05/16/2011 04:54 pm ET Updated Jul 12, 2011

The Overzealous 10 Percent and the Ask Upon Congress

Last month, the Medicare Payment Advisory Commission (MedPAC) asked Congress to require prior authorization for doctors who order many diagnostic imaging scans. With prior authorization, doctors would need to first verify the legitimacy of the scans they'd like to run on patients before ordering them.

This request comes on the heels of the Commission's finding that 10 percent of doctors "order substantially more advanced diagnostic imaging services than their peers" and are responsible for more than half of the imaging services performed. The increase in medical imaging utilization has dramatically outpaced other clinical services. In fact, from 2000-2009 medical imaging grew by 85 percent whereas all other physician services grew by 47 percent. This disproportionate growth can be attributed to a variety of factors: patient requests for testing, the practice of defensive medicine, and duplicative scans because of limited available information on a patient's testing history. An interesting characteristic of the notable 10 percent, however, is that a "significant number," as defined by Ariel Winter, a MedPAC senior analyst, are ordering tests that will ultimately be performed on equipment they own, which has the potential to favorably impact the reimbursements they receive from Medicare. As MedPAC points out to Congress, a mechanism to ensure doctors are soundly ordering exams is warranted.

The topic of over utilization as it relates to diagnostic imaging is not new. In 2008, the industry group America's Health Insurance Plans (AHIP) criticized growth of imaging services with a published report, "Ensuring Quality Through Appropriate Use of Diagnostic Imaging," which cited that 20 to 50 percent of diagnostic imaging exams fail to provide information that improves patient diagnosis and "may be considered redundant or unnecessary." This same report made public that unnecessary CT and MRI scans cost the U.S. healthcare system $26.5 billion and that by 2012 spending on medical imaging, which was then approaching $100 billion a year, would double.

As increased attention has been paid to this topic so have efforts to identify a solution. As such, medical imaging appropriateness criteria has been created, is being continually updated and is proving to show significant value for patients, clinicians, healthcare organizations and the healthcare industry at large.

The American College of Radiology and other organizations such as Massachusetts General Hospital have produced comprehensive guidelines that are used to provide clinicians with electronic decision-support as they order tests. These guidelines are meant to help clinicians determine if they should or should not go forward with ordering a patient's exam and in many cases may suggest another, more appropriate exam be considered. As part of the decision-support process, cost is removed from the equation. Exams are ranked on clinical appropriateness and effectiveness exclusively, not cost. While patient care decisions should ultimately reside within the physician-patient relationship, such guidance can often produce better outcomes, which is especially valuable when the ordering physician may see the opportunity for financial gain with every test he or she orders.

As reported in the Journal of American College of Radiology in January in the study "Effectiveness of Clinical Decision Support in Controlling Inappropriate Imaging," targeted use of decision support solutions is associated with large decreases in the inappropriate utilization of imaging tests. In this study, clinical decision support (CDS) technology was shown to decrease the use of lumbar MRI for low back pain, head MRI for headache and sinus CT for sinusitis. In a similar study in Minnesota, the same chief finding was realized; the use of CDS can facilitate the elimination of unnecessary imaging, contributing to increased patient safety and in Minnesota's case, reduced health care costs by $28 million annually.

Appropriately designed CDS systems offer physicians timely access to medical resources that facilitate better-informed decision-making, which has been shown to result in reduced exposure to ionizing radiation and optimization of costs without compromising care. In addition, CDS and the use of evidence-based guidelines is specified in the American Recovery and Reinvestment Act of 2009. In order for hospitals and physicians to qualify for government reimbrusements associated with healthcare IT they must demonstrate meaningful use of CDS technology that leverages patient-specific information to offer diagnostic or treatment options. If we accept the premise that the ultimate goal of the clinical, regulatory, payor and patient communities is efficient and effective delivery of high-quality care, CDS systems have the potential to significantly contribute to achievement of that goal. As Congress works to understand the overzealous 10 percent and MedPAC's request for prior authorization, CDS, a seemingly winning scenario for all should be considered.