Medical imaging has revolutionized screening and diagnosis, but this technology is not risk-free. As use of advanced imaging has grown, attention has increasingly focused on the risks of radiation exposure, the anxiety associated with incidental findings, and the costs of such imaging. This issue of the NCMJ will address the pros and cons of medical imaging and will discuss how this technology can be used more safely and effectively.
The Value of Diagnostic Medical Imaging
Radiologic and other diagnostic medical imaging has evolved at a rapid pace over the past 120 years, beginning with Röntgen’s discovery of x-rays in 1895 and continuing through further advances in more recent decades: the clinical use of nuclear medicine in the 1950s; the growth in the 1970s of innovative diagnostic imaging modalities including ultrasound, computed tomography (CT), nuclear magnetic resonance imaging (MRI), and position emission tomography (PET); and digitalization of radiographic images in the 1980s [1-3]. More recently, PET/CT has become available, providing both metabolic and anatomic insights.
These modalities have had a significant positive impact on diagnostic capability, but they are also expensive. The cost of medical imaging—especially that of sophisticated imaging studies—has grown faster than overall inflation of medical costs; it has also grown faster than overall inflation of gross domestic product growth or worker wages [4, 5]. To know whether this expense is worthwhile, we need to know whether medical imaging improves health outcomes and whether the value of those improvements exceeds the economic costs. But answering the question “How valuable is imaging?” depends on one’s perspective, and any assessment requires an analysis of the quality, effectiveness, efficiency, safety, diagnosis, setting, patient population, and ownership of each diagnostic modality [6-8].
Diagnostic medical imaging costs in North Carolina—driven in large part by MRI, CT, and PET—have accelerated rapidly as the number of imaging machines has increased from the mid-1980s to the present. Internal data collected by Blue Cross and Blue Shield of North Carolina (BCBSNC) show that diagnostic medical imaging accounted for 9.7%–11.5% of total per-member-per-month medical expenses from 2005 through 2013, and advanced imaging (CT, MRI, and PET) accounted for more than 50% of diagnostic medical imaging costs during that time period. These figures are consistent with national data, which show that diagnostic medical imaging accounts for 10% of all US health care costs .
The 2013 State Medical Facilities Plan  notes that North Carolina had only 2 MRI programs in 1983, and they performed a total of 531 procedures that year; in comparison, there were 260 fixed and mobile MRI scanners in 2010–2011, and they performed 776,852 scans. Similarly, in 1985 the state had only 1 PET scanner, but by 2010–2011 there were a total of 27 fixed dedicated PET scanners, which performed 34,900 procedures, and mobile PET scanners performed another 5,716 procedures . Increased utilization has often been driven by appropriate clinical indications for these procedures. However, a significant portion of the increase has been driven by clinical overuse—and perhaps to some extent by the financial lure of self-referral [11, 12].
Imaging utilization has several potential adverse outcomes. There are some risks from the imaging study itself, including radiation exposure and procedural complications, and there are also risks from the contrast material, when contrast is used [13, 14]. In addition, workup of incidental findings involves significant costs, anxiety, and further potential adverse outcomes.
Most of us engaged in health care feel that we need more and better studies of cost effectiveness and comparative effectiveness to provide clearer and more understandable diagnostic imaging guidelines and/or decision support tools for clinicians and patients. Unfortunately, the Patient Centered Outcomes Research Institute (PCORI), which was established by the Patient Protection and Affordable Care Act (ACA) to address questions of comparative effectiveness, has no clear mandate to study cost effectiveness . To complicate matters further, a recent study indicated that only 36% of current physicians believe that they have a “major responsibility” to reduce health care costs , and another recent study found that the majority of patients are unwilling to consider costs when making medical decisions for themselves .
