Diagnostic imaging transitions from volume to value

Under fire for years for causing healthcare costs to spike, diagnostic imaging utilization has been on the decline for nearly a decade and payers are curbing payouts. But radiologists are developing new ways to use imaging to diagnose and monitor disease, along with methods to control costs and radiation exposure to patients from unnecessary scans.

In 2003, roughly 206 million imaging services were provided to 34.8 million Medicare beneficiaries, increasing to 326 million services by 2006 for 35.9 million beneficiaries, according to the Harvey L. Neiman Health Policy Institute report, “Medical Imaging: Is the Growth Boom Over?” A reversal began in 2007, however, and by 2010 diagnostic imaging expenditures for Medicare recipients declined by 21% from the 2006 levels.

For privately insured patients, imaging is the slowest growing service, with a decline of 5.4% from 2009 to 2010, according to the 2013 report from the American College of Radiology (ACR), "Trends in the Utilization of Medical Imaging From 2003 to 2011: Clinical Encounters Offer a Complementary Patient-Centered Focus." That same report found that imaging in patients over age 65 years fell from 12.8% in 2003 to 10.6% in 2011.

Patrick Hope, executive director of the Medical Imaging and Technology Alliance, says that diagnostic imaging utilization has been curbed over the last decade as a result of lower reimbursements and a greater push to make sure that imaging is appropriate and necessary. This is important not only to contain costs, but to control exposure. “You don’t want to expose the patient to too much radiation,” says Hope, adding that more safeguards are being built into imaging equipment to enhance patient safety.

“Sometime the best imaging exam is no imaging exam,” adds Katherine P. Andriole, PhD, associate professor of Radiology at Harvard Medical School, assistant medical director of Imaging IT at Brigham and Women’s Hospital, and director of imaging informatics at the Center for Evidence-Based Imaging.

Next: Balancing cost and quality

Balancing cost and quality

If used correctly diagnostic imaging can be extremely valuable in terms of early diagnoses and better management of the patient-particularly if a physician is trying to determine if a patient is improving, says Andriole.

Studies have linked imaging to longer life expectancy, declines in mortality, avoiding surgeries, fewer hospital admissions, shorter hospital stays, and shorter emergency department wait and treatment times, according to the Harvey L. Neiman Health Policy Institute report.  

If providers are too conservative with diagnostic imaging utilization, they could also miss or delay diagnoses. It’s obviously better to catch breast cancer in stage 0 or 1 rather than in stage 4, Hope says.

Keith J. Dreyer, DO, PhD, FACR, FSIIM, vice chair of radiology at Massachusetts General Hospital and associate professor of radiology at Harvard Medical School, says there has been criticism over the cost and volumes of imaging services in the past, but radiologists themselves have little control over these factors, Dreyer says.

“We don’t order exams,” he says. “They’re ordered and we perform them.”

The Center for Medicare and Medicaid Services (CMS) has decreased the amount it pays for exams, and new legislation will require physicians to consult guidelines before ordering high-cost diagnostic exams by 2017 in order to reduce the amount of unnecessary exams.

Using these types of guidelines can reduce ordering rates by 10% to 15%, Dreyer says, but they typically are not used by commercial payers.  Dreyer adds that physicians who consult guidelines before ordering diagnostic exams may even get them the care they need faster, since ordering the wrong exam can delay accurate diagnoses and necessary treatment. “Doing too much imaging or anything in medicine is never a good thing, and following guidelines is the best way to practice medicine.”

New tools that utilize guidelines and offer feedback to physicians as soon as they order imaging may also help providers balance cost and quality, Dreyer says. “The message to get to commercial payers is that this is happening with Medicare/Medicaid, and because providers are putting this in place inside of their electronic health records, it will be there for commercial payers to take advantage of as well,” he says.

Andriole agrees that interest in programs that advise physicians on the use of imaging exams is increasing. Hospitals that are investing in such systems can have a computerized order entry system give a physician immediate feedback regarding whether they ordered the right test, whether there is a better test, or whether the test they ordered will be useful for the data they are seeking. “It reduces waste, radiation to the patient, and so forth,” she says.

New business management tools are also being introduced that allow radiologists to track how their department is performing, volumes in scanning, where there are bottlenecks, and where improvements can be made. “It can help identify better work flows,” Andriole says. “By making the process more effective, [imaging] goes to the physician faster and gets the patient treatment faster. Now that we have a lot of electronic systems, we are able to automate some things, which expedites and improves [productivity].”

Today’s imaging provides better images and more customizations than in the past, allowing physicians to get more specific information from the scans, says Dreyer. Patients also have greater access to more low-cost, low-dose options such as low-dose CT scans for lung cancer screening.

Dreyer also predicts that precision medicine-the combination of genetics and imaging-will be increasingly used to monitor populations of patients to screen for diseases with genetic dispositions.

Next: Exploring new frontiers

Exploring new frontiers

A number of new uses for diagnostic imaging are also on the horizon. While these uses could result in higher utilization rates, they could also result in lower healthcare costs in the long-term as diseases are detected and addressed earlier.

A German study, “F-FDG PET Is an Early Predictor of Overall Survival in Suspected Atypical Parkinsonism,” revealed that FDG-PET scans can predict the survival of patients suspected to have atypical Parkinsonism syndrome. A European study, “Detection of Alzheimer's disease signature in MR images seven years before conversion to dementia: Toward an early individual prognosis,” found that MRIs may be able to detect Alzheimer’s as early as seven years before the onset of symptoms, and MRIs may also be useful in predicting therapeutic effects of antipsychotics-traditionally a trial-and-error class of medications, according to the study, “Baseline Striatal Functional Connectivity as a Predictor of Response to Antipsychotic Drug Treatment.”

Other new frontiers in diagnostic imaging include digital breast tomosynthesis (DBT), which is a three-dimensional scan of the arch above each breast to give a dimensional reconstruction. “The thought is that in a two-dimensional mammogram, there can be lesions behind tissues that you might not be able to see or tell exactly where in the breast it is,” Andriole says. “There are often times where the radiologist may call the patient back [after mammograms] for a lesion and it turns out it’s a negative thing.” Although this technology isn’t really new, it is just now gaining traction and patients are beginning to ask for it, she says, adding that radiologists who use DBT report feeling as though they make fewer recalls for false negatives.

Ultrasounds are also on the rise for use in mammography to determine densities, and multimodality imaging that allows more thorough imaging and interpretation is become more popular in cancer care, says Andriole.
Other newer diagnostic tools include the combination of PET and CT scanning to detect changes in lesions over time. Radiologists can give oncologists better information on whether growth is stable, quick, or the patient is not responding to treatment, she adds.

Today’s diagnostic imaging gives overall better, clearer pictures, and is even starting to use artificial intelligence, for example, in cancer imaging to detect and analyze tumors, Hope says. “It’s a sort of a backstop that helps the radiologist make sure they don’t miss anything,” he says. “Frequently, radiologists miss things because the image isn’t clear. This could be where the future is going.”

Hope says a lot of research is being conducted and funded through Medicare into determining whether PET scans can lead to earlier diagnoses of Alzheimer's and dementia. “There’s a lot on the line because, up until now, there hasn’t really been any good, effective treatments,” Hope says. “We’ve done such a good job in treating cancer and heart disease, but as people are living longer, you’re going to start seeing more Alzheimer’s and more dementia patients. It’s becoming really important now that we focus on these diseases, and we feel you can use medical imaging as a good tool to recognize and diagnose and get treatment sooner.”

Rachael Zimlich is a writer in Columbia Station, Ohio.