A recent study concludes that rising cancer care costs were fueled by imaging, but understanding the big picture is critical.

?Michaela Dinan, Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Duke University

The numbers don?t lie. Cancer care cost has risen, and imaging is one of the culprits. But, while the numbers don?t lie, they don?t tell the whole truth either.

A recent study conducted by Michaela Dinan of the Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Duke University, Durham, NC, found that, overall, the costs for cancer imaging have increased at twice the rate of total cancer care. In an age where any health care cost increase is a harbinger of doom, it is not surprising that Dinan?s study has garnered quite a bit of ink and pixels.

There is no doubt that Dinan?s study, which examined Centers for Medicare and Medicaid Services-supplied reimbursement data from 1999 to 2008, is accurate; it?s the story behind the numbers that gives a much more complex picture of the world in which radiologists and oncologists operate. Yes, the costs have increased, but they are still only a small part of the overall costs, and, because of its diagnostic power, imaging has been key in helping to cut cancer deaths and make care more efficient and cost-effective.

The Numbers

Dinan and her team examined a 5% sampling of all the cancer claims from CMS between 1999 and 2008. The more than 100,000 diagnoses were categorized as breast cancer, colorectal cancer, leukemia, lung cancer, non-Hodgkin lymphoma, and prostate cancer. The imaging modalities ran the gamut from bone density studies to ultrasound to PET.

According to the findings, every modality, except conventional radiographs, showed a significant rise in annual use with PET leading the way, seeing a mean annual increase of 35.9% to 53.6% during the course of the study period depending on the type of cancer being imaged. Of the other imaging tests, bone density studies increased between 6.3% and 20.0%, echocardiograms 5.0% and 7.8%, MRI between 4.4% and 11.5%, and ultrasound between 0.7% and 7.4%. As of 2006, lung cancer and lymphoma patients had the highest imaging costs, exceeding a mean imaging cost of $3,000 per CMS beneficiary.

While these percentages are large, Dinan noted that they have to be viewed in the proper context. ?Imaging costs have increased, but they still made up less than 6% of the total costs, so they?re still relatively small,? she said, adding that this fact was, for her, the most surprising thing she discovered while she was analyzing the data.

PET imaging utilization grew the fastest during the study period, and it was one of the most expensive tests performed by clinicians and radiologists. But the high costs followed by the high utilization are not surprising considering that the modality, which had just come on the scene in 1999, was not being reimbursed by CMS, but was extremely popular with radiologists and oncologists.

While the numbers show that utilization?and thus cost?is increasing, it did not answer the more crucial question: is it worth it?

Behind the Numbers

For Douglas W. Blayney, MD, an oncologist and president of the American Society of Clinical Oncologists (ASCO), the answer is a decided ?yes,? and, in his opinion, the study was ?interesting, but had the wrong conclusion.?

Dinan conceded that there are two sides to the cancer imaging cost story, and she and her colleagues had looked at only one?so far. ?In our study we were not looking at outcomes,? she said. She said that she is planning a follow-up study that will evaluate outcomes.

But, both as president of ASCO and as a practicing oncologist, Blayney focuses on the side of the story Dinan?s current study didn?t tell, and those numbers are painted with negative signs in front of them. After reading Dinan?s study, he came to a completely different conclusion. ?It showed that more information is better,? he said. The proof is in the outcomes?costs might be up, but cancer deaths continue to fall at about 2.5% per year.

The increased utilization of imaging on the front end has led to savings downstream, he said, cutting down on surgeries and other expensive care for lung cancer and lymphoma patients, the two groups that were the most expensive for CMS. Blayney said that this shows that ?oncologists are putting [imaging] to good use? with the result that care is much more efficient and effective.

And advanced technologies, like PET, which was not reimbursed at the turn of the 21st century, were not used just because they were new, but because they were the most effective and safest modalities available. For instance, Blayney said that he has gotten away from routinely using CT scans because of his concerns of repeatedly exposing his patients to radiation. He now typically uses PET and plain chest x-rays to manage his lymphoma patients?the group that forms the lion?s share of his practice.

Taken together, Dinan and Blayney?s two sides of the story give a fuller picture of the cost and benefits of imaging. Ask any radiologist or oncologist and they will agree that imaging is the most powerful cancer-fighting weapon they have at their disposal. The numbers prove this. But the numbers show something else, too. Some clinicians are too quick to image a patient with the latest and greatest imaging technology for reasons other than good medicine.

