of U S West
Good or Useless, Medical Scans Cost the Same
New York Times
Published: March 1, 2009
When Gail Kislevitz
M.R.I. scan of her knee,
it came back blurry, “uninterpretable,” her orthopedist told
Juan Arredondo for The New York Times
Her insurer refused
to pay for another scan, but the doctor said he was sure she had
torn cartilage that stabilizes the knee and suggested an
operation to fix it. After the surgery, Ms. Kislevitz, 57, of Ridgewood, N.J.,
the cartilage had not been torn after all.
She had a long rehabilitation. And her insurer
paid for the operation. But her knee is no better.
More than 95 million high-tech scans are done
each year, and medical imaging, including CT, M.R.I. and PET
scans, has ballooned into a $100-billion-a-year industry in the United States, with
Medicare paying for $14
billion of that. But recent studies show that as many as 20
percent to 50 percent of the procedures should never have been
done because their results did not help diagnose ailments or
“The system is just
totally, totally broken,” said Dr. Vijay Rao, the chairwoman of
the radiology department at Thomas
Hospital, in Philadelphia.
Radiologists say a decent M.R.I. scan should
have clearly shown whether the cartilage in Ms. Kislevitz, a
meniscus, was torn. But
bad scans, medical experts say, are part of a growing problem
with medical imaging.
Many factors contribute. Insurers pay the same
for a scan done on a 10-year-old machine as one on the latest
model, though the differences in the images can be significant.
Insurers do not distinguish between scans that
are done poorly or done well or read by less- or more-qualified
doctors. Aside from
standards were established by a law that went into effect more
than a decade ago, the field is largely unregulated. And
increasingly, doctors refer patients to scanning centers they
own and profit from.
Ten years ago, the age of a scanner might not
have mattered so much. Now, said Dr. Gary Glazer, the chairman
of radiology at Stanford, technology has advanced so much that
the older scanner “is not the same machine.”
“I can tell you from my experience that
between those extremes the gap is huge,” Dr. Glazer said.
Yet, he added, many scanning machines used
today are a decade old.
Imaging centers can, if they choose, become
accredited by the American College of Radiology. That requires,
among other things, scanning a phantom, a device that simulates
a body part. Technologists must also be certified, and there are
standards for supervising physicians. And the scanners must be
regularly assessed to ensure they are properly functioning.
But many centers are not accredited, although
the percentage is not known because there is no national
registry of imaging centers.
Accrediting will be partly addressed by a
little noticed aspect of a wide-ranging Medicare law passed last
year. After it goes into effect in 2012, Medicare will pay only
for scans done at accredited centers. But imaging experts say
the law fixes only part of the problem. High-tech scanning is
complicated, and there is no consensus on objective measures to
ensure quality. Even with the new law, there is still little
assurance that scans will be appropriately ordered and
interpreted or that a scanner will be up to date.
Radiologists are struck by the wide variation
in the quality of scans, and they say there is little patients
can do other than to ask why the scan is necessary and, if it
is, to ask about accreditation, the credentials of the person
reading the scan and the age of the scanner.
“The studies I see coming from the outside
vary from marginal quality to very good quality,” said Dr. Chris
Beaulieu, a Stanford radiology professor. “Some of it is related
to equipment, and some is related to people with very good
equipment who don’t know how to use it right. And on the
interpretation side, there is also a very wide range of quality
or accuracy, in my opinion.”
Interpretation can be crucial, Dr. Beaulieu
added. “A good radiologist can sometimes accurately read scans
off of a lower-quality scanner,” he said. “I see that all the
time. A good radiologist and a lower-quality scan could be
better than a bad radiologist and a good scan.”
But logical as it might seem to pay more for a
better scan, there are problems. Health insurers have no way of
knowing whether scans are good, said Susan Pisano, a spokeswoman
for America’s Health Insurance Plans, a
trade group. Doctors, not insurers, receive the images and
reports, and all insurers can do is notice if there are frequent
requests to redo scans from a particular center.
“We see a lot of poor-quality scans,” said Dr.
Freddie Fu, the chairman of the orthopedic surgery department at
the University of Pittsburgh Medical Center. “I joke with the
patients: The insurance pays the same amount of money for the
scan. You get a hamburger somewhere else and a prime rib here
for the same price.”
Another concern is the growing number of
doctors who refer patients for imaging done by scanners they own
and profit from. Studies have found that up to 3.2 times as many
scans are ordered in such cases
In a recent report, the
Government Accountability Office
said nearly two-thirds of the money Medicare paid for imaging
was for scans in doctors’ offices. And, the report added,
doctors were receiving an ever larger part of their income from
providing scanning services. Not only were patients more likely
to have scans if a doctor did this, but the quality of some of
the scans was questioned.
“No comprehensive national standards exist for
services delivered in physician offices other than a requirement
that imaging services are to be provided under at least general
physician supervision,” the G.A.O. wrote.
Private health insurers were concerned, too.
“These are alarming patterns that have also been observed in the
private sector,” America’s
Health Insurance Plans wrote in a response to the G.A.O.
It is clear why
self-referral can be tempting, said Dr. Bruce Hillman, a
radiology professor at the
University of Virginia.
“It’s all profits,” Dr. Hillman said, adding
that a group of doctors can make an extra $500,000 to $1 million
a year simply by acquiring a scanner.
For now, radiologists said, patients and
insurers are often in a bind.
“If you are going to buy a car,” said Dr.
Beaulieu, the Stanford professor, “and you have a certain amount
of money to spend, you know what you are getting. You know what
you will get if you buy a Yugo or if you buy a
But with imaging, Dr. Beaulieu said, “you
don’t know: you might get a Yugo and you might get a BMW.”