A number of medical specialty societies have worked to develop pertinent clinical guidelines covering the use (or nonuse) of diagnostic imaging, and the US Preventive Services Task Force has published evidence-based preventive care screening guidelines. Of particular interest to diagnostic medical imaging providers is the 2013 “Choosing Wisely” campaign, in which 50 specialty societies each identified 5 clinical services that patients and clinicians should question . Mahesh and Durand  noted that 56% of the lists include at least 1 medical imaging service, which suggests that clinicians believe some types of imaging are overutilized. Depending on the type of imaging, clinicians may have concerns about the safety of imaging (due to ionizing radiation exposure, for example) or about patients demanding imaging based on misperceptions, or they may believe that a specific type of imaging is not useful in the management of care.
Guidelines provide a framework for optimized use of diagnostic imaging, but most guidelines are nonbinding recommendations that only address clinicians’ ordering behaviors. In contrast, shared decision making engages patients in their care and has been shown to reduce utilization of services for preference-sensitive conditions, including angina, joint arthritis, back pain, and early-stage prostate cancer . In one study, use of shared decision making tools reduced use of advanced imaging studies by 7% and reduced use of standard imaging studies by 30% . This approach requires clinician support, at the very least, if not direct delivery of shared decision making techniques; however, use of shared decision making may conflict with the provider’s own (and legitimate) clinical judgment or with his or her financial interests based on productivity or ownership.
Payers have responded to continued increases in the cost of imaging by employing several techniques, including radiology benefit management (RBM) programs, consumer transparency tools, increased cost sharing for advanced diagnostic imaging, and clarification of medical and reimbursement policies. Although Congress forbade Medicare from using RBM programs, the Centers for Medicare & Medicaid services reduced reimbursement for imaging performed in physician offices, and this step was believed to have a major impact . For example, the combined annual growth rate for utilization of MRI, CT, and nuclear medicine among Medicare outpatients was 10.2% from 2000 to 2006, but it dropped to only 1.7% in 2007 . The 2008 recession also reduced overall health expenditures, including expenditures for medical imaging, although these reductions have not been well quantified.
The experience of commercial payers lagged behind the decelerating trends seen for Medicare outpatients. Commercial payers began implementing prior-approval requirements through RBM programs in 2006, and an analysis published in 2012  found that increases in utilization rates slowed to between 1% and 3% per year from 2006 to 2009. This analysis suggested that “a meaningful fraction” of the reduction in utilization involved services considered to be of marginal clinical utility .
The rates of imaging utilization for BCBSNC members underwent an escalation similar to that of Medicare outpatients, and beginning in 2003 there was discussion about the possibility of implementing an RBM program. Despite provider-based attempts to curb utilization, rates of use continued to accelerate, and BCBSNC implemented an RBM program in 2007. Figures 1 and 2 show the impact of this change using BCBSNC data derived from internal analyses. Figure 1 shows smaller increases and even decreases in imaging utilization rates beginning in 2007. Figure 2 shows variable but generally decreasing rates of change in total allowed medical expenses, allowed expenses for advanced imaging, and allowed expenses for other imaging; despite these trends, the actual cost of medical care and imaging continued to rise until 2013.
Health plans, including BCBSNC, have also increased cost sharing for members, especially as high-deductible health plans have grown in popularity. Individuals enrolled in any of the health plans offered to North Carolinians through the federal health insurance marketplace will be responsible for the first $500–$5,000 of medical expenses, depending on which benefit plan they chose . After this deductible is met, the member will be liable for 10%–40% of the cost of services (coinsurance) , up to a total out-of-pocket expense of $6,250 .
To support members as they begin to pay a larger portion of the cost of advanced imaging, most health plans have introduced transparency tools that share several types of information: the total cost of a service; physician or hospital quality measures, such as board certification, accreditation, and recognitions; the estimated total cost of the service for a given provider; an estimate of the member’s out-of-pocket cost; and the geographic distance to the provider from the member’s zip code. For example, a BCBSNC member seeking an outpatient radiology provider in Durham for a lumbar spine MRI will find more than a 3-fold difference in cost between providers within a 25-mile radius. The actual out-of-pocket cost for an imaging study will depend on how much of the member’s deductible has already been met and the member’s level of coinsurance. To date, health plan members have not often used online transparency tools for medical imaging. When they are used, however, patients tend to select providers who offer higher quality care and/or provide care at a lower cost . Whether use of transparency tools is driven by patients’ financial liability, patients’ concern for quality, or providers’ consideration of the information that is provided, transparency will continue to grow, both in commercial health plans and in Medicare.
