Magical Thinking About Imaging
Cheryl ProvalI understand that the government does not want to spend money on an imaging examination that is unnecessary. As a fiscal conservative, I have an inherent distaste for waste and actively resent the idea of my tax dollars being spent on anything that isn’t necessary. When it comes to finding opportunities to reduce health-care spending, however, it is clear that the needle is skipping on the government’s record—because imaging cuts keep playing over and over and over again. Most recently, imaging cuts and containment found their way onto the White House’s recommended hit list for balancing the budget. As part of its deficit-reduction proposal, the Obama administration suggests raising the equipment-utilization–rate assumption (already at 75%). It also recommends implementation of a prior-authorization program for high-tech imaging in the Medicare program. For a summary of the major cuts that imaging has experienced and some of the results through 2010, take a look at the Imaging Market File. Thinking that imaging cuts are going to solve the Medicare expenditure problem is not only increasingly wishful; it is downright magical. First, the growth of imaging has slowed dramatically, and in some settings, has veered into negative territory. Second, although it sometimes is necessary to spend money to make money, what is the wisdom of adding another administrative layer (to a system already bloated with administrative costs) in the form of a radiology benefit management program? Aside from the per-member, per-month cost, CMS would be liable to monitor the program to ensure that policies were consistent and necessary care not denied, in a further investment of resources. We now are spending more than $18 billion in tax dollars on the Health Information Technology for Economic and Clinical Health Act’s incentives to modernize health care through IT. The Obama administration could compound its investment payback by making computerized provider order entry for radiology, with clinical decision support, a part of stage 2 meaningful-use requirements: clear and simple guidance at the time of ordering. Third, there is lower-hanging fruit that might not be as sexy as those big, sophisticated imaging machines, but that packs a much bigger wallop when it comes to savings potential. Lower-hanging Fruit Recently, Kale et al1 did an analysis of work by The Good Stewardship Working Group,2 which published, in May 2011, its list of the top five overused clinical activities across three primary-care specialties (pediatrics, internal medicine, and family medicine), as determined by physician-panel consensus. That list included MRI for lower-back pain, head-injury imaging for children, and dual-energy x-ray absorptiometry for women under 65 and men under 70. Kale et al performed a cross-sectional analysis using data from the 2009 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, limiting its sample to visits by patients to their primary-care physicians. The most prevalent activity was ordering of a complete blood count for a general medical examination, associated with a cost of $32.7 million. The activity associated with the highest cost ($5.8 billion) was the prescribing of brand-name statins instead of generic statins. The least prevalent activity was bone-density testing in women younger than 65, but it did account for $527 million in costs. MRI for lower-back pain had a $175 million price tag. Head-injury imaging in children and bone-density exams in men under 70 were too infrequent to report. Kale et al conclude that most primary-care activities identified by the working group are not major contributors to health-care costs. What we need now is an efficiency expert in Washington—someone who is aware of all health-care programs and initiatives and how they affect each other, so that we can begin truly economizing our health system. We need a health-care controller who can look at the system holistically and recognize that the unintended consequence of cuts to the imaging technical component could be the wide-scale shuttering of a low-cost, community-based provider. We need to begin making some of the tough choices that will result in real savings, such as raising the Medicare eligibility age (as recently proposed by the Healthcare Leadership Council) to 67, gradually, at a rate of two months annually. What we don’t need now is yet another round of cuts to the imaging technical component and another layer of bureaucracy that will increase the administrative cost of imaging delivery.