Rx for Health Care Reform

9. Physicians Go for the Gold

121 9 Physicians Go for the Gold The Imaging Explosion In recent years, medical imaging services have been growing rapidly. The total cost of CT, MRI, and PET scans, X-rays, ultrasound, and other imaging tests was roughly $100 billion in 2005, compared with about $75 billion in 2000.1 Between 1999 and 2002, the use of CT and MRI tests by Medicare patients increased 15 to 20 percent a year, and the cost of those tests shot up 10 percent annually.2 Beneficial medical advances accounted for some of this cost growth. For example, MRIs are used to detect brain tumors. CT scanners using “multi-slice” technology allow better imaging of soft-tissue organs.3 And image-guided biopsies to diagnose bone cancer produce fewer complications and faster wound healing than open surgical biopsies.4 The new imaging technologies, however, are often overused or misused. For example, many primary-care physicians order X-rays for chronic back pain or CT scans for stomach pain;5 MRIs for persistent headaches are not unknown, either.6 Much of this inappropriate use of imaging technologies is, of course, driven by doctors’ constant fear of malpractice suits.7 Recall the physician who said that he’d rather X-ray a hundred ankles unnecessarily than have to defend himself against a single suit because he missed a broken ankle. Consumer demand is also a big factor: Americans feel they deserve to have every test under the sun and that someone else should pay for it. When noninvasive imaging studies replace invasive tests or exploratory surgery, the demand rises even further.8 But current market dynamics explain much of the current explosion in imaging work. 122 Rx for Health Care Reform Proliferation of Technology Once upon a time, doctors would order tests, and radiologists would perform them in hospitals or imaging centers. That still happens, but radiologists performed only about half of the 543 million diagnostic imaging tests done in 2003.9 Most of the rest were conducted by other doctors in their offices or in imaging facilities that they owned. Why did this occur? Partly because, in certain fields, advances in imaging techniques and related procedures obligated physicians to learn how to use the new technology. Cardiology is a good example. From 1999 to 2004, the number of cardiac nuclear imaging procedures, including echocardiagrams and electrophysiology studies, jumped from 3 million to 5 million a year.10 Orthopedists have also found new uses for imaging tests: At one time, for example, they might have just splinted a sprained wrist. Now if a group can afford an MRI machine, they might perform the $800 test to see whether there are any torn ligaments that need repair.11 More and more specialty groups can afford the $1.2 million for a CT scanner or the $1.35 million for an MRI unit, and even primary-care groups can pony up the $250,000 for an ultrasound machine.12 One reason is that single-specialty groups have grown larger—and conversely, physicians have formed bigger groups partly in order to invest in imaging equipment. In some instances, new technology can ignite an “arms race” among specialists, just as it does among hospitals (see Chapter 10). Take the new sixty-four-slice CT scanners that some physicians say can pinpoint blockages in the coronary arteries as well as invasive cardiac catheterization does.13 Even though Medicare hasn’t yet approved routine coverage of this technique, and commercial insurers are paying for it only case by case, cardiologists expect a boom in this area as patients demand to know whether they’re at risk for a heart attack.14 So, like the hospitals that their imaging facilities compete with, many cardiology groups are buying the $1.7 million machines. If they don’t, they risk losing business to other practices or hospitals. Retreat of Managed Care The imaging explosion has coincided with the retreat of tightly managed care and the restoration of feefor -service.15 When HMOs moved away from prepayment and reduced preauthorization rules for imaging tests, specialists such as cardiologists and orthopedists stood to benefit from investing in equipment and imag- Physicians Go for the Gold 123 ing facilities. These physicians also did better in single-specialty groups where they didn’t have to share any of the profits with primary-care physicians. Meanwhile, primary-care groups began to buy “ancillary” equipment that could be...