The rise in low-value imaging services—and how to reduce them

The U.S. has one of the most inefficient health systems in the world, with waste spending representing $750 billion of annual expenditures. Overtreatment accounts for some $200 billion, including a significant amount of unnecessary diagnostic imaging, according to a study published in the Journal of the American Medical Association.

Researchers took a sample of 2011-2013 UnitedHealthcare commercial claims for patients aged 18-64 years—totaling nearly 1.5 million individuals—and found that 7.8 percent received low-value services costing $33 million. Diagnostic imaging accounted for two of the top three treatments and nearly $7 million in spending.

Part of this is due to the huge increase in imaging over the past decade; between 2000 and 2007, use of imaging grew more quickly than any other service in the Medicare population, according to New England Medicine study. Reports like these have provoked investigations into low-value services.

The American Board of Internal Medicine Foundation worked with Consumer Reports to create a comprehensive list of unnecessary services, called the Choose Wisely Initiative. Drawing on large organizations such as the American College of Radiology and the American Academy of Family Physicians, nine medical associations chose treatments under their umbrella they deemed overused.

The resulting list of 45 treatments was announced in 2012 and pointed the finger squarely at imaging; more than half the list was diagnostic imaging exams. This is partly due to the advances in high-tech imaging equipment and its rapid proliferation throughout the industry, according to a American College of Physicians study.

“Advanced imaging equipment is installed in non-radiologist physician offices with some frequency and incentivizes these physicians to order abundant imaging tests to generate revenues,” wrote Vijay M. Rao, MD, et al. “Numerous studies over the past four decades have shown that self-referral invariably leads to higher use of imaging studies.”

Other large drivers of low-value service are the patients themselves. Most radiologists are familiar with patients requesting the latest in MR or CT after hearing about it from the media, friends and family, or even direct-to-consumer advertising. In addition, some tests are duplicated when a patient switches imaging sites or physicians, often because physicians have more trust in their own staff and equipment.

However, simple strategies adopted at the organizational level can help reduce overuse of diagnostic imaging. The American College of Radiology publishes an exhaustive list of appropriateness criteria, outlining relevant situations for specific exams. Incorporating resources like these into a radiologist’s daily routine—or simply introducing a non-radiologist physician to the list—can ensure imaging only happens as needed. In fact, some of these criteria are being integrated into computerized image ordering tools or benefit management programs.

Another slightly uncomfortable reality is a conflict of interest for every radiologist; the more imaging studies they preform, the more money they make.

“Radiologists should recommend additional imaging tests in their reports only when such additional testing is truly warranted. Too often, such casual recommendations about additional testing ties the hands of treating physicians and compels them to order further tests largely for defensive purposes,” wrote Rao et al.

In short, while the overutilization of low-value services is pervasive and expensive, simple and cost-effective strategies can reduce waste at the organizational level.