Too Many Unnecessary MRIs and CT Scans?

Dr. Jon LaPook Looks Takes a Closer Look at Health Care Costs in the Users Guide to Health Care Reform

(CBS)  In our healt hcare system, scanning has become a prime example of technology's unintended consequences.

Molly Birnbaum was in a car accident that left her with multiple injuries. She fractured her pelvis, and hurt her knee.

"I broke the windshield with the back of my skull," she said.

She was given a total of nine CT scans during her week-long hospital stay. Doctors wanted even more, but her father, resisted. And he's a radiologist.

"At that point, I drew a line in the sand and said, absolutely not. There is no reason to do this anymore," said Dr. Steve Birnbaum.

CT scans use radiation similar to x-rays. MRI's use magnetic fields. Doctors order one or the other depending on what they're looking for. Both have revolutionized medical diagnosis.

Health Care Special Report
American College of Radiology
More about CT Scans
More about MRIs

The problem is a growing number of critics say tests like these are overused.

"We're definitely doing too many procedures," said Dr. Howard Forman, Professor of Radiology at Yale School of Medicine. "Every time we work in the ER or in the in-patient setting, after the fact, it becomes very obvious that certain studies either could've been avoided, delayed or not done at all."

Now there's also widespread concern over skyrocketing costs.

CT scans are big money makers, costing anywhere from $300 to $1,000. MRIs run as high as $1300.

The annual price tag for imaging? $100 billon. And experts estimate 35 percent of these tests aren't even necessary. That's potentially $35 billion wasted every year.

Forman says faster machines are helping to drive demand. "Fifteen years ago, the CT scanner would scan at a rate that could maybe get 3 or 4 patients through in a given hour. Now if you have able-bodied people moving the patient on and off the table, you could probably do a dozen or more patients in an hour."

In fact, from 2000 to 2007 the annual number of CT scans almost doubled to 69 million.

"It's too easy, too fast, too good. So it's much easier to order the test than it is to observe the patient, to monitor the patient," said Dr. Steve Birnbaum, "and avoid doing the CT scan."

Then there is the potential harm to patient safety. Experts are concerned that tests like CT scans - which use radiation - might increase the risk of cancer.

So how do you fix the overuse of CT scans and other high tech procedures?

The bills before Congress aim to reduce Medicare payment rates for scanning, increase funding for studies comparing different treatments to see what works best, and encourage conversion to electronic medical records. So tests aren't mistakenly duplicated and doctors have a database of results to learn from.

But some people aren't waiting for Washington's version of reform. Motivated by his daughter's experience, Dr. Birnbaum started a program flagging doctors if a patient seems to be receiving too many tests.

I'm very pleased with the results. I feel like I've done something in the fall of my career to really help patients," Dr. Birnbaum said.

Patients have to take responsibility, too. So often they demand instant answers and high tech tests.

But giving patients what they want is not necessarily what's best for them. Doctors need to spend time doing a careful history and physical before you can reassure somebody that their pain could be from something innocent. It's a lot quicker and easier to order a scan.

[JENNX1HX1]

I WORK IN THE HEALTHCARE INDUSTRY DOING AUTHORIZATIONS FOR CERTAIN DIAGNOSTIC PROCEDURES SUCH AS MRI'S CT'S AND SURGERIES....I WOULD LIKE TO KNOW SOMETHING....THE STUDY CONCLUDES THAT 35% OF TESTING IS NOT NECESSARY, IS THAT BEFORE OR AFTER THE TEST WAS PERFORMED? WHEN YOU ARE SICK AND NOT FEELING WELL AND THE DOCTOR WANTS TO RULE OUT AN ANEURYSM OR TUMOR OR FRACTURE,WOULD'NT IT BE EASIER TO HAVE AN IMAGING TEST RATHER THEN GO THROUGH OTHER VARIOUS TESTING FIRST? SOMETIMES AN MRI OR CT CAN FIND THINGS LIKE CANCER EARLY ENOUGH TO BE TREATED....THE PEOPLE DOING THESE CLINICAL STUDIES (LIKE NIA, CARE CORE AND MED SOLUTIONS) ARE NOT DOCTORS OR NURSES. THEY MAKE LIFE CHANGING DECISIONS...I THINK IF A DIAGNOSIS CAN BE MADE AS SOON AS POSSIBLE, IT WOULD BE IN THE PATIENTS BEST INTEREST, SO WHY NOT UTILIZE THESE TESTS, NOT ABUSE THEM.

