Imaging

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The use of computed tomography (CT scans), magnetic resonance imaging (MRI), and ultrasound increased dramatically in the U.S. between 2000 and 2006. Among Medicare beneficiaries, the increase was higher than any other physician-provided services. Steep increases in the rates of these imaging studies can be attributed to technical improvements, physician and patient demand, and strong financial incentives (to those providing the imaging services). Medical imaging contributes to accurate disease diagnosis and improved treatments, but there are down sides to increased rates of imaging, and they include increased patient costs and patient harms such as overdiagnosis, incidental findings, increased patient anxiety, and radiation exposure (with CT). It has been estimated that 30 percent or more of imaging studies are unnecessary, costing approximately $30 billion in the U.S. alone. In a recent study that compared the U.S. with 10 other developed countries, the U.S. ranked one or two in the number of CT and MRI studies done per 1000 individuals.

Recently, a large study was published that examined medical imaging rates in the U.S. and Ontario, Canada from 2000 to 2016. It assessed changes in the rates of imaging among individuals across diverse integrated healthcare systems by country, health system, and patient demographic factors. Not surprisingly, the use of CT, MRI, and ultrasound in seven integrated healthcare systems in the U.S. and Canada has continued to rise in recent years. Although the rates of increase were highest from 2000 to 2006, the rates continued to rise, albeit more slowly, from 2006 to 2016 (from 1 to 5 percent annually). The notable exception was for pediatric CT scans, which declined since 2006, most likely due to pediatricians’ concerns of exposing children to ionizing radiation. The data suggested that imaging rates were lower in healthcare systems that had stronger incentives to constrain imaging (and thereby keep costs lower).

The data from this and other studies conform to my experience and that of many of my colleagues. For example, someone on straight Medicare (meaning not a member of a Medicare advantage plan) does not require any pre-authorization or prior approval in order to have an MRI or CT scan performed. The tests are automatically covered. On the other hand, a member of a Medicare advantage plan or most other commercial plans (i.e. EmblemHealth, HealthCare Partners) requires pre-authorization before an MRI or CT can be performed as an outpatient (in a non-emergency situation). Because these plans are in business to turn a profit, they make the prior approval process very difficult, especially for primary care practitioners. Many of these plans also offer financial incentives to physicians who order the least number of tests, thereby keeping costs low. The prior approval process is lengthy and tedious, and very often the person who processes the prior approval request has little to no clinical experience and is not a healthcare professional. It is for this reason and others that many primary care providers are opting for early retirement or taking non-clinical positions. If nothing changes, primary care providers will be just a memory, replaced by large multi-specialty groups with large staffs and no personality.

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