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After several years of crisis, there is some evidence that the personnel shortage in radiology may be easing: the number of active radiologists has increased and the specialty is bulking up its ranks with additional residency slots.
According to the most recent data from the American College of Radiology (ACR), there were approximately 26,800 active post-training radiologists, including ACR members and nonmembers, working in the United States in 2003—up from 25,600 in 2000. Those numbers include diagnostic radiologists, interventional radiologists, and nuclear medicine physicians with a major link to radiology.
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Decisions in Axis Imaging News gratefully acknowledges the following organizations, which submitted data for this State of the Industry report:
Special thanks to Jagruti Mehta, Ascend Media, who provided added statistical computation. |
In 2004, there were also 4,670 residents and fellows, and 5,870 retirees who were active ACR members—also up from 2000, when there were 4,500 residents and fellows, and 5,100 retirees.
“We’re trying to train more radiologists,” says James Borgstede, MD, chairman of the ACR’s board of chancellors, and a clinical professor of radiology at the University of Colorado Health Science Center in Denver. Borgstede is also in private practice in Colorado Springs. “I think the jury is still out as to whether we’re going to be able to keep up or not. I’m optimistic that we will.”
According to Borgstede, the ACR approved about 300 new residency slots over the past few years.
The ACR monitors shortages in the industry in a number of ways, including the number of advertisements seeking radiologists.
“We’ve seen a drop in the number of ads,” Borgstede says. “That could be because the shortage is easing. It could also be the fact that people [who have an opening] have given up looking. And it could also be the fact that we’re working more efficiently. I think it’s probably a combination of all of them.”
The latest data from the American Medical Association (AMA) shows that in 2003, there were 38,041 physicians in the field, including those who identified themselves as being in diagnostic radiology, nuclear medicine, radiation oncology, and radiology. The specialties listed were self-designated by the physicians from a list included on a questionnaire. The specialty classifications are based on the 40 specialties used by the AMA.
The radiologist shortage is not equal across the subspecialties within the field. For instance, it is higher in such areas as mammography, which is not considered to be a high revenue-producing area and has had numerous litigation issues, Borgstede says.
Progress also appears to have been made in addressing the radiologic technologist shortage, which has left departments from coast to coast scrambling to find suitable staff. “Probably, there is a greater technologist shortage than there is a nursing shortage,” Borgstede notes.
According to the American Registry of Radiologic Technologists, as of January 2004, there were 238,567 registered technologists in the United States, including its territories. In a survey on job vacancies based on responses from more than 800 hospital-based radiology departments, the American Society of Radiologic Technologists (ASRT) found that the vacancy rate for radiologic technologists fell from a national average of 10.2% in January 2003 to 7.7% in September 2004.
The survey also showed that the national averages of vacancy rates for technologists across the specialties declined from January 2003 to September 2004.
“We think we’ve turned the corner with the kinds of shortages we were looking at just 3 to 5 years ago,” says Sal Martino, EdD, ASRT’s executive vice president and chief academic officer.
Martino says there was an average 15% vacancy rate just a few years ago. “Unfortunately, what we had is an increasing number of procedures and a decreasing number of people going into the field,” Martino says. “We’ve now turned that around. There have been steady increases in enrollment over the last 4 years.”
While the vacancy rates have dropped, the overall shortage in radiologic technology persists. According to a 2004 ASRT study on enrollment, students are entering educational programs in radiologic sciences at a slower rate than in the previous 3 years—a trend that could be attributed, however, to the fact that many educational programs are at full enrollment.
The ASRT predicts that if current trends in enrollment, attrition, and retention remain the same, the nation will not meet the US Bureau of Labor Statistics’ projection for an estimated 72,000 additional radiologic technologists through 2012. The ASRT projects that about 61,746 will join the ranks by then—about 14% less than the bureau estimated.
“We’re not completely out of the woods,” Martino says.
SITE OF IMAGING
 Table 1. Medicare Part B non-managed care utilization, share of each place of service, measured in number of procedures, 1997-2003. (Click the image for a larger version.) |
Outpatient imaging continues to shift gradually away from hospitals to freestanding imaging centers.
“The imaging tends to be cheaper. That’s one reason why the carriers are interested in having imaging outside of a hospital,” Borgstede says. “Charges reflect the resources that it takes to provide that service.”
