applesoranges_webWhile every culture is unique, U.S. radiologists can surely learn something about imaging utilization, access, and quality from healthcare models across the globe.

By Michael Bassett

Comparing healthcare systems from around the world to each other may be a little like comparing apples and oranges, but, according to T.R. Reid, author of The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, American physicians should remember one simple fact—they are paid more than their international colleagues.

That holds true for radiologists as well, says Reid, who traveled around the world to see and document how the other developed democracies provided healthcare. “American radiologists are probably the best-trained radiologists in the world, as well as the best paid,” Reid said. “Other radiologists don’t have anything close to the annual income of American radiologists.”

Yet, that simple fact should come with a warning, he said, particularly as policy makers start to look at the healthcare models of other countries and realize that radiologists are making more than their international peers and that imaging exams and radiological procedures cost much more than in other western-style democracies. And all of this is happening despite the fact that performance of the American healthcare system is mixed, at best.

In a report published last year in the Journal of the American Medical Association, researchers from the Institute for Health Metrics and Evaluation (IHME) found that when it comes to overall health outcomes, the United States is falling behind. For example, IHME found that in nearly every category of major causes of premature death, the United States compares unfavorably with its economic peers.

At the same time, the United States is spending an extraordinary amount on healthcare—about 18% of its gross domestic product (GDP). This is almost twice that of Japan, which spends 9.5% of GDP on healthcare (which is also exactly the same as the average amount of GDP spent on healthcare in the 34 countries that belong to the Organisation for Economic Co-operation and Development or OECD).

According to Reid, while American consumers might look with some envy at a country like Japan that is providing excellent healthcare at “ridiculously affordable” prices, the Japanese system will likely be a sobering reminder to radiologists of what can happen to reimbursements in a system that relies on strictly controlling costs to provide that inexpensive care.

T.R. Reid, Author

T.R. Reid, Author

“I’ll give you a striking example,” Reid said. “I had an MRI scan in Denver of my anterior neck region and the fee was $1,234. Four or 5 weeks later, I was in a doctor’s office in Japan and saw that he had an MRI scanner in his office and asked him how much it would cost if he did a scan of my neck. He checked [the fee schedule] that was set by the health ministry and told me it would cost $98.”

Not only are advanced imaging examinations inexpensive by American standards, but when it comes to utilization of these advanced modalities, the Japanese are “prodigious consumers.” Japanese patients get twice as many CT scans and three times as many MRI scans as Americans on a per capita basis.

Aspects of the Japanese model will look familiar to Americans, with the Japanese paying for healthcare from private providers through insurance plans. But prices are set through negotiations between the government and providers, resulting in one fee schedule with extremely low prices.

How are the prices kept so low in Japan? Basically, Reid writes in his book, the “system shafts doctors and hospitals, paying some of the lowest fees on earth for medical treatment.” And physicians have little choice in the matter. On average, Reid says, specialists in Japan earn less than $200,000 a year, about the average of a midlevel corporate executive.

The Japanese system is similar to others found in countries such as Germany, Switzerland, Belgium, and some Latin American countries in the sense that these countries rely on private health insurance plans, but also strictly regulate fees and medical services to keep costs down (though not to the degree found in Japan).

In short, the Japanese system is not unique when it comes to keeping costs—and prices—down. David Kaiser is a healthcare consultant based in Poland. Kaiser, who went to Poland in 1998 to help open a small hospital for expatriates, says that healthcare prices in that country are “outrageously low,” compared to a country like the United States. An MRI exam, for example, runs around 450 Polish zloty—or about $150—while a CT exam would be even less expensive.

Why so low in Poland? Again, unlike the United States, radiologists are not particularly well paid. “A radiologist may make—and this is on the high side—about 25% of what a radiologist makes in the United States,” Kaiser said. “There is just no comparison there.”

Kaiser suggests, however, that despite the low level of compensation, there is something to be said for the payment model from the perspective of an American radiologist in the sense “that there are relatively few bad debts.” Radiologists who have Polish National Health Fund contracts know exactly how much they are going to be compensated, while patients who use private health services are expected to pay for them as soon as they walk through the door, Kaiser said. This means that the bad debt rate is probably less than 1%, Kaiser said, adding, “that’s something I think the American market would like to have.”

Utilization and Appropriate Imaging

In the United States, organizations like the American College of Radiology have put much emphasis on imaging appropriateness as one way of reducing unnecessary imaging and reducing costs while ensuring that patients still have access to the imaging services they need.

According to Ismail Rasool, a general manager with Discovery Health, South Africa’s largest private health insurer, the private health sector in South Africa is also facing issues related to imaging overutilization and rising costs.

