Medical imaging promises transformative benefits for the practice of medicine. However, the technologies involved are already costly and getting more so, making it crucial to ensure that techniques such as computed tomography (CT) scans, magnetic resonance imaging (MRI), and positron emission tomography (PET) are used cost-effectively.
I interviewed E. James Potchen, the University Distinguished Professor and chairman of radiology at Michigan State University, and Bill Clarke, the president and CEO of Cellectar and former chief technology and medical officer at GE Healthcare, on the ways in which their interests intersect for the good of U.S. patients, with a focus on imaging technology. We excerpt the interview here. The full conversation was published this week online at Health Affairs [2-week free access].
John K. Iglehart: Is the United States anywhere near the point at which there’s too much capacity in the system to perform imaging services?
Bill Clarke: The question of capacity really hinges on the question of “capacity to do what?” There is certainly a lot of capacity to do imaging in the United States, and it is unequally distributed. Thus, one might argue that there is too much capacity for certain types of imaging in certain geographies. One approach some states have pursued is the use of certificate-of-need to blunt capacity growth. However, I think the more important issue from a health policy standpoint is this: “What is the demonstrable value of imaging in improving health care and in substituting imaging in diagnostic processes for other, less effective diagnostics or even in substituting imaging for certain interventions and therapies?” The short and unfortunate answer is that we really don’t know when imaging is the most effective next step in health care–and when we use too much or too little. We simply don’t know.
E. James Potchen: Wow! What a question. There is not too much capacity in people who have expertise at it. There is, no question, a lot of capacity–it is so profitable to buy a machine and put it in your office–that it becomes the dominant source of income for many physicians independent of their training. For example, ultrasound is being done widely by a lot of physicians, and it becomes a very important part of their revenue stream. Then there is the issue of physicians who self-refer their patients to facilities in which they have an ownership interest. It’s only human to expect people to want to use equipment they own or are invested in once it is installed in their office. When I was in general practice, I had an x-ray machine. And there’s no question: I would weigh in my mind whether to order an x-ray based upon whether I could do it on the machine in my office. That’s just the way people’s brains function.
Determining Appropriate Use
Iglehart: If you were the CMS administrator, where Medicare spending for radiology services has increased from $5.6 billion in 1998 to somewhere around $10.2 billion in 2003, how would you deal with this growth? Obviously Congress took a step in the Deficit Reduction Act by directing the CMS to reduce Medicare payments for selected imaging procedures. But how can the CMS determine what is appropriate use, what’s misuse, what’s overuse? How do you do that on a macro level?
Potchen: Appropriate use is very much tougher to come by. The proper indications for a procedure are much tougher. We have not measured the marginal utility of alternative indications for diagnostic procedures. But it isn’t hard to measure results. And you could set rules that improve use. The value added by any diagnostic procedure is “diminished uncertainty,” which can be measured as “information.” For example, the CMS could establish a rule that the observer has to be in the top 95 percent on the ROC [receiver operating curve] to get paid for reading the film. With radiology, you’ve got the image after the fact. You can actually see it and see what happened. With internal medicine, for example, you don’t know exactly all of the information that the physician had at the time of the interaction. But you do have all of the information the radiologist had. So you can measure what value the radiologist added to the information available for a particular patient. This could be made available through the widespread use of the electronic medical record. If an agency did that, I think it would have a dramatic impact on the inappropriate growth of imaging. Because you could control use, this is rational. This is reasonable. This is not a political survey for radiologists versus cardiologists. Whoever does the job well should be paid. The American College of Radiology has a project under way that will lead to greater documentation of which imaging studies provide the greatest value.
Clarke: From my standpoint, in industry, the larger imaging community has to start showing demonstrable clinical value. In GE Healthcare, we started doing prospective randomized clinical trials because we just think it’s the right thing to do. I don’t know if it’s fair to say that radiology or imaging as such has been more remiss than other medical specialties about showing the value of what they do. I do think it’s accurate to say that unless and until that’s done with imaging, the huge opportunities that the new biology and the new technology bring forward aren’t going to actually go into clinical practice because of concerns over the cost of these advancements. So, to facilitate what I think is going to be a transformation of medicine, we are simply going to have to do high-quality clinical trials to show the value.
For more, read the full interview.