According to Medicare Part B data provided by the ACR, 106,870,892 imaging procedures were done in 1997 by all providers—radiologists and nonradiologists—in all settings (Table 2). Of the total, 29.8% were done at a freestanding facility or office; 34.9% were done on an inpatient basis in a hospital; and 35.3% were done on an outpatient basis in a hospital or other setting (Table 1).
 Table 2. Medicare Part B, non-managed care utilization, growth in number of procedures, across all places of service, 1997-2003. (Click the image for a larger version.) |
By 2003, the total number of imaging procedures skyrocketed to 150,905,903, with 33.2% of the procedures done in a freestanding facility or office, representing the biggest increase in share of place of service; 31.1% on an inpatient basis in a hospital (down from 34.9% in 1997); and 35.7% on an outpatient basis in a hospital or other setting (up slightly from 35.3%).
The most dramatic changes in share of place of service occurred in the offices of nonradiologists, especially in MRI and interventional and nuclear medicine modalities. In 1997, 4.5% of all MRI procedures were performed in an office or freestanding site by a nonradiologist. That number jumped to 10.3% by 2003. Similarly, 5.7% of interventional procedures were performed by nonradiologists in an office/freestanding site in 1997, increasing to 11% by 2003; and 21.9% of nuclear medicine procedures were performed in-office in 1997, with 45.1% in 2003 (see Table 1).
While imaging volume in all but one category grew between 1997 and 2003, the growth was most dramatic among nonradiologists in the office setting (Table 2). In 1997, nonradiologists performed 100,740 CTs; 95,523 MRIs; 248,188 interventional procedures; and 989,318 nuclear medicine procedures in an office setting. Those numbers increased by 2003 to 368,610 CTs, a 24.13% 6-year compound annual growth rate (CAGR); 530,488 MRIs (33.07% CAGR); 816,722 interventional procedures (21.96% CAGR); and 4,455,328 nuclear medicine procedures (28.51% CAGR). The only negative CAGR for any site or provider was in-office mammography by nonradiologists, which dropped by -0.40%.
While radiologists’ share of imaging done in an office also increased over the course of the 6 years represented in the Medicare data provided by the ACR, the increase was not as dramatic as among nonradiologists (Table 2). In 1997, radiologists performed 795,739 CTs; 675,689 MRIs; 75,581 interventional procedures; and 244,912 nuclear medicine procedures. In 2003, radiologists performed 1,867,616 CTs (15.28% 6-year CAGR); 1,500,793 MRIs (14.23% CAGR); 156,057 interventional procedures (12.84% CAGR); and 495,575 nuclear medicine procedures (12.46% CAGR).
Radiologists’ share of in-office imaging as a percentage of all imaging across all facilities diminished in the modalities of MRI, nuclear medicine, and mammography, according to the Medicare data provided by the ACR (Table 1). In 1997, 31.9% of all MRI procedures were performed in an office or freestanding site by a radiologist. That number decreased slightly to 29.2% by 2003. Nuclear medicine procedures also dropped slightly, with 5.4% performed by radiologists in-office in 1997, and 5% in 2003. Radiologists’ share of in-office mammography dropped from 35.5% in 1997, to 32.9% in 2003. However, radiologists’ share of mammography in a hospital-based outpatient setting grew from 51.8% in 1997, to 60.4% in 2003.
Among in-office interventional procedures, 1.7% were performed by radiologists in 1997, while 2.1% were done in 2003 (Table 1). In-office CT imaging read by radiologists increased from 9.6% in 1997 to 11.8% in 2003 (Table 1).
In the inpatient hospital setting, radiologists lost share of imaging over time in every modality except MRI, which grew from 18.4% in 1997 to 20.3% in 2003. (see Table 1).
IMAGING CENTERS MULTIPLY
 Table 3. Number of imaging centers. Source: Verispan. |
As of December 2004, Verispan identified 5,769 diagnostic imaging centers (DIs), up from 5,450 in the third quarter (Q3). The number of DIs has risen steadily from 3,337 in Q3 2000; to 4,159 in Q3 2001; to 4,773 in Q3 2002; and to 5,163 in Q3 2003 (see Table 3).
In its 2004 Diagnostic Imaging Center Market Report , Verispan profiles 4,608 DIs for which it obtained information as of August 2004.