In South Africa, a parallel private and public system exists, with a public system that covers most of the population, but is understaffed and underfunded. The private system, on the other hand, serves about 20% of the South African population and is responsible for about 60% of all expenditures on health. The privately insured in South Africa expect to get the most sophisticated care, Rasool says, which means that the private market is seeing an increasing shift toward the use of advanced imaging modalities like PET, CT, and MRI, and is seeing rising costs as well.

And while imaging guidelines exist, from the third-party payor standpoint, they are rather “self-serving,” said Craig Owens, the Discovery Health executive responsible for clinical risk management for radiology services, in the sense that they have been devised by local radiological societies with little input from the payors or other medical specialties.

A case in point is breast tomosynthesis, says Rasool, which insurers like Discovery Health are being asked to cover as a screening exam on a broader scale. “We don’t believe that should be the appropriate starting point for [breast cancer screening] in South Africa, because the price element involved in that will be quite substantial,” he said. “We propose that it should be done only on a very select group or people, but we are in a bit of a stalemate with the radiological societies about which patients we should allow funding for.”

What Discovery Health would like to see, said Owens, are appropriateness criteria that are established on a multidisciplinary basis, “where you have, for example, oncologists and surgeons getting involved with the radiologists to determine the appropriateness of care, rather than just having a somewhat self-serving system where the radiologists give us their view and expect us to accept it. That is a change we are trying to drive, and it relates to the fact that costs just keep going up.”

According to Reid, systems like the National Health Service (NHS) in the United Kingdom succeed in keeping imaging utilization and costs down by being fairly “stingy.”  That means that when it comes to medical imaging, the NHS contains costs by trying to reduce access to imaging.

There are a couple of ways this is being accomplished. For one thing, according to the OECD, while the UK has seen an increase in the utilization of imaging exams like CT and MRI, the number of MRIs in the UK in 2011 was still only 5.9 per million population, less than half the OECD average, while the number of CT scanners stood at just 8.9 per million population, less than 40% of the OECD average of 23.2.

Like the United States, the UK also has taken steps to deal with the issue of appropriate use of MRI and CT exams with the creation of the Diagnostic Advisory Committee by the National Institute for Health and Clinical Excellence.

Reid says another factor that helps keep costs down outside the United States has to do with the negligible amount of malpractice litigation that occurs in most countries. “You certainly don’t have the malpractice problems in Poland that you have in the United States,” agreed Kaiser. “You have very few lawsuits.”

In Japan, medical malpractice insurance is very inexpensive, said Reid. In his book, he relates the example of one general practitioner whose insurance is covered by dues to his medical association (about $100 per month).  According to this doctor, he buys the insurance for peace of mind, but has never needed it in 40 years of practice.

It’s a similar situation in many other countries, Reid says. In France, which is one of the most expensive countries in Europe when it comes to healthcare, doctors pay just a fraction of what American doctors pay in insurance. The reason has much to do with the system used to deal with cases of alleged malpractice. France uses an approach—similar to Scandinavian countries—in which cases are settled administratively by special review boards set up outside of the legal system, with payments coming out of a national fund.

The situation is changing in South Africa, however, says Owens, with evidence that more defensive medicine is being practiced, which is further driving utilization, as well as costs.

Imaging Exam Wait Times

Wait times can be affected by a number of different factors, depending on the health system involved. In the United States, for example, how long a person has to wait for an imaging exam can depend on whether they have the funding necessary to pay for the exam, or by the availability of services in the area in which that person lives.

In Poland, which has a publicly funded healthcare system (with a growing private system), wait lists can be long for certain procedures, says Kaiser. His wife, for example, had to wait 4 months to undergo a breast MRI exam.

The UK has had issues with wait times, said Reid, and the evidence seems to bear him out. For example, according to a report from the BBC, in November 2013, 32% of patients in Wales in need of ultrasound scans had been waiting longer than 8 weeks, which is the operational standard for the National Health Service.

Canada has long had the reputation of having a serious problem with wait times for diagnostic imaging services, although according to the Wait Times Alliance annual report, however, several provinces are making “real progress” in reducing wait times for MRI and CT exams, specifically Ontario, Newfoundland, Labrador, and Saskatchewan.

But the “horror” stories about wait lists in Canada, Reid says, are generally true. In Canada, healthcare services are provided by private entities, but through a publicly funded healthcare system.  It is a system that is very good at providing acute care, Reid says, but “if you need an MRI for a bum shoulder, you’re going to have to wait.”


Michael Bassett is a contributing writer for Axis Imaging News.