Medical imaging a heavy contributor to Medicare waste, study finds

Medical imaging accounts for 4 of the 5 most prevalent low-value healthcare services among Medicare beneficiaries, according to new research published Friday. 

“Imaging for plantar fasciitis” was the most frequently delivered unnecessary exam, occurring nearly 84 times per 100 Medicare beneficiaries, experts write in JAMA Health Forum. Low-value imaging for headache (76/100), syncope (72/100) and lower back pain (39/100) also made the top five, with vertebroplasty and kyphoplasty at No. 4. 

The findings are based on a review representing claims from over 3.7 million Medicare beneficiaries treated between 2018 and 2020. Altogether, the payment program spent approximately $484 million on 15 different low-value imaging services, a figure that balloons to nearly $584 million when factoring in beneficiaries’ out-of-pocket costs.  

“Findings of this cross-sectional study highlight that reforms aimed at reducing spending for low-value services are feasible to achieve billions in savings without compromising patient health,” David D. Kim, PhD, and A. Mark Fendrick, MD, with the universities of Chicago and Michigan, respectively, wrote Aug. 1. 

The authors used a 5% random sample of fee-for-service Medicare claims to calculate their figures, pinpointing the presence of 47 low-value services. Items were identified as low value based on recommendations from the Choosing Wisely campaign and the U.S. Preventive Services Task force, including screenings, diagnostic tests, imaging and procedures. For instance, providers should not perform brain CT or MRI for non-post-traumatic, non-thunderclap headaches because it provides no clinical benefit, according to the American College of Radiology. 

Based on the analysis, Medicare each year spends about $3.6 billion, across 2.6 million cases, on the 47 low-value services. Patients paid another $800 million out of pocket annually for these unnecessary tests and treatments, the study found. And the top 20 services accounted for about 95% of total annual spending on low-value care. 

While imaging featured heavily on the list of most prevalent services, it accounted for a smaller overall dollar figure, due to the low reimbursement amount for some of these exams. Chronic obstructive pulmonary disease screening was the biggest ticket item, representing over $1 billion in unnecessary Medicare spending.  Electrocardiogram for cardiac screening was the imaging service representing the largest dollar amount at No. 9 on the list, accounting for less than $92 million in Medicare spending (or nearly $115 million with out-of-pocket costs). Other imaging services leading the list included head imaging for headache at No. 12, costing Medicare $67 million (nearly $84 million with OOP); carotid imaging for asymptomatic patients at No. 13, costing $61 million ($70 million); and head imaging for syncope at No. 14, costing $60 million ($77 million). 

These estimates are considered conservative, since the authors didn’t assess cascading costs for other services after the initial low-value exams. One previous study showed that every $1 spent on unnecessary PSA screening resulted in $6 spent on related care afterward in Medicare Advantage. The authors suggested implementing “careful prior authorization” to deter the use of unnecessary medical imaging. 

“All of the estimated savings may not be fully realized due to gaming claims-based rules (e.g., head imaging for syncope gets coded as head imaging for a fall or trauma) or substitution of other services that might be pursued instead of low-value services,” the authors concluded. “Nevertheless, reducing payments for low-value services could lead to substantial savings to create headroom to pay for high-value services while preserving the health of the Medicare population.”