Florida had the most imaging centers, with 617, followed by New York at 540, and California at 503 (see Figure 1).
 Figure 1. Map illustrating the national distribution of imaging centers shows the highest concentration in the states of Florida, New York, and California. Source: Verispan. (Click the image for a larger version.) |
The average number of patient visits per year for the facilities included in the report was 14,264. The states reporting the largest average number of DI visits per facility were Maryland, with 21,524; Ohio, with 21,413; and Maine, with 21,250.
According to Verispan’s market report, the number of DIs should continue to increase due to the aging of the population, continued advances in imaging, and increased awareness of and demand for imaging services.
In separate data, Verispan identified 10,232 radiologists, full- and part-time, reading for freestanding imaging centers in 2004, compared to 9,957 in 2003. DIs also employed 22,049 full- and part-time technologists in 2004, up from 21,672 in 2003.
Verispan’s market report indicated that besides radiologists, other specialties involved in imaging at diagnostic centers included cardiology and neurology. The report noted that cardiologists represented the highest volume of specialists performing services at imaging centers, but did not offer hard numbers.
 Table 4. Imaging center ownership status. *Other includes university facilities, government facilities, hospital-owned facilities and public companies/corporations. Source: Verispan. |
According to Verispan, ownership of freestanding imaging centers in 2004 broke down into 37% private, 12% radiology group, 9% partnership with a hospital, 4% physician partnership, and 38% other, a category including university, government, and hospital-owned facilities, as well as public companies and corporations (see Table 4).
Verispan’s market report showed that diagnostic imaging center chains (DICs) continue to acquire and/or merge with other facilities. In 2004, Verispan identified 514 DICs that owned, managed, or leased 3,217 DIs, representing a 59% share of the freestanding imaging center market, a 31% increase in chain ownership from 2003.
In 2004, at least 98.1% of imaging centers or chains contracted with managed care organizations; of those, 98.1% contracted with at least one health maintenance organization; and 96.4% contracted with at least one preferred provider organization.
As of August 2004, 13% of DIs belonged to an integrated health care network, which provide referrals, an increase from 509 to 722 DIs between August 2003 and August 2004, according to the Verispan Integrated Healthcare Network Profiling Solution©.
TECHNOLOGY DEPLOYMENT
Two sources provided Decisions in Axis Imaging News with data on the estimated number of scanners deployed. According to Verispan, there were 5,789 CT scanners and 4,816 MRI scanners deployed at hospitals, according to Q3 2004 Verispan data. PET and single photon emission computed tomography (SPECT) scanners were among the fewest deployed with 1,275 and 2,123 units, respectively.
 Table 5. *Modalities deployed at freestanding diagnostic imaging centers (no hospitals). Source: Verispan. |
In freestanding diagnostic imaging centers, radiography accounted for the most units, with 3,948, followed by MRI with 3,449 units. Lithotripsy at eight units and nuclear cardiology at 31 units accounted for the scarcest modalities in imaging centers in 2004 (Table 5). Verispan found that most imaging centers do not have two units of the same modality.
IMV Medical Information Division data on the installed base of fixed units for CT, MR, nuclear medicine, and PET came from the company’s census studies for the correlating year.
In 2004, the total installed base in hospitals for CT scanners was 6,275; and for MRI was 3,395. In comparison, in nonhospital settings, there were 2,730 CTs, and 3,655 MRI (Table 6).
 Table 6. Total installed base as of IMV’s 2003 or 2004 census studies. |
The IMV 2004 data shows an increase in the installed base from 2001 when there were 6,135 CT scanners and 2,575 MR systems in hospitals. In nonhospital settings, there were 2,095 CTs and 2,395 MRIs.
IMV’s information on nuclear medicine and PET for 2003 showed that, in hospitals, there were 9,095 fixed gamma cameras (SPECT) and 150 PET scanners. There were also 85 combination PET/CT scanners. Nonhospital settings accounted for 3,605 nuclear medicine cameras, 225 PET scanners, and 85 combination PET/CTs.
Information from 1999/2000 showed there were 8,820 fixed gamma cameras in hospitals and 2,360 in nonhospital settings.
