The most important contributing factor to the higher cost of health care in the United States of America is the overutilization of services, including a growth in medical imaging that reflects advancements in imaging technologies and their contribution to improved detection and diagnosis of disease and injury. A fraction of imaging studies, perhaps as much as one-third, may be inappropriate.
Several approaches to addressing overutilization of medical imaging procedures are being explored, including the development of appropriateness criteria and referral guidelines for imaging procedures. This can help in the selection of procedures judged to be in the best interests of patient care, and requires improved communication and cooperation among practitioners.
Expenditures for health care in the United States of America exceed those in any other country by a substantial margin. In 2005, the United States spent US $6401 per person on health care, 2.4 times the average expenditure (US $2759) on health care in developed countries. In spite of these expenditures, health outcomes (e.g.
life expectancy, disease specific mortality rates, and other variables) for US residents compare unfavorably with those for residents in many other countries [1].
Several factors contribute to the higher cost of health care in the United States of America. One factor is the expense of providing a plethora of health insurance programmes, each of which has a different administrative process for paying for health care services. The complexity of billing and collecting for health care services, and for keeping individuals insured under a variety of insurance programmes, creates extraordinary administrative costs not experienced in other countries, especially those with a single payer system for health care coverage.
Another factor is the steeper price for health care goods and services in the United States of America compared with other countries. Physician incomes are considerably higher in the United States of America, and goods such as pharmaceuticals and hospital supplies cost much more as well [2]. Also, health care in the USA offers amenities such as private hospital rooms, ancillary services and more individuals involved in patient care than is found in many other countries. These and other factors contribute in large and small ways to the greater cost of health care in the United States of America compared with other developed countries.
An additional factor is the ‘moral hazard’ of a payment system for health care services in which the recipient of the services does not pay directly for the services [3]. Instead, the services are paid for by a third party, usually an insurance company to which the recipient has paid a periodic fee for some period of time. As a consequence, many recipients have little interest in the cost of health care services they receive, and often feel they are entitled to the services irrespective of the cost.
The most important contributor to the high cost of US health care, however, is overutilization of services.
Overutilization can be either higher volumes or higher costs of services, or both, where services include items such as office visits, hospitalizations, tests, procedures, and prescriptions. In the United States of America, it is the cost as well as the volume of services that accounts for a substantial fraction of the higher expenditures for health care compared with other countries. In particular, the use and overuse of health care services, especially those that employ medical technologies, help make health care in the United States of America more expensive than in comparable developed countries.
Medical imaging, especially ‘high tech’ imaging procedures such as computed tomography, positron emission tomography, and magnetic resonance imaging, is one of the principal drivers in the growth of health care spending.
Medical imaging is reported to be the fastest growing area of medical technology, with spending approaching US $100 billion in the US and with the expectation that this amount will double over the next four years [4].
Much of the growth in medical imaging reflects advancements in imaging technologies and their contributions to improved detection and diagnosis of disease and injury, and to more effective treatments through
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image guided interventional procedures. Computed tomography is today a mainstay in hospital emergency departments to detect acute conditions such as pulmonary emboli and appendicitis and to rule out heart attacks [5].
Magnetic resonance imaging provides exquisite images of low contrast tissues in all areas of the body, and is essential to the detection and diagnosis of soft tissue abnormalities, including tumors. Positron emission tomography is widely used for staging cancer and for monitoring the response to cancer treatment with radiation and chemotherapy. Ultrasound and X ray imaging are ubiquitous in the health care arena and are used by many medical specialists including, but not limited, to radiologists.
Advancements in imaging technologies are occurring at an ever increasing rate, leading to shortened product life cycles, spiraling capital costs for equipment purchases, and high reimbursement charges needed to offset the financial investment in imaging technologies. Over seven years, total imaging costs paid to physicians by Medicare increased more than two-fold, from US $6.89 billion in 2000 to US $14.11 billion in 2006. The compound annual growth rate in costs for medical imaging over this period was greater than 14% [6]. Unless drastic measures are taken, Medicare expenditures for medical imaging will certainly be higher in the next few years as a greater fraction of the population (the ‘boomer’ effect) reaches the age of Medicare entitlement.
However, not all of the growth in the use of medical imaging reflects advancements in medical technologies.
Some fraction of imaging studies, perhaps as much as one-third, may be inappropriate. These studies represent the overutilization of imaging services. Examples of inappropriate imaging procedures include the use of MRI to assess low back pain in the first 30 days after the onset of symptoms without evidence of serious cause, the employment of whole body computed tomography in asymptomatic individuals who desire reassurance that they are not at risk for cardiovascular disease and X ray examinations acquired as evidence to defend against possible future legal actions brought against a physician. These types of examinations contribute to the overutilization of imaging services, excess costs to payers for the services, and unnecessary exposure of individuals and the population to ionizing radiation.
Several factors drive the overutilization of services in the arena of medical imaging. These factors include the referring physician’s lack of knowledge about imaging procedures, the strong and growing practice of self-referral to imaging facilities owned or partly owned by physicians, the prevalence of procedures requested for purposes of defensive medicine rather than patient welfare, the absence of the radiologist in decision making about preferred procedures for individual patients, the demand of some patients for imaging studies they have read or heard about, and fundamental flaws in the health care system, particularly those associated with fee-for-service medicine. These factors, all of which contribute to the overutilization of imaging services, are discussed in some detail in a recent report of a medical summit in Washington, DC, entitled Addressing Overutilization in Medical Imaging [7].
