From the mid-1990s to mid-2000s, imaging use for Medicare beneficiaries grew by over 6% annually. Both in the Medicare and commercially insured populations, this raised concerns, especially since much of the use appeared of marginal benefit. A study reported in the journal Health Affairs examines the more recent slowdown in imaging growth. (HA Article) The growth in imaging was attributed to new technologies and equipment, favorable reimbursements, patient demands and defensive medicine concerns. Policies to control the growth were implemented by payers, including reimbursement changes, benefit changes, such as higher cost-sharing by patients, utilization management, including prior authorization, and jaw-boning or frequent discussions with providers about inappropriate use. The researchers looked a Medicare claim sample and a relatively small sample of commercial insurance claims. For both payer types, by 2009 imaging growth had slowed to the low single-digits. Costs also decreased as competition and greater effective capacity among radiologists weakened their bargaining position.
Utilization has been controlled in the private insurance world by widespread adoption of prior authorization or computerized guidelines that have the same effect. While Congress in its usual wisdom has precluded CMS from using imaging benefit managers, there may be a spillover effect. Also in private insurance, the general presence of higher deductible plans, and some specific cost-sharing directed toward imaging may have contributed to the slowdown. Medicare did reduce its imaging reimbursements, which appears to have had an effect, particularly among free-standing or physician office-based centers, suggesting that these might have been sources of excessive, inappropriate use. Widespread recognition of the danger to patients from too-much radiation exposure has also helped limit use. Imaging studies for several conditions, for example, low back pain, have been flagged as particularly vulnerable to inappropriate use. It appears that the imaging slowdown has been more concentrated among these questionable uses, suggesting little harm to quality from the decrease in use. All-in-all, a success story in cost control.