Professional organizations are supporting a campaign that offers a responsible alternative to blanket cuts and RBMs.

The American Board of Internal Medicine Foundation’s Choosing Wisely campaign is a responsible step in leading physicians to manage costs, reduce unnecessary procedures, and promote evidence-based care. It is heartening to see that the American College of Radiology and the American College of Cardiology have already joined the campaign, and that the Society of Nuclear Medicine will be contributing to the effort shortly. By taking the lead on responsible use of medical imaging, these organizations demonstrate that the application of appropriateness criteria—not blind cuts to reimbursement—is the most effective way to control imaging utilization while preserving patient access.

Medicare payments for medical imaging services have been cut repeatedly since 2006, some by more than half. A November 2011 independent analysis of Medicare data showed that per-beneficiary imaging spending has dropped 13.2% since 2006, and imaging utilization per beneficiary fell 3% in 2010. Meanwhile, spending for nonimaging services has grown 20% since 2006 and utilization increased 2% in 2010. These trends have been confirmed by the Medicare Payment Advisory Commission, whose analysis found that imaging services use declined by 2.5% in 2010.

Unfortunately, we are already seeing the harm engendered by this draconian approach to utilization reduction. In December 2011, Health Affairs published a study showing that cuts to Medicare payments for bone density scans led to the performance of 800,000 fewer tests than expected (based on historic trends)—tests that could have prevented up to 12,000 fractures.1 One of the study’s authors, Donna Fiorentino, noted, “Bottom line, had the rates not been cut, we would not have seen that devastating number of fractures.”

In addition to payment cuts, policymakers are still considering using radiology benefit managers (RBMs) in Medicare. These organizations take medical decisions out of the hands of patients and their physicians, place huge administrative burdens on providers, and have not been shown to reduce costs over the long term. They directly impede patients’ access to necessary and potentially life-saving medical imaging tests. Research has shown that RBMs delay needed care and more often shift costs to providers rather than producing actual savings.2 Recent data from the Patient Advocate Foundation revealed that among reversed coverage denials for medical imaging services, 90% of the denials were in fact covered by the patients’ health plans.

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Choosing Wisely, on the other hand, is a common-sense, evidence-based approach to the use of health care services. The Access to Medical Imaging Coalition has similarly supported the widespread adoption of physician-developed appropriateness criteria, which guide physicians without limiting their professional judgment or placing barriers between patients and necessary care. When deployed with clinical decision support software to assist physicians in determining when to perform medical imaging and which modality to use, appropriateness criteria have proven effective in reducing unnecessary tests—a 2009 study found that decision support software helped generate marked decreases in CT, MRI, and ultrasound utilization growth.3

Choosing Wisely is an important step toward responsible decision-making by physicians who order and perform medical imaging tests. The expansion of efforts like Choosing Wisely and universal use of physician-developed appropriateness criteria will ensure that providers and patients, not bureaucrats, are making crucial medical decisions—preserving access to the right scan at the right time.


Tim Trysla is Executive Director of the Access to Medical Imaging Coalition (AMIC), which represents physicians, medical providers, and patient organizations throughout the United States. It also includes health technology firms that manufacture imaging equipment and supplies. Thus, AMIC represents those who develop medical imaging technologies, those who apply them, and those who benefit from them.

REFERENCES

  1. King AB, Fiorentino DM. Medicare payments cuts for osteoporosis testing reduced use despite tests’ benefit in reducing fractures. Health Aff (Millwood). 2011;30:2361-70.
  2. Lee DW, Rawson JV, Wade SW. Radiology benefit managers: cost saving or cost shifting? J Am Coll Radiol. 2011;8:393-401.
  3. Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH. Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes. Radiology. 2009;251:147-55.