Could Photon-Counting CT Expose the Paradox of Health-Care Economics?

What if photon-counting CT (PCCT) is too good?

Health care says it wants diagnostic certainty. But many health-care systems still pay for activity, not for information.

Therein lies the paradox.

A diagnostic test with substantial uncertainty — particularly one generating false-positive or inconclusive results as may occur with functional testing in selected populations — often creates a certain cascade:Test → uncertainty → another test → imaging → invasive angiography → more procedures.

Every step generates activity.

Now consider the opposite model. A highly accurate cardiac CT examination — increasingly so with PCCT — can provide detailed coronary anatomy, plaque characterization and spectral information while potentially reducing equivocal findings and unnecessary downstream testing.

One examination. More information. Less uncertainty. Fewer additional tests.

Clinically, that sounds like progress. But is that the case in a fee-for-service system?

It creates an uncomfortable economic paradox. Uncertainty generates procedures. Diagnostic certainty may eliminate them.

This doesn’t mean physicians deliberately choose inferior tests to generate revenue. The problem is more structural. A system that rewards the number of procedures may inadvertently assign greater economic value to a diagnostic pathway that generates additional procedures as opposed to one that solves the clinical question immediately.

Perhaps the real disruption of PCCT will not be spatial resolution, spectral imaging or dose reduction. It may be exposing a fundamental contradiction in health-care economics.

We say we want diagnostic certainty but are we actually paying for it?

Dr. Cademartiri is the director of advanced cardiovascular imaging and photon-counting CT at the Scientific Institute for Research, Hospitalization, and Healthcare Synlab Diagnostic Network in Naples, Italy. He is also a consultant in advanced cardiovascular imaging at CDI/Centro Diagnostico Italiano in Milan, Italy.

(Editor’s note: This blog is adapted with permission from Dr. Cademartiri’s original LinkedIn post available at

https://www.linkedin.com/in/filippocademartiri/recent-activity/all/