Overuse of Medical Scans Is Under Fire

The government is likely to join a growing number of private health plans that are attempting to rein in the use of diagnostic scans.

This week, a Medicare advisory panel is expected to make several recommendations to Congress on the best way to curb the sharply escalating costs of MRIs and other scans.

The recommendations will be voted on by the panel today or tomorrow and aren't final. But one that is being considered would let Medicare edit claims to possibly reduce payment for tests that scan two body parts at once but have often been billed as two separate procedures. Another would require doctors and imaging centers to meet certain quality criteria in order to bill Medicare for services.

The idea is to join efforts already begun by private insurers to curb the costs of advanced imaging, which are fast approaching $100 billion a year. WellPoint Inc. -- the health-insurance giant newly created from the merger of Anthem Inc. and WellPoint Health Networks -- now requires doctors in several states to get authorization first for advanced, nonemergency scans.

A brain MRI. Read some tips0 on how to help ensure you get a high-quality scan.

And several Blue Cross plans are considering following the lead of Highmark, an operator of Blue Cross and Blue Shield plans in western Pennsylvania that is setting rigorous quality standards for imaging staff and equipment.

There were a remarkable 45.4 million CT procedures performed in 2002 nationwide, according to IMV, a medical marketing research and consulting firm, compared with 39.6 million in 2001. And growth has only accelerated since then. The number of PET scans performed in 2003 increased 58% from 447,200 in 2002, according to IMV.

As Medicare and private health plans have squeezed reimbursement for other physician services, many doctors have installed scanning equipment as a source of extra revenue. And with the influx of new providers have come concerns that quality hasn't kept pace with growth, and that scans are being overused.

"The fact is a lot of imaging is being done today where the benefit is far from proven," says Samuel Nussbaum, WellPoint's chief medical officer.

National Imaging Associates estimates from its own experience that about one-third of advanced imaging tests are either inappropriate for the medical problem at hand, or don't contribute to a doctor's diagnoses or a patient's outcome -- suggesting serious room for public and private plans to save.

Some health plans say they see great variations in standards. For instance, when Blue Cross Blue Shield of Massachusetts inspected 1,000 imaging providers in its area to evaluate the quality of their technical staff and equipment, it found 11% had at least one serious deficiency, such as machines that weren't properly calibrated. As a result, the Massachusetts plan suspended those facilities from its network for 18 months to make necessary changes.

Highmark estimates that some providers in western Pennsylvania will fall out of its imaging network due to the tougher standards it is beginning to implement this month. But hundreds more are investing in higher-grade equipment or hiring full-time radiologists to make the grade.

Instituting more hands-on involvement in doctors' decisions has led to better testing, some health insurers say. WellPoint has implemented imaging cost controls in Colorado, Nevada, New Hampshire, Connecticut and Maine, and plans to extend the program to Indiana, Ohio, Kentucky and Virginia this spring. The company says that where it has implemented controls, it has lowered the annual rate of increase in spending on scans to below 10% from the 20% to 25% increases it sees in other areas. But in 10% of all cases it reviews, its clinicians redirect care, sometimes to a more-advanced and expensive test because it might be more appropriate.

"In many cases we're suggesting going right to a [more-expensive] PET scan, versus a CT scan first, because we can prevent that patient from having duplicate tests," Dr. Nussbaum says.

But some doctors say these efforts smack of the old-style managed-care controls that have largely fallen out of favor in recent years because of concerns that they placed too many limits on access to care. Intervention in medical decision making will only delay patients' care and produce more red tape, these doctors say. That already happens in seeking authorization to perform scans for worker's compensation cases, says Shahid Mian, an orthopedic surgeon in New York. "Sometimes it takes weeks, even months," says Dr. Mian, who worries the same might happen in regular medical cases.

He and other doctors also argue that overly stringent criteria will restrict advanced medical scanning to hospitals and big diagnostic imaging centers able to make such costly investments, forcing patients to make an extra appointment and trip to get a scan.

Requirements for Providers

In Pennsylvania, one of Highmark's most-striking changes is that it will pay for CT or MRI tests only at locations that make the testing available for at least 40 hours a week, plus some Saturdays, and have at least one accredited radiologist on site during normal business hours. The idea is to ensure that only the most-experienced providers will be eligible for the program.

Mark Goodman, an orthopedic oncologist in Pittsburgh and president of the Allegheny Medical Society, says, "We see a lot of poor tests done or from centers where no one is in attendance, so from that point of view, Highmark is right on."

Highmark says it has made some exceptions to its standards in rural areas to avoid access problems.

If Congress approves the recommendations for Medicare, they could spur imaging centers, radiologists and other doctors to implement standards nationwide. Congress often passes the recommendations of Medpac, an independent panel set up to advise it. It would then be up to the Department of Health and Human Services to draft the specific quality guidelines for imaging professionals and equipment.

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Scan Check

Questions patients should ask to help ensure they are getting an appropriate and high-quality scan.

• Ask why you are being referred to a particular center.
 
• Does your doctor have a financial interest in that particular facility?
 
• Ask about the radiologist's specialty -- e.g., orthopedics, pediatrics, or neuro-radiology. His or her specialty should be relevant to your condition.
 
• Ask about the age of the scanner and how recently the software was upgraded. Both should be less than a few years old.
 
• Ask about the strength of the scanning equipment. Closed machines should be at least 1 Tesla (a measure of scan strength).
 
• For open machines, half a Tesla is the norm but may be inadequate. In some cases, scans that produce low-quality images may be meaningless and require a repeat scan. Patients typically pay at least part of that added cost.
 
 

Source: National Imaging Associates

Write to Vanessa Fuhrmans at vanessa.fuhrmans@wsj.com¹