[gramto8]

My late husband was the CT tech on duty one night while I was the unit secretary in the ER. One of our ER patients came in with a laceration to the front of his head, just inside the hairline. Our doc cleaned and sutured and was ready to discharge this patient, but decided to do a CT 'just in case.' My husband was totally pi...ed off. He always raised Cain (at me) when the ER did this. I got to see him come back to the ER with his tail between his legs when he asked our doc to come look at the pictures on the scope, even before he printed the films. This 'just in case' CT found that the board that had split the skin on this man's head had a nail in it. The nail had penetrated the skull and entered between the halves of the brain. Dirt and air were inside the skull. Hubby never again said anything about the 'just in case' studies.

The patient was shipped to a larger facility that had neurosurgery and was ok.

[smoknmirrors]

"...after the fact, it becomes very obvious" should be engraved on every tombstone. After nine CTs, he "drew a line in the sand;" why not after two or four or six? If a professional radiologist cannot call the precise number needed, what chance does a layman have? If doctors don't want lawyers interfering in the quality of care given their patients, stop your negligence, carelessness and reckless behaviors. The lawyers don't get involved until after the fact, and by then, it has become very obvious.

[sammy111537]

Katie..I'd like to see you do a follow up story on this and focus on the Federal Stark Regulations that allows doctors to have diagnostic imaging equipment within their office...and they get a cut off every one they do..yes, they make money off of the amount of tests they order...so why wouldn't they order as many tests as they'd get paid for.
Hospitals can't do this..no one gets a cut when you have an imaging test done at a hospital....hospitals don't abuse this..but independent physician clinics do.
When you come into the ER..many times the docs don't have time to wait to see how you do...they need to look inside quickly to save your life.
In many cases diagnostic imaging is much much better..and less costly than going into an OR to look inside.
It is fantastic technology...that we should be grateful for..but docs should not make money off the pain and suffering of others.
Physician self referral to service or places they have a financial interest in is wrong. When this is allowed to happen it is not always what's best for the patient but what puts money in the doctors pocket.

[govmess]

Obama recently approved a 2% salary increase for all federal employees effective January 1, 2010. Members of the executive, legislative and judicial branch are due for an automatic pay increase in January as well. All this on the backs of seniors who will not incur any COLA increases for several years.


For the first time in history, the Congress will not allow an increase in the social security COLA (cost of living adjustment).

In fact, The Henry J.. Kaiser Family Foundation predicts there may
not be any COLA for the next three years.

However, the per person monthly Medicare insurance premium will be increased from the 2009 premium of $96.40 to $104.20 in 2010 and to $120.20 for the year 2011.

I encourage all seniors not to vote for the incumbent senators/representatives in your state in upcoming elections. It is time WE changed Washington since Obama promised change but has not delivered on his promise!!

[maybury1851]

I happen to have to pleasure of working with Dr. Birnbaum as one of his team members who has developed the tracking database he speaks about. This is just a small amount of patient's, about 200, that we have so far....BUT for those 200 patient's it means everytime they come to the EW or the hospital for a CT scan, a red flag goes up. It gives the opportunity to have a dialogue with the patient's attending MD or the EW MD and possibly look at another test that doesn't use ionizing radiation to get the same answer. Maybe in some cases that is not possible and the patient needs that scan of the abdomen again to rule out a severe diverticulitis or abcess. This is saying that we should completely shutoff performing imaging tests on patients, our program gives us the opportunity to look at those we tracking and possibly offer them some other exam without the ionizing radiation. Take a look at the statistics on the web about how much radiation 1 CT scan of the abdomen is equal to. It is a considerable amount which is why especially for chronically ill patients that come into your EW all the time keep getting scanned over and over again. This is madness ! We just need to take a step back and look at all the wonderful imaging procedures we have before we just order the one that is the easiest and the fastest, CT Scans ! We are talking about Hiroshima levels of radiation in some cases for patients who are chronically ill. The problem is how can we get every hospital to participate in some sort of tracking mechanism for these patient's. Not an easy task !

Sincerely,

maybury1851...

[vonBismarc]

sorry for the duplication, i thought i only hit submit once.

[vonBismarc]

The article is a nice overview, unnecessary depends on the point of view.

