So what is the most significant health care technology implemented in health care in the last thirty years? The DaVinci robotic surgery system? Proton Therapy perhaps? No, not those. We want diagnostic, not treatment, technologies.
The answer is advanced imaging. Thirty years ago, a patient presented with non-specific abdominal pain. How did we diagnose it? Palpate, lab tests, order an x-ray. No conclusive results? Send them off to surgery.
OK, so what? Well, compare the cost in dollars and risk for a patient getting surgery thirty years ago with the risk and costs (and time savings) for that same patient to get a CT scan today. Some might argue it’s not a fair comparison. I would disagree.
The Problem with Imaging
As a clinical and financial tool, to date advanced imaging (MRI, CT, PET/CT, Nuclear Medicine) along with conventional imaging has delivered astounding diagnostic benefits. Depending on who you are, these goals may have illuminated and prioritized themselves differently for you. For example, many of the leading teaching and clinical institutions have adopted and promoted advanced imaging for the clinical and learning opportunities, choosing to do research and development after hours, once the patients that needed “routine” diagnostics were examined. On the other end of the spectrum is the physician practice who invested in the technology because a financial pro forma looked appealing. Think of these examples as the book ends of a bell curve representing exam volume. Most imaging providers fall somewhere between these two extremes.
Effect and Cause
Of inpatient, imaging center outpatient and physician practice outpatient providers, in the last five years which has been the fastest growing? Here is a hint: The Stark in-office exception. Non-Radiologist physicians that, by law, cannot own an interest in an imaging center, but can own their own equipment, in their own office and order exams on all their patients if they like.
Granted, with any generalization there are always exceptions. Not all physicians that install advanced imaging have done so because of cash flow. However, data points to this being the fastest growing segment over the recent few years. This utilization increase is driving up what commercial payers and Uncle Sam pay, as a percentage of total health care dollars for imaging.
What this is causing is a less than helpful view of imaging by all payers. Please notice, I did not say that imaging exam costs have risen, but that the imaging spend has increased as a percentage of all health care expenditures. This is a result of utilization growth and the relative size of the health care spend on imaging. The effect? Imaging as a service line is being vilified and targeted because of inappropriate utilization.
A short time back, I visited a “world class” cancer treatment center in Tennessee. Frankly, I’ve visited and met with many business owners and physicians over the years, all possessing a passion that their operations are unparalleled. So, as I toured and met the physicians and staff, and the amazing statistics of this center were repeated like a great sales pitch, I was polite but skeptical.
So I set out to confirm these statistics for myself. My first call was to the clinics’ largest payer, a major national insurance company. It sounded like the contracts VP was on the centers’ payroll. He gushed over their performance. So I called the competition. I was shocked. They admitted defeat quite quickly. Long story short, this center has the lowest metastatic rate in the US in this cancer segment while using…wait for it…not the latest greatest imaging technology for diagnosing cancer, but just “run of the mill” several year old imaging equipment.
How do they do it? Put simply, they take a quality approach, utilizing physicians with unusually high levels of direct experience, sharing best practices, new insights and ideas. During an interview, one of those physicians related it as the ten-thousand hour rule. The point is, while technology is helpful, well trained, experienced physicians make the difference even with bread and butter technology.
Care and Cost
Today the imaging industry is in a state of change due to lower reimbursement, consolidation and the pressure asserted by Radiology Benefits Management Companies (RBM) engaged by payers to ensure any advanced imaging exam is absolutely, positively necessary…in their opinion. Meanwhile, many clinicians have grown complacent to the value imaging technology provides for diagnosing disease and have come to expect it. The downward trend in reimbursement that began with the Deficit Reduction Act in 2006 continues to threaten with the postponed (again, for 1 year) Sustainable Growth Rate (“SGR”) adjustments. Technology is aging with many not able to upgrade because years of refinancing have left them with debt on older technology. Imaging locations are closing across the country.
In an attempt to squelch explosive growth in imaging utilization, the rapid adoption of RBM companies by payers now approaches 70% of covered lives nationally. While embraced by few other than the payers, it is unarguable that RBM’s have had an effect on utilization and growth. Our research has revealed 2010 as a year of stable-to-slightly-declining volume as a result. But, this is not the future.
Being a technology-driven discipline of health care has been a challenge for imaging, from its discovery by Roentgen in 1895. And the technology continues to advance while new uses (exams) are discovered for existing technology. Read that as: with a stable population (not the case) that is not aging (an aged population uses more health care services), utilization of imaging will continue to increase.
Interviews with many radiologists across the country reveal a significant difference between imaging exam ordering patterns for MD’s referring patients to outside imaging providers and those MD’s who own their own equipment. Why? There are many reasons that may not always be supported by data. Some say it’s an access issue, or timing. But in most cases it appears to be as simple as dollars. While some Radiologists will politely shrug off the inappropriate utilization from these MD’s, others simply refuse to provide their professional interpretive services.
Like any complicated system, there is no silver bullet that will solve the issues in imaging. However, some problems are not all that hard to figure out. There are solutions to the inappropriate utilization. Solve it and the perception of imaging driving up the cost of health care will change.
My question is why doesn’t anyone notice that the Emperor has no clothes?