The total number of PET and PET/CT scanners deployed in 2003/2004 was more than double the number in 2001, according to IMV data. In 2001, IMV identified 120 PET and PET/CT scanners in hospitals, and 100 in nonhospital settings.
With the increase in the number of imaging units and procedures in this country, one thing is certain: spending is expected to soar.
 Figure 2. Estimated spend by category (excluding drugs) for 2002. Source: Booz Allen Hamilton. |
In a 2003 Booz Allen Hamilton report, The Cost of Medical Technologies-Maximizing the Value of Innovation , the estimated total expenditures for diagnostic imaging in 2002 were expected to be $70 billion to $80 billion (Figure 2). Between 2002 and 2007, diagnostic imaging was expected to grow $30 billion to $40 billionmaking it one of the largest components of the United States nonpharmaceutical medical technology market spend (Figure 3).
 Figure 3. Projected cost growth by technology category (excluding drugs) for 2002-2007. Source: Booz Allen Hamilton. |
When analyzing data from 2000 and projecting growth in installed base through 2005, Booz Allen Hamilton found that ultrasound had equipment sales in 2000 of $1.1 billion, with an expected growth rate of 5.8% between then and 2005.
That would lead to estimated sales of ultrasound equipment of roughly $1.5 billion in 2005.
With the typical cost per ultrasound machine at $250,000, and the absolute number of machines sold between 2000 and 2005 estimated at 25,582, Booz Allen Hamilton estimated that the total new equipment sales between those years would be $6.4 billion.
MRI was just behind ultrasound in the Booz Allen Hamilton projections, with $940 million in equipment sales for 2000, and an estimated growth rate between then and 2005 of 4%. Its equipment sales for 2005 were estimated at $1.1 billion. With the typical MRI cost of $1.4 million, and the absolute number of machines sold between 2000 and 2005 estimated at 3,859, the company estimated that total new equipment sales of MRI between 2000 and 2005 will be $5.2 billion.
Booz Allen Hamilton’s projections indicate the growth rate of PET scanners will be most substantial. With $34 million in equipment sales in 2000, the growth rate between then and 2005 was estimated at 14.3%, with $66 million in equipment sales in 2005. At a typical cost per machine of $1.2 million and absolute machines sold between 2000 and 2005 estimated at 300, the total new equipment sales between those 5 years is estimated at $250 million.
PROCEDURE UTILIZATION BY MODALITY
 Table 7. Utilization of outpatient imaging by procedure, age, and sex. Source: National Imaging Associates. (Click the image for a larger version.) |
Utilization of some outpatient procedures rise precipitously as a person ages, judging from utilization rates by age group and gender at a freestanding imaging center, physician’s office, or hospital prepared by National Imaging Associates (NIA) (see Table 7). The data represents patients imaged between 2000 and 2004 and has economic implications for an aging population.
For CT scans, the radiology benefits management company has established that there are an estimated 26 annual procedures per 1,000 patients among women in the 0-19 age group, and 28 for men in that same population. In the 20-44 age group, that number increases to 71 among women and 56 among men per 1,000 patients. It increases even more in the 45-64 age group, with 132 annual procedures for women, and 111 for men; and in the 65+ age group, with 237 for women, and 251 for men.
The increase in CT utilization in older populations can be attributed to their increased risks of such problems as fractures and cancers, according to Thomas G. Dehn, MD, NIA’s executive vice president and chief medical officer. Echocardiography and nuclear cardiology utilization also increases among older age groups, which have more heart problems than those in the younger age groups, notes Dehn.
While MR utilization also increases in the older age groups, the rate of growth is not as dramatic. In the 0-19 age group, the NIA found that there are an estimated 18 annual MRI procedures per 1,000 female and 1,000 male patients. In the 20-44 age group, there are 54 for women, and 44 for men per 1,000 patients. Those numbers increase and separate from each other even more in the 45-64 age group, with 95 procedures for women and 75 for men; and in the 65+ age group, with 103 for women and 92 for men.
Dehn says the data offered no surprises to the NIA. “It provided validation of what we all have believed for a long time, and that is that primary consumption of health care occurs between 45 and 64. As people move into that age group, there is going to be an appropriate, not inappropriate, increase in utilization with the aging of the population,” Dehn says.
