Medical Imaging Rates Slowed Sharply Since 2006

The use of advanced imaging has declined significantly among Medicare patients over the past seven years and a similar decline has been seen among privately insured patients, according to a study published in the August issue of Health Affairs. The study findings confirm research from 2010 that also found lower rates of imaging.

Study authors David Lee, PhD, general manager of health economics at GE Healthcare, and Frank Levy, of Harvard Medical School, wrote that use of advanced imaging grew consistently from the mid-1990s through the mid-2000s, but imaging use in Medicare and non-Medicare patients slowed to a rate of 1 percent to 2 percent through 2009. The decline was first reported in the January 2010 issue of the same journal.

The reduction in use of imaging also affects radiologists professionally, the authors wrote. When fewer tests are performed, fewer radiologists are required. “One by-product of this deceleration in imaging growth was a weaker market for radiologists, who until recently could demand top salaries,” wrote the authors.

In determining the reason for the decline, particularly when the decreases affected both Medicare and non-Medicare patients, the authors found that these exams often required pre-authorization, insured patients were forced to pay higher co-pays to undergo the examinations, decreased reimbursement by Medicare, as well as fear of radiation exposure from CT, PET, and nuclear medicine tests.

In response, the American College of Radiology (ACR) said that the list of factors cited for the drop is incomplete.

“Imaging utilization has tightened due to a number of factors, including greater use of evidence-based ACR Appropriateness Criteria and electronic physician order entry systems based on these guidelines, which ensure that patients get the right scan for the right indication,” the association said in a statement.

The ACR also reported that ACR accreditation of many facilities is improving quality and reducing scan duplication that result from poor quality images, which result in fewer imaging scans overall.

The ACR also pointed out that imaging cuts are affecting patient care. While the study’s authors said that it is unclear that slowdown in imaging rates is harmful to patients, the ACR did point out that according to a study published in December 2011, again in Health Affairs, as many as 12,000 seniors in the United States may have sustained fractures due to Medicare cuts in dual energy X-ray absorbtiometry (DEXA scans).

In addition, cutbacks in mammography facilities have made it more difficult to get a scan due to limited appointments and greater inconvenience (travel and time) to get to facilities that are still offering the services.

“Various studies show that imaging exams are directly linked to greater life expectancy, and for many indications, declines in mortality rates,” the ACR said. “Scans are also safer and less expensive than many of the invasive procedures that they now replace.”

The decrease in imaging use makes sense in some cases, according to the authors. For example, MRIs of the lumbar spine are often used to diagnose lower back pain. However, as determined in a study in 2002, unless systemic disease is strongly suspected or the patients are considering surgery, X-rays were just as effective in providing necessary information as were MRIs. MRIs of the joints in the upper and lower limbs are also not always necessary. The authors wrote that conservative therapy is frequently the best approach with requests for imaging to be done only if there is no response or there is worsening of the joint after the therapy.

Paul Ellenbogen, MD, FACR, chair of the ACR Board of Chancellors, said in a statement that the study shows further evidence that imaging scans are being used more efficiently. “Those who contend that imaging is primarily responsible for rising costs are either misinformed or purposefully misinforming others. RMBs 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 serious illnesses and deny patients access to potentially lifesaving services,” he said. “This can’t be allowed to happen.”