Going forward, some of the financial risk for the cost of diagnostic medical imaging—and for the total cost of care for a population—will shift from health plans and patients to providers. In principle, accountable care organizations (ACOs) will receive a set payment or budget for a population of patients, and they will be expected to use those funds to provide care and produce acceptable health outcomes and patient satisfaction for that population. Clinicians will be rewarded financially if the cost of care is less than the budgeted amount, or they will incur losses if costs exceed their estimates.
Although the health care delivery system will need to be reengineered in order to succeed, incremental building blocks have begun to emerge. For example, patient-centered medical homes facilitate the coordination and integration of care, and bundled payments have been introduced for discrete procedures (eg, knee or hip replacements). In the future, all providers in an ACO will need to take on some of the roles currently performed by health plans, including enforcement of adherence to evidence-based guidelines. If guidelines can be embedded in the ACO’s electronic health record (EHR) system as decision support tools that can be employed at the point of care, then enforcement will be more timely, less disruptive to providers and patients, less expensive (from an administrative cost perspective), better documented, and more consistent.
In 2006 the Institute for Clinical Systems Improvement (ICSI), which is based in Minnesota, implemented a pilot program in which an imaging decision support tool was embedded in a health system’s EHR . This strategy reined in utilization of high-tech diagnostic imaging in a manner similar to that of RBM programs in other states, but with considerably less administrative burden. Unfortunately, the vendor of the tool announced plans to discontinue the product (Rad Port) in February 2014, although most health systems that have installed the tool will continue to use it . The collaborative approach spearheaded by ICSI was incubated in a medical environment and culture in which health maintenance organizations have thrived for 50 years and a majority of clinicians work within ACO-like health systems. North Carolina is not Minnesota, but there is still an opportunity for providers and health plans to collaborate, even outside an ACO setting.
In addition to changing physicians’ behavior, providers and health plans will need to better engage patients in taking responsibility for their own health and well-being. As noted earlier, increased utilization of diagnostic imaging is not just a provider issue; it is also a patient issue. The Choosing Wisely campaign has collaborated with Consumer Reports magazine to create patient information materials  that encourage patients to consider imaging choices carefully.
Finally, the digitalization of diagnostic medical imaging has created opportunities to lower costs and to improve the quality and timeliness of services. Images are created locally, but digital copies can be transmitted globally and interpreted anywhere (in India, for example, where labor costs are lower). Clinicians and health systems already utilize Nighthawk Radiology Services or other international resources to provide interpretation of diagnostic imaging at night, and use of teleradiology could be expanded . Digital images can also be compared with images in larger databases to facilitate decision support and to build more effective and efficient care plans .
To summarize, diagnostic imaging provides tremendous value when used appropriately, but it carries potentially significant risks for patients. The cost of diagnostic imaging is also substantial and highly variable, and although cost trends have been mitigated, the absolute cost of imaging continues to increase. Virtually all stakeholders in our health care system have responded to rapid increases in rates of utilization. As a result, rates have increased more slowly over the past 5 years, and imaging is used less frequently in circumstances in which it is believed to be of marginal value. Going forward, new technologies and business models will continue to disrupt traditional roles and practices. As the broader health care environment changes dramatically with implementation of the ACA, financial risk will be transferred to different parties, and providers and payers should recognize that they have an opportunity to collaborate for the benefit of patients.
Potential conflicts of interest. D.B. is an employee of Blue Cross and Blue Shield of North Carolina. K.E.B. has no relevant conflicts of interest.
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Don Bradley, MD, MHS-CL senior vice president of health care and chief medical officer, Blue Cross and Blue Shield of North Carolina, Durham, North Carolina.
Kendall E. Bradley, BS medical student, Duke University School of Medicine, Durham, North Carolina.
Address correspondence to Dr. Don Bradley, PO Box 2291, Durham, NC 27702 (firstname.lastname@example.org).