Your ER doc is pressured by patients demanding immediate CT, ultrasound and MRI.

All your doctors are surrounded by lawyers and litigious patients waiting for any perceived opportunity to land a jackpot settlement, and if ordering a test helps protect them from losing their home and livelihood then perhaps they will. Notice the endless string of advertisements from lawyers recruiting patients?

Some doctors are trying to regain losses from repeated cuts in reimbursement and look to CT and MRI as a way to do so, they may own their own imaging equipment and self-refer patients to it. Many studies have been published documenting if there is profit involved, more tests will be ordered than if there is no profit (such as if patients are referred to a radiologist owned imaging center which cannot self-refer). The congressional budget office has recommended this 'in office exception loophole' in the anti-self referral laws be closed, and bill ammendments have been put forth to close the loopholes as recommended, but thus far the ammendments have always been denied.

What is to prevent this country from following the successes of other countries and utilizing expert health care review panels or dedicated health care courts? It works well in other countries with lower cost, fast decisions and a much larger percent of any settlement actually goes to the victim, rather than the one-third of the settlement which actually goes to the victim after years in an american court.

There are many, many ways to improve healthcare but it doesn't seem we're asking the right people.

[PAielloMD]

Self referral by non radiologists drives the cost of imaging skyward, say if your orthopedist owns an MRI, don't you think he will be a bit more liberal in having his back pain patients scanned? This is a major problem and it is one that the College of Radiology has been addressing, however, curbs on this practice have recently been voted down by those responsible for creating a new health care plan, giving in to pressure by large multispecialty groups, specifically physician owned hospitals. Why don't you run stories on this?

[sammy111537]

You are so very right..Physican self referral is wrong...doctors should not make money off the pain and suffering of their patients. Patients trust their doctors too much. Patients need to start taking more ownership in their healthcare and questioning more. Doctors take advantage of patients lack of knowledge..and their need to feel better.
Thanks for your comments

[MKirschMD]

Anyone not aware of the tsunami of CAT scans and other imaging tests in the medical profession must be in a coma. It's part of a culture of excessive medical care that drives up costs and harms patients. Many stakeholders are fighting to preserve the status quo. Lots of blame to go around. See www.MDWhistleblower.blogspot.com

[amy2121]

I have worked in emergency medicine for 15 years, and I agree that CT scans and MRI's are overused. I feel that the problem is two-fold. First, we are a "quick fix" society. Many people will present to the ED within minutes of the onset of symptoms (coughing, vomiting, diarrhea,etc.) instead of waiting it out at home or waiting to see their general practitioner. They will then research their symptoms and demand the tests/treatments that they feel are necessary and an immediate diagnosis and cure. Because of this, and because of the current medical malpractice climate in the US, providers are forced to practice defensive medicine.
I encourage patients to participate in and take responsibility for their own healthcare. I think patients should questions procedures, know the results and should understand how each medication they are on works. However, I would never dream of telling my mechanic how to fix my car or my electrician how to wire my house. Both of whom, by the way, make more per hour than I do.

[davisliumd]

Good doctors and medical students know that getting the right diagnosis is getting an accurate history and physical. CT and MRI are only tools to help assist us in getting the right answer. The public wrongly believes that they are the truth, when they are not. After all, can you "see" a migraine on CT or MRI? No. Wouldn't the patient be better off if we treated it? Certainly if there are "red" flags that worrisome, then of course the test should be ordered.

The FDA has never approved either modality as screening tests because they are not proven to save lives. The point that 35% of scans are unnecessary seems reasonable. How many of us have seen a doctor with symptoms and then been told that the CT / MRI is normal? What does that mean? You still had symptoms and paid to get an expensive test. Do you feel any better?

With more individuals paying to get healthcare, we all need to be mindful of when these tests are truly helpful and when they are not.

Davis Liu, MD
Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System
Website: www.davisliumd.com
Blog: www.davisliumd.blogspot.com
Twitter: davisliumd

[gramto8]

by davisliumd September 25, 2009 12:47 AM EDT
Good doctors and medical students know that getting the right diagnosis is getting an accurate history and physical. CT and MRI are only tools to help assist us in getting the right answer. The public wrongly believes that they are the truth, when they are not. After all, can you "see" a migraine on CT or MRI? No. Wouldn't the patient be better off if we treated it? Certainly if there are "red" flags that worrisome, then of course the test should be ordered.

