Medical Facilities Plan [10] notes that
North Carolina had only 2 MRI programs in 1983, and they
performed a total of 531 procedures that year; in comparison, there were 260 fixed and mobile MRI scanners in
2010–2011, and they performed 776,852 scans. Similarly,
in 1985 the state had only 1 PET scanner, but by 2010–2011
there were a total of 27 fixed dedicated PET scanners, which
performed 34,900 procedures, and mobile PET scanners
performed another 5,716 procedures [10]. Increased utilization has often been driven by appropriate clinical indications
for these procedures. However, a significant portion of the
increase has been driven by clinical overuse—and perhaps
to some extent by the financial lure of self-referral [11, 12].
Imaging utilization has several potential adverse outcomes. There are some risks from the imaging study itself,
including radiation exposure and procedural complications,
and there are also risks from the contrast material, when
contrast is used [13, 14]. In addition, workup of incidental findings involves significant costs, anxiety, and further
potential adverse outcomes.
Most of us engaged in health care feel that we need
more and better studies of cost effectiveness and comparative effectiveness to provide clearer and more understandable diagnostic imaging guidelines and/or decision support
tools for clinicians and patients. Unfortunately, the Patient
Centered Outcomes Research Institute (PCORI), which was
established by the Patient Protection and Affordable Care
Act (ACA) to address questions of comparative effectiveness, has no clear mandate to study cost effectiveness [15].
To complicate matters further, a recent study indicated that
only 36% of current physicians believe that they have a
“major responsibility” to reduce health care costs [16], and
another recent study found that the majority of patients are
unwilling to consider costs when making medical decisions
for themselves [17].
A number of medical specialty societies have worked
to develop pertinent clinical guidelines covering the use
(or nonuse) of diagnostic imaging, and the US Preventive
Services Task Force has published evidence-based preventive care screening guidelines. Of particular interest to
diagnostic medical imaging providers is the 2013 “Choosing
Electronically published March 11, 2014.
Address correspondence to Dr. Don Bradley, PO Box 2291, Durham, NC
27702 ([email protected]).
N C Med J. 2014;75(2):121-125. ©2014 by the North Carolina Institute
of Medicine and The Duke Endowment. All rights reserved.
0029-2559/2014/75209
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Wisely” campaign, in which 50 specialty societies each
identified 5 clinical services that patients and clinicians
should question [18]. Mahesh and Durand [19] noted that
56% of the lists include at least 1 medical imaging service,
which suggests that clinicians believe some types of imaging are overutilized. Depending on the type of imaging, clinicians may have concerns about the safety of imaging (due to
ionizing radiation exposure, for example) or about patients
demanding imaging based on misperceptions, or they may
believe that a specific type of imaging is not useful in the
management of care.
Guidelines provide a framework for optimized use of diagnostic imaging, but most guidelines are nonbinding recommendations that only address clinicians’ ordering behaviors.
In contrast, shared decision making engages patients in their
care and has been shown to reduce utilization of services
for preference-sensitive conditions, including angina, joint
arthritis, back pain, and early-stage prostate cancer [20]. In
one study, use of shared decision making tools reduced use
of advanced imaging studies by 7% and reduced use of standard imaging studies by 30% [20]. This approach requires
clinician support, at the very least, if not direct delivery of
shared decision making techniques; however, use of shared
decision making may conflict with the provider’s own (and
legitimate) clinical judgment or with his or her financial
interests based on productivity or ownership.
Payers have responded to continued increases in the
cost of imaging by employing several techniques, including
radiology benefit management (RBM) programs, consumer
transparency tools, increased cost sharing for advanced
diagnostic imaging, and clarification of medical and reim-
bursement policies. Although Congress forbade Medicare
from using RBM programs, the Centers for Medicare &
Medicaid services reduced reimbursement for imaging performed in physician offices, and this step was believed to
have a major impact [21]. For example, the combined annual
growth rate for utilization of MRI, CT, and nuclear medicine among Medicare outpatients was 10.2% from 2000 to
2006, but it dropped to only 1.7% in 2007 [21]. The 2008
recession also reduced overall health expenditures, including expenditures for medical imaging, although these reductions have not been well quantified.
The experience of commercial payers lagged behind
the decelerating trends seen for Medicare outpatients.
Commercial payers began implementing prior-approval
requirements through RBM programs in 2006, and an analysis published in 2012 [22] found that increases in utilization
rates slowed to between 1% and 3% per year from 2006 to
2009. This analysis suggested that “a meaningful fraction”
of the reduction in utilization involved services considered to
be of marginal clinical utility [22].
The rates of imaging utilization for BCBSNC members
underwent an escalation similar to that of Medicare outpatients, and beginning in 2003 there was discussion about
the possibility of implementing an RBM program. Despite
provider-based attempts to curb utilization, rates of use
continued to accelerate, and BCBSNC implemented an RBM
program in 2007. Figures 1 and 2 show the impact of this
change using BCBSNC data derived from internal analyses. Figure 1 shows smaller increases and even decreases in
imaging utilization rates beginning in 2007. Figure 2 shows
variable but generally decreasing rates of change in total
figure 1.
Changes in Rates of Imaging Utilization by Membersa of Blue Cross and Blue Shield of North Carolina, 2006–2013
Note. RBM, radiology benefit management.
a
Only includes members enrolled in nongovernment health plans.
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figure 2.
Changes in Amount Spenta by Blue Cross and Blue Shield of North Carolina on Imaging, 2006–2013
Note. RBM, radiology benefit management.
a
Only includes spending for members enrolled in nongovernment health plans.
allowed medical expenses, allowed expenses for advanced
imaging, and allowed expenses for other imaging; despite
these trends, the actual cost of medical care and imaging
continued to rise until 2013.
