Imaging examinations, especially high cost imaging studies such as computed tomography (CT) and magnetic resonance (MR) imaging examinations, have been targeted and are under scrutiny by insurance companies, the government as well as by patients for being overutilized and unnecessary.
Should we curb or eliminate expensive imaging examinations or limit access? The answer is two-fold: yes and no.
Let's start with "YES."
Imaging examinations have a critical role in diagnosis, treatment and management decisions. However, some imaging examinations are not indicated and are one of the major factors responsible for the escalating health care costs. Unnecessary examinations are a true waste of financial resources, are an inefficient use of the physician's expertise and time and account for poor utilization of resources. Unnecessary examinations also cause patient inconvenience and anxiety as well as being costly and frustrating. In addition, X-ray examinations and CT studies expose the patient, particularly children, to unnecessary radiation risks.
Elimination of overutilization of imaging is a legitimate target requiring attention. Excessive use of imaging has been addressed in previous blogs that placed a spotlight on overutilization caused by self-referral. Self-referral, as discussed previously, is when a non-radiologist health care provider purchases his/her own imaging equipment -- such as MRI and CT equipment -- and then orders these examinations for his/her patients. While most physicians put their patient's interest first, for some it is extremely tempting to order a test regardless of its necessity because it helps cover the cost of their equipment. The more tests, the more offset of costs and eventually more profit. Under this scenario, patients receive what they think (or are told) they need and the physician's practice profits. The patient and the physician are satisfied; so, what is the problem?
The Government Accountability Office (GAO) report best illustrates the extent of the problem. Based on Part B claims data, non-radiologists who own their own MR equipment (self-referrers) increased their MR utilization by approximately 84 percent from 2004 to 2010 compared with an increase of approximately 12 percent in the group of physicians who send patients to imaging facilities where the physician does not have a financial incentive (non-self-referrers). Over the same time period, the number of CT examinations performed by the self-referrers increased by approximately 107 percent, compared to an increase of approximately 30 percent by the non-self-referrer group. The GAO summarized that in 2010 "providers who self-referred made 400,000 more referrals for advanced imaging services than they would have if they were not self-referring" and the GAO concluded that "financial incentives for self-referring providers were likely a major factor driving the increase in referrals." According to the Healthcare Savings Chronicle, unnecessary imaging is estimated to cost the country billions, even as much as $10 billion annually.
Now, to the return to the question: Should expensive imaging examinations be eliminated or restricted? Let's discuss "NO."
The answer to the question regarding the limiting of access and utilization of imaging examinations is based on the role the examination has in the treatment. While it is easy to understand that less imaging would curb health care costs, this may be penny wise and pound foolish as the long-term patient outcomes and health care costs may be negatively affected. An appropriately ordered, performed and interpreted imaging examination can be life-altering. An MR, CT or other imaging examination performed early after the onset of symptoms, when imaging findings of a condition or a disease process are subtle, can be extremely important. These imaging examinations are more sensitive and specific than routine X-rays and can detect certain conditions even before there are significant clinical symptoms. The cost of a CT or MR imaging examination under these circumstances is justified as accurate diagnosis early in the disease process helps prevent prolonged unnecessary suffering, and helps avoid more complex and expensive treatment and preventable lost time from work and interruption of life activities.
Imaging examinations are linked to radiologists; however, radiologists do not order imaging examinations. Radiologists are physicians who spend dedicated years of residency and fellowship training following medical school focused on all aspects of imaging. Radiologists are trained on image acquisition. They learn how to optimize the equipment by setting the correct imaging protocols for demonstration of pathology. Radiologists are also trained to protect patients from ionizing radiation and to prevent injury. They spend their entire careers learning how to interpret images and to identify subtle signs of disease, trauma, etc. on images. Most radiologists are also subspecialty trained and conduct research and closely monitor the technologic imaging breakthroughs in their subspecialty. They have the skill set to determine appropriate utilization of imaging.
Because imaging examinations are often performed by a radiologist who the patient does not see, patients frequently ask questions such as: Who is this doctor billing me for this examination? My doctor looked at the study and told me what it showed; did I need this X-ray interpretation by a doctor I never saw? What patients are usually not made aware of by their referring physicians is that they often consult with a radiologist regarding the findings on imaging examinations. These consultations are pivotal to patient care. A suspected diagnosis can be confirmed or excluded and finalized by this clinician -- radiologist collaboration reviewing an appropriately ordered and interpreted imaging examination. Even though the radiologist may not actually see or be seen by the patient, their training and collaboration benefits the patient, the referring physician, the insurances and ultimately, the healthcare system. I like to think that although the radiologist may not see the patient, the radiologist sees inside the patient.
So, should we curb or eliminate expensive imaging examinations or limit access to imaging? To help lower escalating overall health care costs, as well as personal health care expenses, patients need to become active participants in their care. Patients should ask their physician about the imaging studies being ordered and determine for themselves if the study being ordered is needed. A specific question to be asked and satisfactorily answered is: Will the results of the imaging examination influence the treatment? If the need is justified, then instead of opting for the convenience of having the non-radiologist physician who has imaging equipment in his/her office perform and interpret the imaging study, patients should seek out a radiologist-run imaging facility or hospital for their examinations.
A properly ordered and acquired imaging examination, with an accurate radiologist's interpretation combined with collaboration between the referring clinician's input regarding the history and physical examination, constitute optimal patient care. This interaction usually results in fewer or more appropriate tests and overall lower costs. Tracking those imaging examinations that are never ordered or performed is a difficult statistic to capture, however. Eliminating unnecessary testing and correctly performing and interpreting justified imaging examinations should, over time, decrease health care costs and improve health care access, patient outcomes and patient satisfaction.
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