“The other thing that is validated is that, with the exception of 65 and over, women cost a lot more to take care of than men do,” he says. “I think it is because males drop out of the health care system after their last high school physical, until they have their first MI or something, whereas women stay connected to the health care system because of their obstetric profile. If you’re in the system, you’ll use the system.”
Also noteworthy, Dehn says, is that among the non-Medicare population, across age groups, “regardless of the community that we go into, it’s a given that the angiography/interventional procedures will be about 10 to 13 per 1,000.
“That was a little bit of a surprise. It’s not the kind of thing that’s necessarily overutilized,” he says.
Verispan offers some insight into how all of that imaging keeps the modalities in the freestanding imaging center humming. Third quarter data for 2004 regarding utilization by modality in a freestanding setting covered procedures done on 3,139 MR units; 1,774 CT units; 177 PETs; 2,726 ultrasound units; and 2,840 mammography units.
The 3,139 MR units produced 190,590 procedures per week, with an average of 60.7 procedures done per unit. The 1,774 CT units were used for 111,021 procedures per week, with an average of 62.6 per unit. The 177 PETs produced 3,612 procedures per week, at an average of 20.4 per unit. The 2,726 ultrasound units were used for 149,281 procedures per week, at 54.8 per unit. And the 2,840 mammography units produced 231,796 procedures per week, with 81.6 per unit (see Figure 4).
 Figure 4. Average weekly volume of procedures performed per unit in a freestanding setting. Source: Verispan. |
The number of outpatient imaging procedures performed at freestanding sites in an average week, according to information from 4,167 DIs provided to Verispan, reached 1,089,361 by Q3 2004. Verispan’s 2004 Diagnostic Imaging Center Market Report indicated that as of August 2004, MRI was the modality offered at the most diagnostic imaging sites, with 62% of the 4,608 DIs profiled reporting its use. The next most common modality was x-ray, offered at 54% of sites, ultrasound at 47%, mammography at 42%, and CT at 41%.
SHARE OF IMAGING
Overall, the utilization of MRI is growing faster than that of any other modality, according to Medicare Part B nonmanaged care data provided by the ACR. Medicare paid for 2,120,500 MRI scans in all settings in 1997 and, by 2003, paid for 5,135,163 scans (Table 2).
In 2003, MRI utilization grew 12.8% from the previous year. Right behind MRI was CT (with 15,890,984 scans), which grew 10.6%; nuclear medicine (with 9,872,691 scans), which grew 10%; and interventional radiology (with 7,452,385 scans), which grew 6.7%.
“A significant portion of that [growth] is because imaging is more relevant to patients than it was 5 years ago, and certainly more than it was 10 years ago. We can make a bigger acute impact on patients, for example, emergency department patients and trauma patients,” Borgstede says. “But also a huge reason for the growth is because of the inappropriate utilization of some of these modalities by nonradiologists, purely for revenue purposes.
“The huge rate of growth is by nonradiologists, and in that segment, the huge rate of growth is by those who have imaging in their office,” Borgstede says.
The growth in nuclear medicine, for instance, is seen as a reflection of the increased use of in-office imaging by cardiologists, according to Borgstede. In 2003, the number of nuclear procedures performed by nonradiologists (5,841,212 scans) grew by 15.6% from the previous year, compared to those by radiologists (4,031,479 scans), for a 2.8% growth rate from the year before.
Growth in other modalities has been relatively stable, according to the ACR, with ultrasound and mammography the low-growth modalities at 2.9% and 0.8%, respectively, in 2003.
“You look at where the revenue is and it’s in the cross-sectional imaging modalities, rather than in general radiology. The only area in radiology in that same time period where radiologists’ growth exceeded the growth of nonradiologists is in mammography, and that’s because there’s no money in it and we get sued,” Borgstede says. Nonradiologist-provided mammography paid by Medicare in 2003 was down dramatically, by 22.9%.
The 2003 Medicare data representing imaging by modality in all places of service showed radiologist imaging growing faster than nonradiologist imaging in all but two categories: nuclear (15.6% nonradiologist versus 2.8%) and interventional (8.7% nonradiologist versus 3.6%).