The FDA has never approved either modality as screening tests because they are not proven to save lives. The point that 35% of scans are unnecessary seems reasonable. How many of us have seen a doctor with symptoms and then been told that the CT / MRI is normal? What does that mean? You still had symptoms and paid to get an expensive test. Do you feel any better?

With more individuals paying to get healthcare, we all need to be mindful of when these tests are truly helpful and when they are not.

Davis Liu, MD
_______________________________________

No, you can't see a migraine on CT or MRI. But you CAN see a mass, or a bleed, or a clot, or an aneurysm, or other problems that could also be causing the headache. Should not those more life-threatening things be ruled out first? To say that the tests should not be done because they may come back negative (normal) is like saying someone coming in with severe chest pain should only be given an antacid.

[jimbo7776]

#

*
o 12:07 am September 25, 2009
o I just diagnosed a huge brain tumor with a CYA head CT wrote:

I?m a primary care physician with 25 years of experience. A young woman came to me with a complaint of a severe headache and a nasopharyngeal mass. By the algorithm in the American Academy of Family Physicians journal, I should have tried some anti-migraine meds and so on. Instead, I got an immediate (well, almost immediate because she is uninsured and to scrape up the money) She has a huge brain-stem mass and we are now in the business of scrounging up money for, you guessed it, an MRI with and without contrast.

At the end of the day I and I hope every other physician will be guided by only one thing, our experience and the patient?s best interest. By the way, as I write this I am reading two ads at the bottom of the page for malpractice lawyers, one who promises to win you millions for your injury, but only if a specialist did it (lipkinhiggins.com). The other isn?t as choosy, Medicalmalpracticeclaims.net will evalate your claim online even if it was by a lowly GP.

James Boland, M.D. Denver, CO

#

*
o 12:12 am September 25, 2009
o Three more Lawyer's ads came up, from Dr. Jim wrote:

As I posted the above, three more ads from Med Mal lawyers came up. Any of you Docs want to hang your rear ends out in the breeze in this climate?
Dr. Jim

[charlesnelson]

For the last twenty years, I have experienced chronic back problems. Back in 2002, after my back went out for the sixth time, I went to medical and informed the Physicians Assistant that I may have a herniated disk. He didn't believe me, and told me I only had a bruised muscle. Wait and it will go away. After a month of barely able to walk and practically begging for an MRI, he finally gave in and put in the referral. When the test came back, guess what, I had a herniated disk.
Now for the rest of the story.
Those twenty years have been spent in the U.S. Navy. The moral of the story is it's not who you are but who's footing the bill. If your insurance company can pay for it, you?ll get test on demand. If you have public option (i.e. Tricare, VA) you aren?t getting squat. In my life, I have had two MRIs and ZERO CAT SCANS. A CAT SCAN is something I will never see.
For those whining about getting too many test, I DO NOT FEEL YOUR PAIN.

[gramto8]

Those twenty years have been spent in the U.S. Navy. The moral of the story is it's not who you are but who's footing the bill. If your insurance company can pay for it, you?ll get test on demand. If you have public option (i.e. Tricare, VA) you aren?t getting squat. In my life, I have had two MRIs and ZERO CAT SCANS. A CAT SCAN is something I will never see.
For those whining about getting too many test, I DO NOT FEEL YOUR PAIN.

by charlesnelson September 24, 2009 10:08 PM EDT
________________________________________________________

While I didn't personally put in the time necessary in order to qualify for Tricare, my late husband did... 21 years in the USAF. I have had both CTs and MRIs and have never had any problem with Tricare paying for them. I don't even have a copay for these, as they are diagnostic exams.

BTW, I also have herniated discs..... 5 of them in my lower back and 2 in my neck, all post trauma. There isn't a day that goes by that I am not in severe pain.

[blixen4444]

In CBS's graphic for this segment, it says "A Users Guide." Sorry to go all English teacher on you, CBS, but "USERS" should have an apostrophe: " A User's Guide." Singular possessive. Apostrophe before the S. Thank you!

[jackielou9]

my doctor thought a scan was unnessary, also. That is until my eye almost popped out of my head, due to a 7cm anyurism. Oops.If it,s needed do it. Don't wait 3 years and then say "oh,look at your fat file" , no look at your fat wallet.

