Some may quibble about their cause, but what is certain is that rapidly rising imaging costs have health insurers scrambling for creative approaches to contain expenditures.
On average, costs of imaging—especially high-tech procedures like MRI, CT, and magnetic resonance angiograms (MRAs)—have been going up 20% annually for the last several years, according to Thomas Dehn, M.D., cofounder of National Imaging Associates, a radiology utilization management firm in Hackensack, N.J.
“Some will say it's the aging of the population, but the key issue is really demand,” said Dr. Dehn, who is the company's executive vice president and chief medical officer. “Patients are bright; they're good consumers. They want a shoulder MRI if their shoulder hurts.”
Physician demand is also an important part of the equation. “If you have physicians who want increased [patient volume] in their office, it is possible that rather than spending cognitive time for which they're poorly reimbursed, they may choose to use a technical alternative.”
For example, a doctor trying to figure out the source of a patient's chronic headaches “may get frustrated and refer the patient for an MRI of the brain, just to show them they're normal,” Dr. Dehn said. “The treating physicians knows in the back of his mind that there isn't going to be anything [there], but it will calm the patient down.”
As to which physicians are responsible for this increase, the answer depends on whom you ask. “We have the perspective that this growth is largely occurring because of outpatient imaging performed by nonradiologists,” said James Borgstede, M.D., chairman of the board of chancellors at the American College of Radiology (ACR). And studies show that physicians who own their own imaging equipment—which most radiologists don't—tend to order more imaging than those who have to refer out for it, he said.
Not so, say subspecialists. “What they're talking about is self-referral,” said Jack Greenberg, M.D., past president of the American Society of Neuroimaging. “Twenty percent of self-referral is done by radiologists, when they 'Repeat in 1 month' or advise a CT scan.”
Dr. Greenberg said that the analysis by the Lewin Group, a consulting firm located in Falls Church, Va., showed that the average growth rate for CT from 2001 to 2003 was 16% with radiologists doing 84% of all CT scans. The average growth rate for MRI during the same time period was 19% with radiologists dominating 65% of use. Because MRI and CT are dominated by radiologists, these results show that removing neurologists, cardiologists, and other specialists from the imaging arena is no protection against the growth in utilization,” he said.
The ACR's recent attempts to develop criteria for imaging providers are really a way for the college to protect its turf, which is diminishing, he continued. “The intent of this is to take all of imaging and create a larger monopoly, so radiologists can control everything that has to do with imaging. All you're going to do is shift scans done in the neurologist's office to the radiologist” without lowering overall imaging costs.
But the ACR says it is just trying to make sure that imaging as a whole does not suffer from attempts to rein in the amount being done. A very simple solution would be to reimburse less for each imaging procedure regardless of which specialist performs it, said Dr. Borgstede, who is also clinical professor of radiology at the University of Colorado, Denver. “But that could be a disaster for everyone doing imaging. If you drive the reimbursement so low, pretty soon everyone will be out of the [outpatient] imaging business, and all the imaging will be done in the hospital where it's more expensive.”
Whatever the reason that more scans are being done, insurers have decided they've had enough. Take Highmark Blue Cross and Blue Shield, a Pittsburgh-based insurer whose imaging costs have risen to $500 million annually in the last few years.
One Highmark strategy for paring down its imaging costs is to develop a smaller network of imaging providers. To be included in Highmark's network, outpatient imaging centers must now offer multiple imaging modalities, such as mammography, MRIs, CTs, and bone densitometry.
“We were seeing many facilities that were single modality—just CT or just MRI,” said Cary Vinson, M.D., Highmark's vice president of quality and medical performance management. “They were being set up by for-profit companies to siphon away high-margin procedures from hospitals and other multimodality freestanding facilities. We were seeing access problems for referring physicians because the single modality centers were outcompeting the multimodality centers, and they couldn't keep up.”