Checking the facts

Radiologists are pushing back against critics of medical imaging overuse with a broad effort that seeks to defend the role of radiology and imaging within new payment and care-delivery models.

Unnecessary medical imaging is often cited as a driver of healthcare costs in the U.S., with a notable growth period occurring from 2000 to 2005 when CT and MRI utilization for Medicare beneficiaries each grew at an annual rate of about 14%. Imaging use has since declined.

In addition to the often-cited growth period and reimbursement cuts, another cause for concern took place last year when researchers at the Medicare Payment Advisory Commission listed repeat testing as a source of cost and waste reduction. A study also published in 2012 in JAMA Internal Medicine found that Medicare beneficiaries frequently receive repeat diagnostic tests. Imaging also is on the lists of tests and procedures that shouldn't be done as part of the physician specialty group-backed Choosing Wisely campaign, which just expanded.

“It makes sense to target imaging and radiology because some are discretionary services,” said Gerard Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins Bloomberg School of Public Health. “It's part of the large picture of looking at everything that clinicians do and making sure there is not overuse.”

Radiologists have become increasingly concerned about the status of their roles within bundled or capitated payment models as well as whether new payment policies may limit patient access to testing.

These factors led the American College of Radiology to last year establish the Harvey L. Neiman Health Policy Institute, which plans to fund and conduct research on imaging utilization.

“There's a widespread belief—and I think it's currently inaccurate and based on dated material—that medical imaging is leading the way in our very expensive healthcare system and its rising costs,” said Dr. Richard Duszak Jr., the organization's CEO and senior research fellow.

The Neiman Health Policy Institute last week proposed a classification system that would separate repeat medical imaging into four categories: supplementary, duplicate, follow-up, and unrelated. “Studies and policy remedies that seek to examine repeat testing for potential efficiencies may produce unintended consequences for overall quality of care if researchers and policymakers do not carefully consider the clinical context of a particular text—a problem that is only confounded by ongoing use of ambiguous terminology,” according to the institute's report.

In addition, the institute plans to pay up to $60,000 each for projects that target the value of imaging, the role of radiologists in alternative healthcare models, the relationship between imaging and quality, and the impact of new payment models on patient access, practice ownership and utilization.

“Our intended primary target for this, because we're really getting to the core of a developing body of research in repeat testing, is to help improve the level of thoughtful conversation among health services researchers and the policymakers that then will be making payment or coverage or other determinations based upon that research,” Duszak said. “Our goal is not to say that radiology should be paid more, or imaging should be done more.”

A commonly cited statistic is that 30% of medical imaging is unnecessary. However, there is a lack of data backing up the estimate.

A study of staff radiologists at Massachusetts General Hospital in Boston found that more experienced radiologists were less likely to call for repeat imaging. Older physicians had a “more finely tuned sense” of when it was appropriate to call for repeat imaging, said Dr. Jeffrey Weilburg, associate medical director of Mass General's physician organization.

Dr. Steven Amis, chair of radiology at the Albert Einstein College of Medicine and the Montefiore Medical Center in New York, said other studies show geographic differences, with more frequent imaging ordered by physicians based in certain regions of the U.S. and for patients with certain clinical conditions.

“Decision support may not force the doctor not to order an inappropriate test,” Amis said. “But at least it may raise the question.”