[mikemac48]

Our youngest son would not be with us today if he had not had a CT scan in the ER and a follow-up MRI ordered by the Neurologist within a few days. At the time, he was 23 at the time. They discovered a brain tumor. A week later when they removed it, using precise surgical techniques aided by another MRI, they discovered the tumor had doubled in size. If they had used traditional "observation" diagnostic methods we would have paid for a funeral instead of surgery. Thank God for medical technology. Thank healthcare reform and insurance companies for rolling back use of technology. I agree with KCIOWA. Medical care is way too expensive.

[jordysnoni]

I wouldn't be alive today if the ER doc hadn't opted to go one step further and do a CT scan to reveal a ruptured appendix in 2004. The surgeon told me that if the ER doc had gone with his guess after a regular E-ray he would have sent me home with medication for kidney stones.

[realcocoa]

I don't feel I have ever had an unnecessary scan. When I broke my foot, the break did not show in a regular x-ray and it was only when they did a MRI did they find the break. I had been treated for tendonitis and was taking NSAIDS (which my stomach cannot tolerate)for no reason. Without the MRI I would have been subjected to a treatment that was not only unnecessary, but would have caused stomach problems.

[camarshall40]

While I respect the opinion of Dr. Steve Birnbaum I must diagree whole heartdly with his OPINION. I do realize to a degree that some diagnositic exams may be over utilized, however if my sister's physician had ordered a CT scan on her early enough she would not have died a herendous death from Kidney Cancer. She suffered 2 years from something I believe could have been prevented by doing proper diagnositic testing. Too often we put aside the fact that a simple Ultrasound, CT or even and MRI might catch a disease in its early stage and possibly prevent death by EARLY DETECTION therefore EARLY CURE. I am sure that with certain practioners, there may be over utilization of certain diagnositic testing. There may not be a very easy solution to this problem, but much more debate needs to be considered on this issue and it certainly should not be left up the the Insurance Carrier, the Government and physicians. Why don't you the give patient and opportunityy to way in on this. We pay for our health coverage an we deserve to be given the highest quality of care. Diagnostic testing is one of the best means for early detection of certain diseases. EARLY DETECTION, EARLY CURE. Isn't that what the Physicains and Insurance Carriers preach. Isn't it funny how the insurance carries don't want to approve or pay for certain diagnostic testings, so what is the alternative, pay millions of dollar for Chemotheraphy. Yes, because that is actually working. No one is every cured of cancer. It is never really gone, just in remission and much to our dismay, at some point it always seems to come back. It may take years, but it comes back. That you can bank on. Get the appropriate diagnostic testing in the appropriate time frame and you may get lucky and have a chance. Don't blame it on the high cost of these tests and over utilization. We all know that even if an MRI is charged out at $1,0000 dollars, that is certtainly not what the insurance carriers are paying. There is no concern in this country for the sick and dying, only for what the Insurance carrier are losing from their profits. How pathetic. There are accrediation committees in place to control the uprising of inadequate dianogtics testing facilities. We don't we focus some control of the actual policing of those policies. I will tell you why. Because those accrediating bodies have fees that you must pay to be considered for the particular accrediation. The more facilities they accredit, the more money they make. Let look at the entire picture and not scare the general public into thinking that they may be being overexposed to too much radiation or that on some level and MRI is not safe. Give me a break. Let finally start being concerned about the patients and their best needs and not the all mightly dollar.

[e-mail]

[tlairdmd]

I am truly sorry for your loss and yes, you are correct that the benefits of imaging are to detect early disease so that patients are cured. That is our goal. That should always take precedent and should never be superseded by considerations of cost or potential exposure to ionizing radiation.

Dr. Birnbaum is truly in your camp in that regards as are all the physicians, nurses, and technologists that provide imaging services. Dr. Birnbaum's comments and program are directed to when patient's may be over imaged for whatever reason, that imaging services must become a patient advocate and alert the ordering physician. Alternative tests can be considered where appropriate. All too often tests are ordered and then performed without question.

When tests are NOT ordered when appropriate is another problem entirely and one that I cannot defend with explanations or excuses.

EARLY DETECTION, EARLY CURE is exactly what we want to provide you, your family, and friends through high quality professional imaging services. I fully agree with you that our concern and attention should always be focused on the patient.

With my deepest regrets for your loss,

TLaird MD