Federal agencies are increasingly calling out problems with the way doctors order expensive imaging tests.
A Medicare Payment Advisory Commission (MedPAC) report in June “Aligning Incentives in Medicare,” devoted a chapter to a critique of the growth of physician office-based ancillary services including imaging. It summarized the growing evidence that many imaging tests are overprescribed because that’s one way physicians can increase their revenue.
While “the ability to provide tests and other services during an office visit may help physicians initiate treatment more quickly,” the MedPAC report said, “on the other hand, physician investment in ancillary services could lead to higher volume through greater overall capacity and financial incentives for physicians to order additional services.”
MedPAC referred to a report earlier this year that found 14% of imaging procedures performed at a sample of six physician practices were inappropriate, “based on criteria developed by the American College of Cardiology Foundation and the American Society of Nuclear Cardiology.”
Even the Mayo Clinic was faulted in a similar report, which found between 14% and 18% of tests were inappropriate.
Especially problematic are cardiology CTs. According to an article last year in the New England Journal of Medicine, 30% of the radiation exposure associated with diagnostic imaging comes from cardiac imaging.
It’s not just heart imaging studies that are at issue. A 2010 analysis “reviewed imaging orders from primary care physicians at a large urban hospital and found that 26% did not meet appropriateness criteria developed by a radiology benefit management program,” the MedPAC report says.
Inappropriate orders included CT for chronic headache, spine MRI for acute back pain and knee or shoulder MRI for osteoarthritis, MedPAC says.
Another study in 2008 “that estimated that each additional MRI scanner in a market is associated with 733 additional MRI scans among Medicare beneficiaries, and each additional computed tomography (CT) machine is associated with 2,224 additional CT scans.
“It is unclear whether the growth in scans is driven by changes in demand for medically necessary care, or change in the supply of machines,” the MedPAC report states.
Additionally, the MEDPAC report points to studies that found that when physicians furnish imaging services in their offices, they “refer patients for more imaging than other physicians.”
Imaging accounted for 38% of cardiology’s Part B revenue in 2008, up from 35% in 2003, and it represented 23% of vascular surgery’s Part B payments in 2008, compared with 20% in 2003.
Many believe that such decision-making software—the kind the demonstration project may test—can avoid unnecessary patient exposures. A March editorial in the New England Journal of Medicine, says that between 31% and 50% of expensive, CT tests could be avoided when trying to diagnose mild traumatic brain injury if a decision guideline system was followed.