Pry That Scan Away At Your Own Risk

You wait in potential terror for the results. Either you or your child goes through a CT or an MRI, and wait to know whether or not the physician will see something that should not be there.

Luckily in my case, the news has always been good. "Everything looks normal," the doctor says, and the diagnosis is altered to reflect what is actually seen versus what is suspected.

To physician and patient, this scan served a purpose: elimination and peace of mind, respectively. To payers, that scan may have been an unnecessary expense, a "cover-your-behind" test by the doctor and an uneducated and expensive reassurance for the patient. Right now, the proliferation of advanced diagnostic imaging is in the cross-hairs of state and federal politicians, as well as health plans, as the dollars become tight in healthcare and fat becomes vulnerable.

Recent weeks have seen renewed chatter in the imaging debate, starting with a GAO report that tracked an increase in Medicare Part B imaging expenditures that rose from $6.89 billion in 2000 to $14.11 billion in 2006. While rising expenditures may be the symptom, Sen. Chuck Grassley sees the relative ease of physician self-referral as the illness, so he has introduced a bill that would amend the in-office ancillary services exception to the Stark self-referral rule by, among other things, requiring physicians to disclose any financial ties in imaging centers to patients, and to even provide a list of conveniently located alternative locations.

While the government wants to provide information in the imaging decision process, the health plan industry wants to be more directly imbedded. WellPoint, Anthem and other commercial insurers are turning to pre-screening, and reporting significant drops in radiology growth trends. AHIP has upped the rhetoric coming from the health plan side, with a report—none-too-subtly titled "Ensuring Quality Through Appropriate Use of Diagnostic Imaging"—quoted studies that found 20% to 50% of advanced diagnostic imaging procedures failed to provide information that was helpful to the diagnosis, and that unnecessary tests add $26.5 billion to healthcare costs. The American College of Radiology agrees with the conclusion that financial incentives for in-office referral are a driver of imaging costs, but they oppose the use of pre-authorization intermediaries because they "would take medical decisions out of the hands of doctors."

The ACR instead recommends mandatory accreditation of all advanced imaging services providers who would follow guidelines for the appropriate use of scans.

While the national players compete for the policy and funding pie, the issues of growth and duplication of services pop up in markets like St. Louis and Minneapolis/St. Paul.

Behind all the rhetoric, studies, numbers, and dire threats being pushed around is the central question: When should the healthcare industry tell a patient "no"? It's hidden in a layer of clutter, but it is the very type of cost-versus-benefit question that the industry and country will have to face in the coming years. This is where high-technology, high-cost, and high-diagnostic value intersect. Can you tell me what tests I can't have? Will I pay for it anyway?

As one leading radiologist told me this week, "advanced imaging enables the modern practice of medicine." The potential for these modalities to see disease at its earliest stages has enormous potential for saving lives. So while no patient ever looks forward to a CT or an MRI, telling me that I can't have one is a different line to cross.