CTs, MRIs, and PET Scans Drive Cost of Healthcare Upward

The point is frequently made in the media that the cost of imaging studies is a significant and growing percentage of the total cost of healthcare. It's useful to put some numbers to this assertion. A recent blog note by KevinMD raised the issue (see: How CTs and MRIs drive health care spending). Here's his note in its entirety:

It’s well known that the use of imaging scans, like CTs, MRIs and PET scans, have been growing at an alarming rate. But a recent study provides some stark numbers (see: MRIs, other scans quadrupled in recent years). According to a recent CDC report, “MRI, CT or PET scans were done or ordered in 14 percent of ER visits in 2007, the report from the Centers for Disease Control and Prevention found. That’s four times as often as in 1996.” Although a physician called that growth “astounding,” it’s really no surprise. Emergency departments are becoming more crowded, and with patient satisfaction scores becoming more influential in financial incentives for physicians, sometimes just ordering a test is the path of least resistance. Factor in the specter of defensive medicine, which, according to a survey from the Massachusetts Medical Society, accounts for up to 28% of tests ordered, it’s a wonder that more scans weren’t ordered. Imaging scans are clear cost driver in health care, contributing $12 billion to Medicare’s bill. But costs won’t resonate with patients requesting the tests, or the doctors ordering them. One encouraging sign is the recent trend of publicizing the harms of scans, like radiation from CTs. I’m finding that patients are becoming increasingly aware of the risk, and making a more informed decision after I explain it to them. It’s a small step forward.

Dr. Kevin raises most of the key factors that contribute to the increasing use of CTs, MRIs, and PET scans in our healthcare delivery system. I will add a couple more ideas to his list: (1) imaging technology is truly outstanding and improving -- clinicians increasingly rely on it to arrive at most diagnoses and to rule-out others; (2) patients, in turn, expect their physicians to order these studies when they are being seen in the office and the ER; (3) physicians are reluctant not to order imaging studies for fear of missing a diagnosis, described above as defensive medicine; (4) imaging studies are often formally incorporated into the standard workup of patients with non-specific complaints such as chest pain, joint pain, or headaches; (5) hospital administrators and physician executives have few incentives to attempt to tamp down the ordering of imaging studies because they constitute a major profit line in the hospital budget; (6) the ordering of CTs, MRIs, and PET scans can facilitate the workflow of patients through busy clinics by generating objective, actionable reports.

I think that it will be extremely difficult to reverse the trends listed above because residents and medical students are adopting these practice patterns during their training years and will adhere to them closely throughout the rest of their careers. I believe that recent reports about the harmful effects of cumulative radiation doses from imaging studies will reach the level of consciousness of only a small percentage of patients, most of whom will probably feel that the small risk is worth it. Look for an even a higher percentage of healthcare dollars in the future to be allocated to imaging studies.The federal government, as the major payer for healthcare, will attempt to bend this curve downward but will meet with little success.

Comments

[bariatric surgery]

Unless and until the patient comes up with the imaging reports as advised by their respective doctors they wont be able to diagnose properly for their treatments and reliefs according to their pains. All the technological devices,instruments and medical equipments are really helping in the diagnostic factors.

[Keith]

Nice post. I would add that physician office imaging services and abusive self-referral practices contribute a great deal to overall cost.

[Jackie Walsh]

Bruce, I agree that it will be hard to reverse this trend for the reasons you state. However, there is a category of imaging exams that can be reduced to offset the overall growing volume. That is the percentage of exams that are ordered simply because a similar or recent exam for the same patient isn't accessible (perhaps because it lives within the firewall of another hospital, or was burned to a CD and from some technical reason is inaccessible). In the US it has been estimated that over 10% of all diagnostic exams may be wasteful duplications because physicians do not have access to their patients’ previous records. This waste is costing billions of dollars annually and some patients are exposed to excessive radiation as a direct result of redundant exams. This is part of the overall cost of diagnostic imaging that we could really tackle.