Imaging growth leveling off due to reimbursement cuts, changes in ordering

The dramatic growth in imaging utilization experienced at the beginning of the millennium has mostly leveled off, according to a study published in Health Affairs. Major cuts to reimbursement and more careful ordering of noninvasive exams are the primary reasons for the decline in growth, but the authors said record levels of insured Americans and expansion of preventative screening should ensure imaging utilization remains stable in the near future.

Advances in advanced imaging such as MRI and CT, an aging population and increased patient knowledge about imaging were primary drivers of the record increase in imaging during the early 2000s. While it peaked in 2007, it prompted policymakers to examine incentives to curb imaging spending, according to the authors.

“Between 2000 and 2007 the use of imaging grew faster than the use of any other physician service in the United States,” wrote Levin et al. “In 2007, both the use of and the fees charged for imaging were higher in the United States than in any other developed country. Such facts raised concerns among policy makers, and between 2008 and 2013 a number of cuts in imaging reimbursement were instituted by the Centers for Medicare and Medicaid Services (CMS) and commercial payers in an attempt to control growth in the use of imaging.”

Researchers from Thomas Jefferson University Hospital in Philadelphia and the University of Wisconsin-Madison examined Medicare Part B databases from 2001 to 2014, measuring the number of discretionary non-invasive procedures. They excluded invasive procedures because those procedures are typically non-discretionary, they said.  

“The rate of utilization of all noninvasive diagnostic imaging increased steadily from 3,520 per 1,000 beneficiaries in 2001 to a peak of 4,422 in 2008 (an increase of 26 percent), representing a compound annual growth rate of 3.3 percent,” wrote Levin et al. “During the next three years, substantial declines occurred, but these were due primarily to code bundling.

They found similar usage curves for CT exams, echocardiography and nuclear procedures. MRI and noncardiac ultrasound didn’t experience any bundling, and therefore didn’t exhibit the precipitous decline in usage of bundled modalities, according to the authors. However, they were careful to note the declines continued past the point where bundling was the primary driver.

“Code bundling ... led to large apparent reductions in utilization rates of some modalities, but further reductions continued even after bundling had occurred,” they wrote. “In addition to these two factors, several others have likely contributed to the slowdown. These include greater attention by physicians to practice guidelines, concerns about exposing patients to radiation, and perhaps the [recession] December 2007 to June 2009.”

Additionally, the authors posited radiology benefits management companies are having a chilling effect, albeit without data-driven, peer-reviewed evidence.

“The companies create what has been called a sentinel or barrier effect: By requiring the ordering physician to get preauthorization before obtaining an advanced imaging examination of a patient, they create a barrier that may discourage the physician from ordering the imaging unless it is absolutely necessary,” wrote Levin et al.

Imaging utilization should remain stable if everything holds, according to the authors. The Affordable Care Act expanded coverage to include more Americans than ever before, and its essential health benefits mandate insurance plans cover certain low-cost preventative screening exams. Further, the pool of exams is growing: Low-dose lung cancer screening was recently approved by CMS and imaging advocates are pushing for mandated coverage of other exams such as virtual colonoscopy.

However, the forces exerting downward pressure on imaging still exist, namely benefits management companies, concerns about radiation, reimbursement cuts and bundling, the authors said. Alternative payment models could also dampen imaging utilization, as the programs have strong incentives to reduce spending and could curb use of diagnostic imaging among commercially insured Americans.

“In view of the complex interplay of these factors, predicting future use is difficult. However, we believe it most likely that, absent further major code bundling, imaging use rates and relative value units rates will remain at current levels for the foreseeable future without sustained or significant moves in either direction,” wrote Levin et al.