X-rays, MRIs, sonograms and other types of medical imaging cost nearly $100 billion each year. Targeting this slice of rapidly rising health care costs, employers are using radiology benefit managers to minimize spending on unnecessary diagnostic scans.

RBMs communicate with doctors and help employers and health plans determine when a scan should be covered and when it would be unnecessary. In addition to requiring authorization in advance, RBMs negotiate discounted fees for scans, require imaging facilities to earn accreditation and guide patients toward cheaper centers. Some of them use claims-auditing software to ensure correct billing and payment for radiology services.

Among the most well-known RBMs are WellPoint's American Imaging Management, the National Imaging Associates

subsidiary of Magellan, Med-Solutions, CareCore National, HealthHelp and Care To Care.

According to a report from America's Health Insurance Plans, a group that represents the interest of health insurers, not only are imaging costs in the billions, but "a full third of imaging procedures are inappropriate, costing between $3 billion to $10 billion annually." In addition, about 20% to 50% of high-tech scans fail to provide information that improves diagnosis or treatment, AHIP reports.

From 2000 through 2006, Medicare Part B spending for imaging services paid for under the physician fee schedule more than doubled, increasing to about $14 billion, and that increase is primarily due to the volume and complexity of the scans, according to a recent Government Accountability Office report.

Spending on advanced imaging - such as CT scans, MRIs and nuclear medicine - rose substantially faster than other imaging services, such as ultrasound, X-ray and other standard imaging, the GAO report states. Some scans cost several hundred dollars or even more than $1,000.

In response, Andrew Whitman, vice president of the Medical Imaging & Technology Alliance, says, "It is disappointing that the GAO report failed to use the most recent data, reference medical guidelines or look at trends in which providers and payers are adopting appropriateness and accreditation criteria to address proper utilization of imaging services. As a result, the GAO report obscures how medical imaging utilization decisions are made and the benefit that imaging has to health care savings and patient outcomes."

Causes for cost increases

Direct-to-consumer advertising and increasing patient demand have contributed to the growth in imaging. In addition, "the improved availability and convenience of in-office diagnostic imaging services are also considered to be contributing factors in the overall rise in utilization of these services," the AHIP report states.

Likewise, an issue brief from the National Business Group on Health attributes some of the growth in imaging to the oversupply of equipment and self-referrals by doctors.

"There is no question that radiology advances are aiding in the diagnosis and treatment of illness, and some studies point to less invasive testing and lower total costs as a result," the issue brief states. "But imaging use varies widely across geographic areas, giving rise to speculation that these increases may be related to other factors, such as imaging equipment availability, and do not necessarily correlate with better quality or superior outcomes."

The group cites back pain as one example of a condition where advanced imaging doesn't necessarily improve the treatment plans or health outcomes for patients. In addition, NBGH has expressed concern that doctors are ordering advanced imaging to protect themselves against malpractice claims, even when the scan is not medically necessary.

Dr. Leonard Berlin, chairman of radiology at Rush North Shore Medical Center in Skokie, Ill., concedes that defensive medicine is happening in response to the increase in medical malpractice lawsuits in recent years. "I think there is some overutilization," he says. "That doesn't happen as often as people would like to think."

Solutions

The primary tool for reducing unnecessary or duplicate scans is prior authorization, where a health plan requires a doctor to obtain approval from the plan before the procedure is covered.

But it's tricky to determine what tests are truly needed. "We really don't know what is necessary until after the fact. How do we define unnecessary?" Berlin asks.

To reducing spending on imaging, NBGH recommends that employers:

• Educate employees and their family members about diagnostic imaging and radiation exposure, presenting a balanced view of benefits, risks and options.
• Educate women of childbearing age to inform health care providers about possible pregnancy prior to undergoing imaging.
• Encourage employees to bring imaging studies to scheduled exams and appointments in order to avoid duplicate studies.
• Provide a secure, portable personal health record that includes a cumulative record of medical radiation exposure.
• Educate employees about why they should keep such a record for each child, as well as for themselves.
• Encourage employees to talk with their physicians about imaging and avoid heavily marketed imaging centers that make claims about how useful imaging is in detecting disease without discussing the relative risks.
• Don't cover full-body CT scans for patients who aren't showing specific symptoms.
• Contract only with imaging providers that meet evidence-based guidelines issued by the American College of Radiology.

"Making certain that evidence-based guidelines are followed should improve quality, encourage appropriate usage and increase the likelihood of affordability," the NBGH issue brief states.

Ginger Plumbo, a spokeswoman for the Mayo Clinic, confirms, "There is no data to support a pre-emptive full-body scan or carotid artery ultrasound when a person does not have associated risk factors or symptoms."

Widespread, universal use of electronic medical records will eventually reduce the number of duplicate and unnecessary scans, Berlin predicts.

Concern over radiation exposure

Some experts have expressed concern about exposure to cancer-causing radiation during medical scans. X-rays, CT scans and certain nuclear medicine services, such as positron emission tomography (PET), use radiation to create the image. Ultrasounds use sound waves to form the image, and MRI uses magnets and radio waves.

It is estimated that more than 62 million CT scans per year are obtained in the United States, including at least 4 million for children, according to the New England Journal of Medicine. "Although the risks for any one person are not large, the increasing exposure to radiation in the population may be a public health issue in the future," David J. Brenner and Eric J. Hall state in the journal article.

Dr. Leonard Berlin, chairman of radiology at Rush North Shore Medical Center in Skokie, Ill., says that the radiation exposure to adults during diagnostic scans is minuscule, and the concern is overblown. However, he notes, the risk to children is greater, so doctors should think twice before ordering an X-ray or CT scan for a child.

"Children and pregnant women are two examples of vulnerable populations at risk from radiation exposure due to overutilization and unnecessary utilization of [medical imaging] services," states a recent report from America's Health Insurance Plans. "Children are particularly at risk because they are more sensitive to radiation and have more years of life remaining in which to develop radiation-induced cancer."

The radiation concern is a relatively new phenomenon. In the 1970s, before MRIs and CT scans were available, doctors used to do exploratory surgery to diagnose an undetermined medical problem. Now that rarely happens because the scans can help doctors make the diagnosis, according to Berlin. The scans are less risky and less costly than exploratory surgery.