More or Less
The Inaugural Policy brief of the Harvey L. Neiman Health Policy Institute reports that the use of medical imaging has declined in recent years.
Clinical utility, financial conflict of interest, physician fear of medical malpractice: these are few factors that drove up medical imaging expenditures in the early part of the last decade.
But, according to the first-ever Neiman Report, a health policy brief distributed by the Harvey L. Neiman Health Policy Institute (HPI), demand for imaging technology has declined in recent years. The brief's author, Richard Duszak, MD, FACR, chief executive officer and senior research fellow at the HPI, examines both the basis for this sustained slowdown and its potential consequences.
What Goes Up Must Come Down
In the brief, titled "Medical Imaging: Is the Growth Boom Over?" (available at www.acr.org/hpi), Duszak notes that between the years 2000 and 2005, advanced medical imaging expenditures rose faster than those for most other medical services. This expansion brought with it, however, a recognition that such a trajectory was not sustainable. Initiatives both within the specialty and outside of it aimed to push back against this trend, with varying degrees of success. Despite the widespread misconception that costs are still on the rise, as of 2007, these efforts had reversed the growth of Medicare Part B spending on diagnostic imaging.
While industry-led best practice guidelines like ACR's Appropriateness Criteria® contributed to this reversal, other initiatives outside of the specialty have taken a different approach, targeting Medicare payments for individual imaging services. For instance, the report notes, "Both the professional and technical components of payment have been cut — by as much as 50 percent — through multiple procedure payment reductions (MPPR) for contiguous body part imaging." These various cuts have resulted in steep unit cost reductions.
In addition, private payers and Medicare Advantage programs have implemented radiology benefits managers (RBMs) that have made physicians more reluctant to request medical imaging. As the report notes, despite the fact that no such programs have been implemented for traditional fee-for-service Medicare, it has been speculated by one group that "RBM implementation for non-Medicare payers has somehow resulted in a sentinel effect behavioral change by ordering physicians, who now request medical imaging with more trepidation for both RBM-participating and non-participating patients alike." Further, CMS has implemented changes in calculation methodologies such as equipment utilization estimations that have resulted in reduced imaging payments. But if the earlier increase in medical imaging was related to its positive impact on patient care, the report states, suppressing its growth could have unintended consequences.
Truth and Consequence
In the report, Duszak wonders if drastic cuts are an overcorrection by policymakers, who continue to rely on outdated information to make their decisions. Since data suggests that medical imaging spending has been cut so much, further reductions in payment may harm patient care.
One public health impact of these cuts could be length of patients' hospital stays. "Coincident with recent national declines in the utilization of medical imaging," states the report, "average patient length of stay has increased." Although factors unrelated to medical imaging may also be at play, and despite the fact that a correlation does not indicate causation, Duszak argues that even the potential for such a link should prompt lawmakers to reconsider their current approach.
In addition to its negative effects on patient health care, imaging service cuts may have the unintended result of increasing costs elsewhere along the chain of patient care. The report indicates that treatment costs for many diseases can be contained by early detection through the use of medical imaging. With the decline of imaging, however, the expense of treated undetected diseases down the line may outweigh any cost savings.
Maintaining patient health while reducing imaging overutilization is a challenge that the industry has shown it can meet. The inaugural Neiman Report asserts that radiology continues to do its part in keeping costs low. It is now up to policymakers to recognize this effort and stop exerting downward pressure on medical imaging. By working together, and with the most up-to-date information, doctors and lawmakers can bring the focus of medical care back to where it belongs: on the patient.
To learn more about the MPPR, read "Safeguarding Radiology" in the July/August issue at http://bit.ly/JulyAugBulletinMPPR. To learn more about RBMs, read "Taking Back Imaging" in the September issue at http://bit.ly/SeptBulletinRBMs.
By Chris Hobson