Health plans, including BCBSNC, have also increased cost
sharing for members, especially as high-deductible health
plans have grown in popularity. Individuals enrolled in any
of the health plans offered to North Carolinians through the
federal health insurance marketplace will be responsible for
the first $500–$5,000 of medical expenses, depending on
which benefit plan they chose [23]. After this deductible
is met, the member will be liable for 10%–40% of the cost
of services (coinsurance) [23], up to a total out-of-pocket
expense of $6,250 [24].
To support members as they begin to pay a larger portion of the cost of advanced imaging, most health plans have
introduced transparency tools that share several types of
information: the total cost of a service; physician or hospital quality measures, such as board certification, accreditation, and recognitions; the estimated total cost of the
service for a given provider; the estimate of the member’s
out-of-pocket cost; and the geographic distance to the provider from the member’s zip code. For example, a BCBSNC
member seeking an outpatient radiology provider in Durham
for a lumbar spine MRI will find more than a 3-fold difference in cost between providers within a 25-mile radius. The
actual out-of-pocket cost for an imaging study will depend
on how much of the member’s deductible has already been
met and the member’s level of coinsurance. To date, health
plan members have not often used online transparency tools
for medical imaging. When they are used, however, patients
tend to select providers who offer higher quality care and/or
provide care at a lower cost [25]. Whether use of transparency tools is driven by patients’ financial liability, patients’
concern for quality, or providers’ consideration of the information that is provided, transparency will continue to grow,
both in commercial health plans and in Medicare.
Going forward, some of the financial risk for the cost of
diagnostic medical imaging—and for the total cost of care
for a population—will shift from health plans and patients
to providers. In principle, accountable care organizations
(ACOs) will receive a set payment or budget for a population of patients, and they will be expected to use those funds
to provide care and produce acceptable health outcomes
and patient satisfaction for that population. Clinicians will
be rewarded financially if the cost of care is less than the
budgeted amount, or they will incur losses if costs exceed
their estimates.
Although the health care delivery system will need to
be reengineered in order to succeed, incremental building
blocks have begun to emerge. For example, patient-centered
medical homes facilitate the coordination and integration
of care, and bundled payments have been introduced for
discrete procedures (eg, knee or hip replacements). In the
future, all providers in an ACO will need to take on some
of the roles currently performed by health plans, including
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enforcement of adherence to evidence-based guidelines. If
guidelines can be embedded in the ACO’s electronic health
record (EHR) system as decision support tools that can be
employed at the point of care, then enforcement will be
more timely, less disruptive to providers and patients, less
expensive (from an administrative cost perspective), better
documented, and more consistent.
In 2006 the Institute for Clinical Systems Improvement
(ICSI), which is based in Minnesota, implemented a pilot
program in which an imaging decision support tool was
embedded in a health system’s EHR [26]. This strategy
reined in utilization of high-tech diagnostic imaging in a
manner similar to that of RBM programs in other states, but
with considerably less administrative burden. Unfortunately,
the vendor of the tool announced plans to discontinue the
product (Rad Port) in February 2014, although most health
systems that have installed the tool will continue to use it
[26]. The collaborative approach spearheaded by ICSI was
incubated in a medical environment and culture in which
health maintenance organizations have thrived for 50 years
and a majority of clinicians work within ACO-like health systems. North Carolina is not Minnesota, but there is still an
opportunity for providers and health plans to collaborate,
even outside an ACO setting.
In addition to changing physicians’ behavior, providers
and health plans will need to better engage patients in taking
responsibility for their own health and well-being. As noted
earlier, increased utilization of diagnostic imaging is not
just a provider issue; it is also a patient issue. The Choosing
Wisely campaign has collaborated with Consumer Reports
magazine to create patient information materials [27] that
encourage patients to consider imaging choices carefully.
Finally, the digitalization of diagnostic medical imaging
has created opportunities to lower costs and to improve
the quality and timeliness of services. Images are created
locally, but digital copies can be transmitted globally and
interpreted anywhere (in India, for example, where labor
costs are lower). Clinicians and health systems already utilize Nighthawk Radiology Services or other international
resources to provide interpretation of diagnostic imaging
at night, and use of teleradiology could be expanded [28].
Digital images can also be compared with images in larger
databases to facilitate decision support and to build more
effective and efficient care plans [29].
To summarize, diagnostic imaging provides tremendous
value when used appropriately, but it carries potentially
significant risks for patients. The cost of diagnostic imaging is also substantial and highly variable, and although cost
trends have been mitigated, the absolute cost of imaging
continues to increase. Virtually all stakeholders in our health
care system have responded to rapid increases in rates of
utilization. As a result, rates have increased more slowly
over the past 5 years, and imaging is used less frequently in
circumstances in which it is believed to be of marginal value.
Going forward, new technologies and business models will
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continue to disrupt traditional roles and practices. As the
broader health care environment changes dramatically with
implementation of the ACA, financial risk will be transferred
to different parties, and providers and payers should recognize that they have an opportunity to collaborate for the
benefit of patients.
Don Bradley, MD, MHS-CL senior vice president of health care and chief
medical officer, Blue Cross and Blue Shield of North Carolina, Durham,
North Carolina.
Kendall E. Bradley, BS medical student, Duke University School of
Medicine, Durham, North Carolina.
Acknowledgment
Potential conflicts of interest. D.B. is an employee of Blue Cross and
Blue Shield of North Carolina. K.E.B. has no relevant conflicts of interest.
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