Despite high growth rates observed in the early 2000s, advanced imaging utilization slowed considerably between 2006 and 2013, falling from $13.8 billion to $9.6 billion.
This decline in spending was due to both Medicare and commercial payers reviving once-eliminated restrictions. It is believed that the additional scrutiny of these procedures will continue to drive spending downward. Below are three of the most common containment measures used today:
Preauthorization is the most common containment measure. Under this process, doctors who order diagnostic imaging must contact a call center staffed with "reviewers." Based on the company's clinical protocol, these reviewers can either accept or deny requests.
Aggressive first-tier preauthorization plans, aimed at significantly impacting bottom lines, will deny at least one in five requests. Second tier ― moderate management ― deny one in 10 requests, and third tier, or cost containment "lite," will approve all requests.
Privileging restricts payment to providers with specialized training or to outside centers that specialize in radiology. For an outside facility to qualify for MRI or CT payment under privileging the facility must offer five imaging modalities, such as ultrasound, nuclear medicine, PET and mammography.
Some healthcare companies are trying to reduce the proliferation of machines through Certificate-of-Need (CON) laws. CON laws were initially enacted to prevent price inflation and protect hospitals from nonhospital competitors that also provide imaging services. However, in the process of safeguarding hospitals from their nonhospital competitors the laws also restricted the imaging services available to patients. There are presently Certificate-of-Need (CON) laws in 21 states that restrict the acquisition of imaging equipment.
In today's healthcare landscape, diagnostic imaging has become as commonplace as the tongue depressor. As insurers work to contain costs, this situation will continue to evolve.