Prove It

It is time for the specialty to take a proactive role in evidence-based radiology If you have any doubt that imaging remains a target for further cuts, you will find an article within a section on imaging¹ in the November–December 2008 issue of Health Affairs enlightening—if not to your liking. The authors are analysts for the Medicare Payment Advisory Commission (MedPAC), and they are urging CMS to take a scalpel instead of a hatchet—as in the DRA—to the technical reimbursement for imaging. In the end, the cuts would be likely to exact a similarly painful pound of cure. You decide whether the fixes proposed by Winter and Ray (summarized on page 12) would render a more accurate payment methodology for practice expenses in this era of dwindling resources. My point is this: Payors, regulators, and, now, health policy experts perceive imaging as a problem, not a solution. What is radiology going to do about that? The price of medical technology is the theme of the Health Affairs issue in which the above article appeared. The first five articles are devoted to medical imaging and are required reading for anyone who cares about the specialty, how it is perceived, and what is required to demonstrate its usefulness. A group from Stanford University, Stanford, Calif, led by Baker, wrote the first article in the section. Using an equipment census and Medicare claims data, the team documents a direct relationship between the growth in the availability of high-tech imaging technology between 1995 and 2004 and the growth of the total number of procedures performed on Medicare beneficiaries. The team acknowledges the difficulty of determining whether the increased expenditures provided an equivalent benefit to society, but it does offer an approach to developing population-level evidence to begin to answer that question, using the diagnosis of abdominal aortic aneurysm as an example. Winter and Ray’s article appears second in the section; a third article is provided by Smith-Bindman (a University of California–San Francisco radiologist) and two researchers associated with the Group Health Cooperative, Seattle, a nonprofit, mixed-model integrated care system covering approximately 10% of Washington state residents through its own facilities. Studying the imaging patterns of 377,048 patients between 1997 and 2006, the authors calculate the number of imaging tests per year by anatomic area, modality, and year within age groups (including elderly enrollees), with a focus on repeat imaging and cost. The Group Health Cooperative data describe patterns in its managed care environment that are very similar to those growth patterns reported by MedPAC in the Medicare population, leading the authors to surmise that disincentives in the managed care model may not suffice to change the impulses toward increased use of imaging in the fee-for-service population. The fourth article in the section comes from a team of researchers led by Pearson at the Institute of Clinical and Economic Review at Massachusetts General Hospital’s Institute for Technology Assessment (ITA), Boston, which is directed by Gazelle (a radiologist who is also one of the article’s authors). Stating that new medical tests and treatments frequently become widely used prior to definitive evidence of their effectiveness, the authors assert that medical imaging is prime for clinical effectiveness studies. After describing the challenges of performing those analyses—and they are considerable—the authors describe a technique called decision-analytic modeling that can accommodate information gaps. The authors demonstrate the method in a case study to assess the comparative effectiveness of CT colonography. In the last of the five articles, a USA Today reporter offers an account of the CMS attempt to roll back reimbursement for cardiac CT angiography (CTA) and the successful efforts of cardiology and radiology to overturn that decision. Exhilarating and troubling Throughout this section, some familiar and new ideas emerge, both exhilarating and troubling. The work done by Smith-Bindman et al in this population is not their first, and we are likely to see the authors continue to mine this rich vein of information over time as they study the impact of coverage decisions and new technologies. They have laid the groundwork for collecting the evidence that is expected to become even more important to health care decision making. In the next article, Pearson et al address the problem of new technologies and procedures adding an extra layer of cost to the system by failing to replace older, less effective ones. The work done at ITA; at Johns Hopkins University, Baltimore; and at the Permanente Foundation, Oakland, Calif, to assess the comparative effectiveness of CT colonography represents a refreshing advance beyond the dithering about the challenges of obtaining outcomes data for radiology. Yes, it is difficult, but this team plots a path around the hurdles. The method described in this article requires the input of a great number of people to preserve the integrity of the results, but in the absence of the gold standard of large, prospective studies, it provides much-needed, well-vetted information on which to base decisions. Here’s the troubling part. In introducing the imaging section, the editor of Health Affairs draws parallels between the boom brought about by subprime mortgage lending and unbridled securitization and the rapid increases in medical imaging. Also disturbing is the reporter’s cynical summation of the struggle to retain reimbursement for cardiac CTA, which is characterized as a money grab by cardiology and radiology. Clearly, radiology has a perception problem. The specialty can reverse this perception by taking a proactive role in proving the value of imaging, but it can’t be done in the absence of the comparative effectiveness studies on new technologies and techniques that are required to address the issue of spiraling health care costs. A new era in medicine has dawned: Prove it or lose it.