Medicare imaging costs skyrocket, draw scrutiny

February 7, 2008

Cardiac CT will propel self-referred utilization up as other nonradiology specialists see modest growth
The explosive growth of Medicare outpatient imaging from 2000 to 2005 explains why federal regulators have singled out radiologists for restraints. Medicare payments for outpatient medical imaging jumped 93% during that period, from $6 billion to more than $11 billion. The increase reflected a shift in preference toward high-cost, high-tech modalities, especially CT and MR. Utilization among cardiologists became a major contributor to imaging-related inflation.

The trend line for Medicare Part B imaging growth was flat through the latter half of the 1990s before beginning to move steadily upward, said Dr. Vijay Rao, radiology chair at Thomas Jefferson University Hospital. By 2005, more than four outpatient imaging exams were performed for each Medicare beneficiary, up from three exams per beneficiary in 1996. On a procedural basis, overall utilization rate for noninvasive diagnostic imaging among the Medicare fee-for-service population increased 23% in the five-year period.

The utilization rate for radiologists rose steadily from 2000 to 2005, though the annual growth rate was slightly lower than that for overall utilization. The growth rate among radiologists during the five years was 22%. They performed slightly more than 2000 exams per 1000 beneficiaries in 2000. That total rose to slightly more than 2500 exams per 1000 beneficiaries in 2005.

Plain-film x-ray and mammography account for the highest overall utilization, but growth for these modalities was a modest 9% during the period. CT performed by radiologists jumped 69% to 500 procedures per 1000 beneficiaries, and ultrasound rose 30% to 200 scans per 1000. MR increased 82% to about 140 scans per 1000 beneficiaries, and nuclear/PET was up 17% to slightly more than 10 scans per 1000.

The percentage growth trend line for other specialties, except cardiology, is similar from group to group: about 24% during the five-year period. Cardiologists experienced a 65% increase in imaging utilization, however, from about 400 scans per 1000 beneficiaries in 2000 to nearly 700 in 2005. No other physician group came close to that explosive growth. Orthopedists implemented about a 25% growth in procedures. They performed around 200 procedures per 1000 beneficiaries in 2005, up from 180 procedures per 1000 in 2000, Rao said at the 2007 RSNA meeting.

She expects the trend to continue as more cardiologists bring cardiac CT into their practices.

“We can anticipate astounding growth rates in cardiac CT by cardiologists if free rein is given to them without checks and balances,” Rao said.

In a keynote scientific address, Dr. David Levin, professor emeritus of radiology at Thomas Jefferson University, identified strategies that help to control physician self referral. They include:

  • Legal action. An example is a 2007 case in Illinois in which state attorney general Lisa Madigan joined in a lawsuit that alleges consumer fraud and violations of state unfair business practices law against at least two Chicago-area imaging centers that participated in MRI block-time leasing deals with referring physicians.

  • State regulations. They include a ban against leasing enforced by the state medical licensing board in Louisiana, an anti-self-referral law in Maryland that prohibits all physicians except radiologists from owning and operating CT and MR services, and mandated quality assurance standards that encouraged some marginal x-ray service providers to cease operations in New Jersey.

  • Health insurer policies. Highlights noted include United Healthcare's requirement, effective in March 2008, for mandatory facility accreditation for some modalities; policies at Highmark Blue Cross-Blue Shield of Western Pennsylvania limiting MR and CT reimbursement to accredited facilities that provide at least five imaging modalities; and Connecticut's Anthem Blue Cross-Blue Shield rules that require hospital or radiology group ownership as prerequisites for payment.