JAMA: Imaging Use Up in HMOs; Industry Leaders Disagree

Changes to Medicare reimbursement and other financial incentives designed to control the use of diagnostic imaging services aren’t working as expected, even in clinical settings without a fee-for-service payment model, according to a study published earlier this week in the Journal of the American Medical Association. However, not all industry leaders agree that imaging utilization is on the rise.

A retrospective study of up to 2 million electronic health records from 1996 to 2010 from six health systems with health maintenance organizations (HMOs) revealed the number of diagnostic imaging studies performed increased between nearly 8 percent to 57 percent during that time period.

The findings, compiled by researchers at the University of California-San Francisco (UCSF), showed the number of ultrasounds doubled, CTs tripled, and MRIs quadrupled during those 15 years. These results indicate that financial disincentives, such as lowered reimbursement or added cost to the patient, aren’t enough to eliminate unnecessary testing, as once was the hope, researchers said.

“Some people are just unrealistically enamored with diagnostic tests. There’s a perception that there’s no harm to these tests, so we can do them and think about the results later,” Rebecca Smith-Bindman, MD, UCSF radiology and biomedical imaging professor and lead study author, said in an interview. “The pictures are extraordinary, and some patients receive enormous benefits from having these tests. But others receive no help at all - they face high radiation doses, false positives, and more unnecessary downstream testing.”

Fear of facing malpractice suits and of missing a malignancy also pushes providers to order diagnostic studies for which there is no true medical indication, she said. If these problems were resolved, she said, radiologists and referring physicians could likely avoid 30 percent to 50 percent of diagnostic studies.

Even an industry-wide shift to an accountable care organization (ACO) or bundled payment model is unlikely to be enough to drive down imaging utilization, she said. Instead, medical imaging should invest in comparative effectiveness studies to better understand when imaging is appropriate. Industry leaders can, then, use that information to create clinical guidelines.

However, several groups, including the American College of Radiology (ACR), the Medical Imaging and Technology Alliance (MITA), and the Access to Medical Imaging Coalition (AMIC) said the study’s findings actually supported existing evidence that imaging use is decreasing.

“National statistics from Medicare and private insurers demonstrate that imaging use has tightened in recent years as providers have become more educated about when and which scans should be ordered and radiation education efforts are more widespread,” Paul Ellenbogen, MD, FACR, ACR Board of Chancellors chair, said in a written statement. “Imaging scans have undoubtedly been proven to save lives, resources, and time. That is the current state of imaging and where responsible efforts to address imaging policy should start.”

Other studies support this assertion. A 2009 AMIC report revealed overall imaging services had fallen 7.1 percent over the preceding 11 years. In addition, a 2010 Health Care Cost Institute study proposed imaging was the slowest growing medical service field while the studies contributed to saving lives and improving quality of life.

Additionally, Smith-Bindman’s study somewhat contradicted the industry-wide belief that radiation exposure per patient is declining. The Image Gently and Image Wisely campaigns have received significant national attention in recent years with organizations, such as MITA, working closely with health care systems to control doses. But data analysis from this study revealed that 4 percent of patients who underwent any imaging received doses above what the U.S. Nuclear Regulatory Commission allows for nuclear power plant employees.

Roadblocks exist that prevent hospitals and practices from successfully limiting dose, Smith-Bindman said. For example, there are benchmarks for how low a dose is achievable, but there are few similar guidelines for what constitutes the lowest reasonable dose. In addition, software packages designed to make dose control easier carry hefty price tags and are often beyond a facility’s financial reach.

“The dosing problem would be solved virtually overnight if the software were made more widely available,” Smith-Bindman said. “If you want to see utilization continue while keeping a lid on high radiation doses, make the software easier to obtain.”

Despite the disagreement over the study’s findings and the question over whether imaging utilization is up or down, one thing is clear, she said. It’s time for radiologists to be more assertive in controlling how diagnostic imaging is used.

“We need to take a more active role in ensuring that our tests are used appropriately rather than overused,” she said. “We must educate referring physicians about when and how to image patients. We’ve, so far, taken a back seat and haven’t gotten involved in helping clinicians know when to use imaging. We must take responsibility for making our tests as safe as possible.”