Under Pressure

Mark Hiatt, MD, MS, MBA, chief medical officer of HealthHelp Inc, Houston, a radiology benefit management (RBM) company that is in the business of helping radiologists manage their imaging costs, admits that it?s not an easy task to control costs. Referring physicians and radiologists are under numerous pressures to prescribe tests that may not be needed.

Among these pressures are patient influence, lack of knowledge by the referring physician, defensive medicine, and the trap of self-referrals.

Hiatt says that, while he likes a collaborative approach between patient and physician, today?s Internet-savvy medical consumer can cause their referring physician or radiologist a lot of headaches. ?Patient research isn?t all bad?but the bad side is that it can lead to inappropriate tests or overuse,? he said.

On the flip side of this coin is the referring physician who hasn?t been able to keep up with technology and who doesn?t know the best test to provide their patient?and ?best? in this case could also mean the perfect pairing of effective and inexpensive. This is where the expertise of an RBM, which acts as a liaison between a referring physician, patient, and payor, comes into play. ?Technology is increasing at such a rapid pace, how can an internist keep up?? he asked rhetorically. ?It?s taken a diagnostic radiologist many years to learn their specialty, and this ?ignorance??that the modality, or the protocol, or the amount of time you wait before performing the test is wrong?is not willful on the part of the internist.?

This lack of knowledge dovetails into the practice of defensive medicine, a consequence of the United States? long history of litigiousness. Hiatt said that for clinicians practicing this way, it?s simply easier to order a test than not to order it.

Finally, self-referral, though often appropriate, can be a dangerous trap that increases imaging utilization and costs. Hiatt said this pressure is ?subconscious,? usually born as much out of the need to help a patient as it is to pay for an expensive piece of imaging equipment. According to a 1990 article in the New England Journal of Medicine, a clinician who owned their own equipment was two to seven times more likely to order an imaging test.

Hiatt, in fact, recently saw a number of these pressures all come into play in the case of a young mother who worked across the hall from his office. The woman, a 28-year-old mother of two, had recently gone for a check-up and her pulmonologist had found a spot on her lung. He wanted to follow up with a CT scan.

A nonsmoker with no other risk factors for lung cancer, the woman?shaken by the finding?researched CT scans online and was concerned about being exposed to additional radiation. Through a friend, she approached Hiatt who reviewed her scan and advised her to wait several months before having a follow-up chest x-ray. The follow-up showed that the spot had disappeared, a finding that didn?t surprise Hiatt.

The referring physician, in this case, didn?t have the knowledge a diagnostic radiologist like Hiatt had, and, in his opinion, was practicing medicine defensively. Whatever the case, if the patient had agreed to the test, she would have been exposed needlessly to additional radiation, and would have increased her health care costs.

While oncologists like Blayney know that the front-end expense of imaging has critical cost savings down the line, the need to manage costs has become paramount in today?s health care environment. This begs the question?is there a rational way to do so? According to Hiatt, there is.

A Solution

Hiatt believes that RBMs can help control imaging costs by providing objective, third-party opinions about when and how to provide a scan.

The method he envisions is not a dictatorial one, but, like his ideal patient-physician relationship, collaborative, based on the patient?s needs and good science to come up with a cost-effective solution. For Hiatt, the benefits of this approach are obvious. ?For the physician, they get a clear-cut answer. For the patient, they get where they need to be, either they?re spared an unnecessary test, or they get a more appropriate if more expensive one that skips other preliminary tests, saving time, radiation exposure, and the possibility of a false-positive. For the health plan, it gets the specialty benefit with a diagnosis that emphasizes quality, which saves money,? he said.

The key is the third-party confirmation that?s based on the best available science to blunt some of the pressures that referrers are feeling. For instance, Hiatt said that it may be very appropriate for a clinician to self-refer a patient in some circumstances. A specialty management company can help determine if this is the right course. It can also help a physician avoid practicing defensively and overuse of imaging as a way to limit potential liability.

The bottom line is that in spite of the pressures, all physicians are united in a common cause, said Hiatt. ?They want to do the right thing, they just want an answer.?

No matter the numbers or the opinions, there?s one thing that is still very clear?imaging will continue to play a critical role in the battle against cancer.

C.A. Wolski is a contributing writer for Axis Imaging News.