The referring physician is usually the individual who decides whether an imaging study is required for a particular condition and a particular patient. In making the decision, the referring physician can look to a number of sources of information for guidance. These sources include appropriateness criteria and referral guidelines prepared by professional organizations, radiology colleagues who have expertise in imaging procedures and their appropriate utilization, decision support algorithms that may be embedded in electronic radiology order entry systems and improvements in general referral knowledge that can be acquired through continuing education programmes, professional meetings, and journal articles. These sources of information are described in greater detail in a companion article [8].
In addition to concern over the financial costs associated with the overutilization of medical imaging, there is considerable worry about the contribution of inappropriate imaging procedures to the radiation exposure of individuals and to the population as a whole. Recently the National Council on Radiation Protection and Measurements reported that in the USA medical radiation constitutes slightly more than half of the average exposure of individuals to radiation [9]. Averaged over the population, the annual dose from medical exposures in 2006 was 3.0 millisieverts (mSv), compared with 2.4 mSv from natural background radiation. In 1980, the natural background level was the same, but medical exposures averaged only 0.54 mSv. From 1980 until 2006, the average dose to individuals from medical exposures increased 560%. When this increase is applied to the larger US population in 2006 compared with 1980, the population dose in person sieverts increased from 124 000 to 800 000, an increase of 710%.
These values of individual and population doses are a bit misleading, because they cannot be used directly to evaluate the risk of individuals for the induction of cancer caused by radiation exposure. The reason is that while background radiation is distributed relatively uniformly across the population, medical exposures are concentrated in the upper decades of individuals’ lives where the cancer risk is diminished because of the shorter expected
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lifespans of the exposed individuals. In addition, risk estimates of cancer incidence and mortality caused by medical exposures do not include lives saved through effective radiation based medical procedures. Nevertheless, the increased exposure of the US population caused by medical radiation is of concern, especially since some of the exposure is unwarranted because it originates from inappropriate imaging procedures.
Several approaches to addressing the overutilization of medical imaging procedures have been examined.
Some of the causes of overutilization, including self-referral and defensive medicine, are not solvable by medicine alone. They will require legislative action leading to restraints on self-referral and on malpractice claims resulting from less than satisfactory medical results, whether or not the physician is at fault. But there are other causes that can be addressed by medicine, including closer cooperation between radiologists and referring physicians concerning the selection and performance of imaging procedures, the development of user friendly decision support systems to aid the referring physician in selecting imaging procedures, and the use of appropriateness criteria and referral guidelines in choosing specific imaging procedures for specific patients. Also, public education programmes should be developed to help individuals understand the limitations of imaging procedures, such as CT whole body scanning, that currently are being marketed directly to patients.
Appropriateness criteria and referral guidelines for imaging procedures currently are developed principally through a consensus process involving the opinion of many experts. Although this process is certainly defensible, a better approach would be to build criteria and guidelines from hard data on the comparative effectiveness of various imaging approaches to yield the needed results in a cost and dose efficient manner. Admittedly, comparative effectiveness research has its difficulties, especially when one particular imaging approach is considered by most experts to be superior to all others in yielding the desired results. Nevertheless, such an approach would be helpful, especially in those cases where the preferred selection of an imaging modality is unclear.
As the burden of financial and radiation costs of imaging procedures continues to mount, medicine can expect increasing restraints on the selection of procedures judged to be in the best interests of patient care. Medicine has an obligation to protect these interests, and therefore should act on its own wherever possible to request and conduct imaging procedures in the most efficacious manner possible. This, in turn, will require improved communication and cooperation among referring physicians, radiologists, and medical physicists who are responsible for the quality and efficient deployment of imaging devices. With enhanced communication and collaboration, the welfare of patients can be preserved while imaging procedures are used in a more efficient and cost effective manner.
REFERENCES
[1] EMMANUEL, E.J., FUCHS, V.R., The perfect storm of overutilization, J. American Med. Assoc. 299 (2008) 2789–2791.
[2] ANGRISANO, C., FARRELL, D., KOCHER, B., LABOISSIERE, M., PARKER, S., Accounting for the Cost of Health Care in the United States, McKinsey Global Institute, San Francisco, CA (2007).
[3] GOLDHILL, D., How American health care killed my father, Atlantic 304 (2009) 38–55.
[4] AMERICA’S HEALTH INSURANCE PLANS, Ensuring quality through appropriate use of diagnostic imaging. Washington DC (2008),
www.ahip.org/content/default.aspx?docid=24057
[5] IGLEHART, J.K., The new era of medical imaging — Progress and pitfalls, New Engl. J. Med. 354 (2006) 2822–2828.
[6] US GOVERNMENT ACCOUNTING OFFICE, Analysis of Medicare Part B: Claims data, US Government Accounting Office (2008), www.gao.gov/index.html
[7] HENDEE, W.R., Addressing overutilization in medical imaging, Radiology 257 1 (2010) 240–245.
[8] HENDEE, W.R., “Whether or not to image: Who decides?”, these proceedings.
[9] NATIONAL COUNCIL ON RADIATION PROTECTION AND MEASUREMENTS, Ionizing Radiation Exposure of the Population of the United States, NCRP Report 160, NCRP, Bethesda, MD (2009).
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