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The Cost-Quality Conundrum: Imaging

Gienna Shaw, for HealthLeaders Media, July 14, 2010
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Editor's note: This is the first in a three-part series on healthcare technologies that have come under fire for driving up utilization and healthcare costs. This article focuses on imaging technologies. The next two articles will explore high-tech cancer treatments and telemedicine technologies, including remote ICU monitoring.

Ask your average American what's wrong with healthcare and one of the top responses will be that it's too expensive. Ask policymakers and politicians what's driving the cost of healthcare and you're likely to hear complaints about overutilization of ever-advancing technology that may or may not improve care. Healthcare leaders see it a different way, of course. They might curse reimbursement rates and throw up their hands at demands from consumers and physicians for the latest tests and gadgets, regardless of whether they are medically necessary (witness last year's fracas over the Agency for Healthcare Research and Quality's U.S. Preventive Services Task Force recommendations about mammography screenings).

Finally, talk to a doctor and he or she will probably talk about defensive medicine and, ultimately, bring the blame back to the doorstep of that average American who, after all, should take better care of his or her health in the first place.

If there's one thing everyone can agree on, it's that something's got to give.

"This is a societal issue," says Andrew Pecora, MD, chairman and executive administrative director of the John Theurer Cancer Center at Hackensack (NJ) University Medical Center. Every generation expects to get more out of its healthcare system, live longer, have fewer deaths or side effects of medications than the generation before it, he notes. "We have to make a decision as a society what we want out of the healthcare system, and it has to be reality-based. It would be wonderful if everybody could get everything and it didn't cost anything." It's an absurd extreme, he says, but so is the idea that you can remove all waste and solve economic incentives and other problems.

"We're going to do all these things, and as a consequence of that, everyone is going to continue to have the relationship they currently have with their physician, be able to pick the hospitals they go to, and have access to any and all new breakthrough technologies," he says. "That's not going to happen either."

The imaging issue
Imaging is one field of medicine, in particular, that has come under scrutiny in the cost-benefit debate. Here's the rub: Better imaging technology can detect more details—right down to the molecular level. That leads to earlier detection of conditions and diseases. Earlier detection leads to increased utilization. And that's led to higher healthcare costs. Of course, it has also saved lives. Still, some argue that advances in imaging technologies do not bring a return on investment in the form of improved outcomes—that, in short, more money is not the same as better treatment.

Eric Slimmer, CEO of Eagle Imaging in Oklahoma City, admits that imaging is an area where doctors practice defensive medicine. But, he adds, the real overutilization problem lies in hospital emergency departments. Like other imaging professionals, he points to the fact that better imaging means earlier disease detection. "I'm a big believer in the screening process; I am a big believer in preventive medicine," he says.

So is Marty Khatib, director of imaging for Mercy San Juan Medical Center in Carmichael, CA. "To find cures you need early detection. And that's one of the cornerstones of effective and quality care, and that's what really has led to one of the causes behind this paradigm shift in technology in imaging," he says.

In addition to earlier detection, another transformation in the imaging field is an explosion in the amount of data available and the power of electronic medical records to record, store, transmit, share, and analyze it.

"There's so much emphasis on evidence-based best practice in the industry right now. Those gray areas are becoming much more clear," Khatib says. "Healthcare IT has allowed us to be much more quantitative in our approach and we're able to measure things much more accurately."

The call for evidence
The pressure to control costs will continue to grow as more Americans gain access to insurance under heathcare reform, putting the squeeze on the Centers for Medicare & Medicaid Services. Prohibited by law from paying for items and services that are not "reasonable and necessary," CMS continues to issue national coverage determinations for about 10 to 15 technologies a year, including computerized tomography scans and positron emission tomography scans.

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