Sophisticated medical imaging is often cited as a leading driver of
health care costs. The increasing availability of techniques such as computed
tomography (CT), magnetic resonance imaging (MRI) and positron emission
tomography (PET), while aiding large number of patients, has also made the
treatment of disease and injury more expensive.
But as a new study co-authored by an MIT
economist observes, the growth of such cutting-edge medical imaging procedures
has slowed, suggesting that the diffusion of technology does not necessarily
lead to steadily increasing health care costs.
Instead, in the paper — “The Sharp Slowdown
In Growth Of Medical Imaging,” published this week in the August issue of the
journal Health Affairs — MIT economist Frank Levy and David W. Lee of GE
Healthcare suggest that a more selective use of high-end imaging is evolving
within the medical profession. This transformation is likely due to the
changing structure of insurance plans — especially the exercise of “prior
authorization,” the preapproval of certain treatments — as well as increased
concerns about the side effects of some imaging methods.
In turn, the findings suggest the need for a
nuanced understanding of the ways new technologies are incorporated into
medical practices over time — and of the relationship medical practices may
have to America’s fiscal situation.
“There’s no chance of ever getting the federal
deficit under control unless you can get health care costs under control,” says
Levy, a professor of urban economics in MIT’s Department of Urban Studies and
Planning. “But just to say technology is the driver, I think, is an easy way
out in terms of looking at the system.”
‘More
consideration’ of avoiding advanced imaging
The study by Levy and Lee builds on a 2010
Health Affairs paper by researchers at Thomas Jefferson University in
Philadelphia, who showed that after a rapid expansion in advanced medical
imaging, use of the technologies for Medicare recipients slowed in 2006 and
2007. Combining statistics for the government-backed Medicare system with data
from commercial insurers, Levy and Lee found that the trend extended at least
through 2009, and included patients enrolled in employer-sponsored health
plans, too.
Specifically, from 2000 through 2005, use of
CT scans among Medicare recipients (who are age 55 and older) grew by an annual
average of 14.3 percent, but that growth then declined every year after 2005, falling
to 7.1 percent in 2006 and 1.4 percent in 2009. Among Medicare enrollees, the
number of MRI exams increased by 14 percent from 2000 through 2005, but only
grew by 2.6 percent during the 2006 to 2009 period. And among a sample of 1.1
million non-elderly, commercially insured people in the study, the number of CT
scans performed on patients increased by 20.4 percent from 2002 to 2006, but by
just 3.1 percent from 2006 to 2009.
Using data from commercial insurers, Levy and
Lee, who is the general manager and head of health economics and reimbursement
at GE Healthcare, found that about half of the slowdown in MRI imaging involved
diagnoses of back, elbow and knee problems; essentially, doctors in those cases
appear to have opted for more conservative treatments to deal with ailments
that may only have been temporary injuries.
“Eight or nine years ago, the atmosphere [in
clinics and hospitals] was that if you’re not doing a scan, you’re not doing
modern medicine,” Levy says. “Now … there’s more consideration about whether
patients really need a scan or not. And in a lot of situations, that’s totally
appropriate.” The study also included interviews with doctors and benefits
managers to shed light on their decision-making practices.
One external factor affecting these treatment
decisions, Levy and Lee believe, may have been increased concerns about the
exposure to radiation involved in CT and PET tests. (MRIs do not involve the
same exposure to radiation.)
But the main reason growth slowed, the paper
suggests, is because of new insurance arrangements. These include larger
deductibles: The percentage of employees with a deductible of at least $1,000
grew from 10 percent in 2006 to 27 percent in 2010. Levy and Lee also cite the
increased use of “prior authorization” in insurance, which requires general
practitioners to conform to guidelines about the appropriateness of medical
treatments, such as exams and medication. Congress’ 2005 Deficit Reduction Act,
which reduced reimbursements for imaging performed in physicians’ offices, also
played a role. This may have reduced the incentives for doctors to acquire,
say, MRI machines for their own offices and then use them frequently to pay for
that initial investment.
The new “fiscal pressure on the system,” Levy
says, likely drove doctors to take a more moderate approach to imaging that
would not have occurred “if money were not a problem.”
Changing
the norms
As Levy notes, the study implies “no general
conclusion that we’re always overutilizing technology in every area.”
Yet other researchers who have seen the study
think the apparent connection Levy and Lee have found between insurance changes
and the altered use of imaging may have parallels in other fields of medicine.
“I find [the paper] very plausible,” says
Richard Frank, a professor of health economics at Harvard Medical School. “It’s
instructive for thinking more broadly about the kinds of things we need to do
to bring down health care costs.”
To be sure, Frank notes, different medical
disciplines “vary a tremendous amount.” However, he adds, “There are a lot of
norms in medical practice, which adapt to the financial and management systems
we have in place. And when we start to change those systems … it starts to
change the [medical] norms in important ways.”
Jonathan Skinner, a health care economist at
Dartmouth College, calls the paper “a landmark study,” and suggests a pair of
further research questions deriving from the study: one, whether the slowdown
in imaging led to a slowdown in the follow-up procedures typically related to
imaging, and two, whether some kinds of health care providers were quicker to
than others to scale back on unnecessary imaging.
For his part, Levy’s ongoing research on
health care will continue to focus on imaging: He is working with a group of
physicians at a major Boston hospital as they develop treatment guidelines to
avoid excessive use of imaging technology.
Levy’s work has been supported by an
investigator award from the Robert Wood Johnson Foundation.
Provided
by Massachusetts
Institute of Technology
This story is republished courtesy of MIT
News (web.mit.edu/newsoffice/), a popular site that covers news
about MIT research, innovation and teaching.
No comments:
Post a Comment