It should be noted that while it is the largest and most influential payor, Medicare accounted for 17.2% of health care expenditures in 2002, according to the Centers for Medicare and Medicaid Services (CMS), the Office of Actuary, and the National Health Statistics Group. Other federal and state government payors foot an additional 19% of the total bill. Private health insurance picks up 35.4% of the bill, patients pay 13.7% out of pocket, and other private payors fund the remaining 5% of the total health care costs.
THE GOVERNMENT’S STAKE
Information provided by CMS on the growth in Medicare expenditures between 1998 and 2003 also is based on Medicare Part B data, and the government’s heightened interest in imaging is a consequence of the escalating numbers.
CMS uses Berenson and Eggers Type of Service Code (BETOS), which was developed primarily for analyzing the growth in Medicare expenditures. According to CMS, the coding system covers all Healthcare Common Procedure Coding System (HCPCS) codes; assigns a HCPCS code to only one BETOS code; consists of readily understood clinical categories (as opposed to statistical or financial categories); consists of categories that permit objective assignment; is stable over time; and is relatively immune to minor changes in technology or practice patterns. The BETOS data includes billing by specialties other than nuclear medicine for imaging.
In 1998, CMS allowed 78,035,351 standard imaging—including chest, musculoskeletal, breast, contrast gastrointestinal, nuclear medicine, and otherprocedures, which accounted for approximately $2.2 billion in allowed charges. Of that, CMS paid approximately $1.66 billion.
That same year, CMS allowed 11,947,760 advanced imaging—including CT and MRI—procedures, for approximately $1.5 billion in allowed charges, of which CMS paid about $1.1 billion. CMS also allowed 22,528,496 echography—including eye, abdomen/pelvis, heart, carotid arteries, prostate and transrectal, and other—procedures, which combined for approximately $1.6 billion in allowed charges, of which CMS paid approximately $1.2 billion.
Also in 1998, there were 3,687,798 allowed imaging procedures that covered the heart, including cardiac catheterization. That translated into about $144.7 million in allowed charges, for which CMS paid about $115 million. There were also 2,498,349 allowed services for imaging procedures that fell into the “other” category, accounting for approximately $207 million, of which CMS paid about $164 million.
By 2003, those figures had all increased.
CMS allowed 108,830,006 standard imaging procedures in 2003, which accounted for about $3.8 billion in allowed charges. Of that, CMS paid approximately $3 billion. CMS allowed 22,062,048 advanced imaging procedures, for a total of approximately $3.2 billion in allowed charges, of which it paid approximately $2.5 million.
Also in 2003, there were 35,205,196 allowed echography services, for about $2.4 billion in allowed charges, of which CMS paid about $1.9 billion. There were also 5,032,304 imaging procedures that covered the heart, including cardiac catheterization, for a total of approximately $179 million, of which CMS paid approximately $142 million. Imaging procedures in the “other” category totaled 6,138,124, which translated into about $493 million, of which CMS paid approximately $391 million.
UTILIZATION RATES UP
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Figure 5. National unmanaged CT utilization. Annual procedures per 1,000 members. Source: National Imaging Associates. 
Figure 6. National unmanaged MR utilization. Annual procedures per 1,000 members. Source: National Imaging Associates. For perspective on the private payor sector, NIA provided utilization rates for CT and MRI from 2000 to 2003 on NIA-managed health plans, excluding Medicare and Medicare patients.
NIA analysis on unmanaged utilization showed that in 2003, there were 115 annual CT procedures per 1,000 members—a 34% increase from the year before when there were 86. In 2000, there were only 61 annual CT procedures per 1,000 members (Figure 5).
Similarly, but not as greatly, MRI utilization rates increased as well. In 2003, there were 76 MRI procedures per 1,000 members—up 19% from the year before when there were 64. In 2000, there were just 45 annual MRI procedures per 1,000 members (Figure 6). The 3-year CAGR for utilization was 23% for CT, and 19% for MRI.
The NIA data also showed that the unmanaged cost of imaging increased at about the same rate as utilization. In 2000, the national unmanaged CT cost was $2.10 per member per month (PMPM) (Figure 7), while the cost of MRI was $2.39 PMPM (Figure 8). Those numbers had jumped by 2003 to $4.09 PMPM for CT, and $4.46 PMPM for MRI.
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Figure 7. National unmanaged CT costs. Actual dollars per member per month. Source: National Imaging Associates. 
