The rapid proliferation of sophisticated medical technology is now creating unrestrained consumer expectations for access to the latest (and most expensive) forms of health care. As a result, an impending collision between those expectations and the cost of meeting them looms over the health care industry. The ability of patients, government programs, and insurers to pay for care will remain limited, but consumer demand will not. The needs of payors and patients must be aligned in order to decrease this conflict. Patients must be educated to ask their physicians to request only the best test (not all applicable tests), as well as to make wise decisions in out-of-pocket spending. Organizations will help by eliminating redundant testing, recognizing trends, understanding equipment capabilities, and using technologies that are cost-effective and up to date.
REGULATORS AND PAYORS
The 2004 Medicare Modernization Act will eliminate fiscal intermediaries beginning in 2005; instead, private-sector Medicare administrative contractors will bid to manage Medicare (including imaging). In preparation for bidding, there will be a dramatic acceleration of imaging-provider consolidation. Larger radiology networks will enter partnerships with bidders or become bidders themselves. Private payors will follow Medicare in seeking bidders for imaging or in becoming Medicare bidders and selecting imaging partners. Insurance companies will not be the only bidders; large banks and credit-card companies will bid after creating partnerships with providers. Small employers will spread risk over a larger base by creating pools, and the larger pools will then adopt a federal-style bidding process.
Medicare’s new payment mechanism based on quality and outcomes will be extended to include imaging. Consultants are now working to understand the effects on imaging costs of poor imaging quality and of imaging provided by nonradiologists. State governments may be the first to move in this arena.
Lawsuits based on denial of care can be expected to continue, and litigators are seeking clients who believe that medical radiation has harmed them. Governmental regulation will be needed to address these complaints and malpractice costs, but MRI and ultrasound use will grow as a result of radiation concerns, especially in pediatric care.
To reduce costs, health care providers will choose areas such as cardiology or oncology in which to develop specialized expertise. Managed care organizations will need to improve imaging quality and curb self-referral. Disease management and quality control will be pursued if results can be measured and costs can be reduced. Precertification and coding problems will be addressed slowly.
Prevention and early intervention will continue to become more important as the emphasis on acute care decreases. As part of this shift, out comes studies will become more important, as will the provision of other solid information upon which clinical decisions can be based. Physicians will be given incentives to increase the quality of care, and performance-based imaging contracts will appear.
ECONOMY AND SOCIETY
The US radiology market will be worth approximately $100 billion in 2005, accounting for as much as 17% of health spending. By the end of the following 8 years, health care costs are likely to represent 17% of the gross domestic product. Recent increases in both health insurance premiums and imaging volumes appear to be unsustainable, leading self-insured employers, payors, and governmental programs to see reducing imaging costs as a high priority. This emphasis on cost control (and the accompanying need to manage the risk of litigation) will lead to the rapid replacement of opinion-based medicine by evidence-based medicine.
Underspending is common in some areas; overspending, in others. So far, payors have lacked the evidence needed to make difficult decisions in the allotment of health care resources. The necessary evidence has been growing, however, in databases maintained in the private sector. Given the need to control imaging safety, quality, and costs, the availability of data will make many formerly tough decisions easier: dollars will simply have to be spent where they will do the most good.
Diagnostic and treatment capabilities will be subject to continuing consolidation and vertical integration. For example, one company has now gained 35% of the contrast-agent market via acquisition of smaller manufacturers.
Patient privacy will remain an important concern, especially as information-sharing mechanisms improve. More of the responsibility for health care costs will shift to the consumer, and consumerism will affect more health decisions, so understanding imaging choices will become more important. Enrollee education on imaging safety and quality will be provided by more employers and health plans. Consumer demand will continue to increase until direct marketing is restricted by governmental action. It will be necessary to find ways to help physicians order appropriate tests without adding to administrative burdens.
Pressure on health care will continue to increase as the population ages because the elderly require a disproportionate amount of health spending. It may be necessary to reconsider the provision of expensive interventions that are unlikely to improve patient outcomes, based on individual risk and lifestyle factors.
TECHNOLOGY, STAFFING, INFORMATION
Body CT may be largely replaced by 3T MRI. Gadolinium use will increase in MR angiography and arthrography. Advances in cardiological CT and its competitor, 3T cardiological MRI, will cause turf problems between cardiologists and radiologists. This battle may be lost by radiology unless the specialty makes an effort to educate legislators.
Rapid growth is likely in functional neuroimaging and MR spectroscopy of the brain. Pressure to reduce the cost of care will promote molecular imaging of metabolic processes and drug-receptor interactions. Positron-emission tomography will, because of new applications, be more widely used in oncology, cardiology, and psychiatry.
Innovative solutions will be required to overcome the radiologist shortage. Other specialists may train to enter radiology; for example, neurologists might become neuroradiologists under grant programs. Extensively trained radiology assistants (sometimes called supertechs) will also be very important in reducing the shortage’s effects. Because radiologists will be forced to limit the use of their own specialty, many will become educators who help referring physicians determine the most appropriate imaging choices.
Younger physicians will drive the vastly expanded adoption of information technology. At the same time, payors will require fully electronic medical images, and the free transfer of the electronic medical record will become a reality. Internet use will increase, and its improving infrastructure and increasing bandwidth will support telemedicine’s expansion (which will include remote robotic surgery). Picture archiving and communications systems will emerge as new entities that handle information not only for providers, but for patients and payors as well.
Cherrill Farnsworth is president and CEO of HealthHelp, Houston, a radiology benefits management company, and president of the National Coalition for Quality in Diagnostic Imaging Services, Washington, DC, a nonprofit association focused on the needs of imaging center owners and operators.