Figure 8. National unmanaged MR costs. Actual dollars per member per month. Source: National Imaging Associates. The 3-year CAGR for CT cost was 25%, and for MR cost was 23%—about the same CAGR as utilization.
NIA data on average unit cost showed a much slower growth rate. In 2000, the national average cost per CT procedure was $410, and for MRI was $636. By 2003, cost per CT procedure was up just slightly at $428, and up to $702 for MRI. Those figures actually dropped from the year before—by 5% for CT, and 3% for MRI (Figures 9 and 10).
“We saw an overall increase in cost, but there isn’t an increase in unit cost, therefore there must be increased utilization,” Dehn says. “The two elements of total cost are the unit cost and the volume. We know that unit cost has not increased and, in fact, has slightly decreased in CT and MRI over the last couple of years, so in order for the total cost to be increased, there must be increased utilization. The increased cost is due to utilization, not to improved payment, per procedure.”
When comparing utilization and PMPM rates for 2003 between unmanaged health plans and its managed plans, NIA found that the annual number of CT procedures per 1,000 among its managed plans was 69, compared to the 115 in unmanaged plans. For MRI utilization, there were 58 annual procedures per 1,000 in the NIA-managed health plans, compared to 76 in unmanaged plans.
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Figure 9. National average unit cost of CT. Annual cost per procedure. Source: National Imaging Associates. 
Figure 10. National average unit cost of MR. Annual cost per procedure. Source: National Imaging Associates. The PMPM rates reflected similar comparisons. CT cost in unmanaged health plans was $4.09 PMPM, and $3.12 PMPM for NIA-managed plans; while MR cost was $4.46 PMPM in the unmanaged plans, and $3.63 PMPM in those managed by NIA.
Looking at the driving factors behind the increase in PMPM rates, NIA found that the huge increase in imaging costs is also due more to utilization than the price of equipment.
In 2000, the PMPM cost for CT and MRI was $4.49: $2.10 for CT, and $2.39 for MRI. By 2003, the combined PMPM cost was up to $8.55: $4.09 for CT and $4.46 for MRI. Of that $4.06 increase between those years, increased utilization accounted for about $3.76 of the change in the PMPM cost, while the price of the units accounted for just 30 cents, according to NIA data.
CONCLUSION/PROJECTIONS
While the unknown will certainly play a major factor in the future of diagnostic imaging, some projections and trends have surfaced from the experts in the field, and through the data submitted.
The overall demand for imaging is expected to continue increasing as the population ages, and advancements in the technology are made.
Verispan’s market report stated that over the next 10 years, imaging volumes are expected to double, with outpatient and self-referral imaging leading the way.
Certain modalities, such as CT, MRI, and PET, are expected to show continued increase in use, while utilization within certain subspecialties will do the same.
Borgstede predicts that within the cardiovascular realm there will be a “huge rate of growth” in coronary artery angiography, a computed tomographic angiography of the heart blood vessels.
“They’ll do that noninvasively in the next few years, whereas a lot of that work is done invasively now; they have to put a catheter in the blood vessels and run all the risks of that catheter and the problems it could cause,” Borgstede says. “You’re going to see a lot of that go away because it will be done noninvasively: you just put a needle in a vein and inject some x-ray contrast and get the same information.”
Outside the cardiovascular realm, Borgstede says there will be continued growth in the molecular imaging technologies, “where you look more at the physiology of the body, rather than the anatomy. PET is a good example of that existing right now, and we’ll see a lot of growth in PET and a lot of growth in the PET-fusion technologies.”
While the technological advances will affect demand for imaging, they will also affect the total cost of imaging, something that CMS and the insurance carriers are already scrutinizing.
“All of that said, the carriers realize that they’re going to have to look a lot more carefully at the appropriateness of that growth of imaging, and is that growth replacing something else or is it just imaging that’s added on to the cost of health care right now,” Borgstede says, “and that’s what they’re trying to curb.”
“Diagnostic imaging, in general, has an exciting future,” Dehn says. “The use of this technology will continue to grow, probably at a more measured rate than it has been, but it will grow because of the introduction of new technology and the aging of the population.”
The challenges will be to meet the need for more radiologists, residents, and technologists to handle that increased demand, and also to curb inappropriate utilization of imaging.
Danielle Cohen is associate editor of Decisions in Axis Imaging News.
