National trends in advanced outpatient diagnostic imaging utilization: an analysis of the medical expenditure panel survey, 2000-2009.

BACKGROUND: Concerns have been raised regarding growth in advanced diagnostic imaging use. This study evaluated trends in national outpatient MRI/CT utilization rates during 2000-2009 and factors associated with utilization. METHODS: This retrospective database analysis used data on all respondents in the nationally representative U.S. Medical Expenditure Panel Survey (MEPS) during 2000-2009. Visits involving advanced diagnostic imaging were identified based on self-reported use of MRI or CT tests at emergency departments, office-based medical providers, and outpatient departments. The imaging utilization rate was defined as the number of outpatient visits with MRI/CT per 1,000 person-years. Results were weighted to create nationally representative estimates at the person-year level for each year and the pooled 10-year period. A multivariate logistic regression was estimated to identify predictors of imaging use. RESULTS: A total of 319,246 person-years were included in the analysis. MRI/CT utilization rates increased from 64.3 to 109.1 per 1,000 person years from 2000 to 2009, with older persons, females and Medicare enrollees having higher rates of use. Growth in imaging slowed in recent years; the average annual decline in the imaging growth rate was larger than that for all outpatient services (4.7% vs. 0.9%). The percentage of respondents with MRI/CT use (6.7% during 2000-2009) also increased at a slower rate in later years and declined during 2007-2009. The average number of MRI/CT visits among imaging users was steady at about 1.5 visits during 2000-2009. Age, female gender, White race, HMO participation, and all payer types (vs. uninsured) were significant predictors of imaging use. Compared to 2005, years 2000-2003 were associated with a significantly lower likelihood of imaging use, while years 2004-2009 were not significantly associated, suggesting a slow-down in later years. CONCLUSIONS: Growth in advanced imaging utilization appears to have slowed in recent years, a finding of potential interest to policy-makers and payers.

Comparative analysis of Medicare spending for medical imaging: sustained dramatic slowdown compared with other services.

OBJECTIVE: The purpose of this study was to assess trends in Medicare spending growth for medical imaging relative to other services and the Deficit Reduction Act (DRA). MATERIALS AND METHODS: We calculated per-beneficiary Part B Medicare medical imaging expenditures for three-digit Berenson-Eggers Type of Service (BETOS) categories using Physician Supplier Procedure Summary Master Files for 32 million beneficiaries from 2000 to 2011. We adjusted BETOS categories to address changes in coding and payment policy and excluded categories with 2011 aggregate spending less than $500 million. We computed and ranked compound annual growth rates over three periods: pre-DRA (2000-2005), DRA transition period (2005-2007), and post-DRA (2007-2011). RESULTS: Forty-four modified BETOS categories fulfilled the inclusion criteria. Between 2000 and 2006, Medicare outlays for nonimaging services grew by 6.8% versus 12.0% for imaging services. In the ensuing 5 years, annual growth in spending for nonimaging continued at 3.6% versus a decline of 3.5% for imaging. Spending growth for all services during the pre-DRA, DRA, and post-DRA periods were 7.8%, 3.8%, and 2.9 compared with 15.0%, -3.4%, and -2.2% for advanced imaging services. Advanced imaging was among the fastest growing categories of Medicare services in the early 2000s but was in the bottom 2% of spending categories in 2011. Between 2007 and 2011, the fastest growing service categories were evaluation and management services with other specialists (29.1%), nursing home visits (11.2%), anesthesia (9.1%), and other ambulatory procedures (9.0%). CONCLUSION: Slowing volume growth and massive Medicare payment cuts have left medical imaging near the bottom of all service categories contributing to growth in Medicare spending.

Willingness to pay for diagnostic technologies: a review of the contingent valuation literature.

OBJECTIVES: To understand how people value information from diagnostic technologies, we reviewed and analyzed published willingness-to-pay (WTP) studies on the topic. METHODS: We searched PubMed for English-language articles related to WTP for diagnostic laboratory tests published from 1985 through 2011. We characterized methodological differences across studies, examined individual- and technology-level factors associated with WTP, and summarized median WTP values across different diagnostic tests. RESULTS: We identified 66 relevant WTP studies. Half focused on oncology, while others analyzed infectious diseases (n = 11, 16.1%) and obstetric or gynecological conditions (n = 8, 11.7%), among others. Most laboratory tests included in studies were biological samples/genetic testing (n = 44, 61.1%) or imaging tests (n = 23, 31.9%). Approximately one third of the analyses (n = 20, 30.3%) used discrete-choice questions to elicit WTP values. Higher income, education, disease severity, perceived disease risk, family history, and more accurate tests were in general associated with higher WTP values for diagnostic information. Of the 44 studies with median WTP values available, most reported a median WTP value below $100. The median WTP value for colon or colorectal cancer screening ranged from below $100 to over $1000. CONCLUSIONS: The contingent valuation literature in diagnostics has grown rapidly, and suggests that many respondents place considerable value on diagnostic information. There exists, however, great variation in studies with respect to the type of technologies and diseases assessed, respondent characteristics, and study methodology. The perceived value of diagnostic technologies is also influenced by the study design and elicitation methods.

The sharp slowdown in growth of medical imaging: an early analysis suggests combination of policies was the cause.

The growth in the use of advanced imaging for Medicare beneficiaries decelerated in 2006 and 2007, ending a decade of growth that had exceeded 6 percent annually. The slowdown raises three questions. Did the slowdown in growth of imaging under Medicare persist and extend to the non-Medicare insured? What factors caused the slowdown? Was the slowdown good or bad for patients? Using claims file data and interviews with health care professionals, we found that the growth of imaging use among both Medicare beneficiaries and the non-Medicare insured slowed to 1-3 percent per year through 2009. One by-product of this deceleration in imaging growth was a weaker market for radiologists, who until recently could demand top salaries. The expansion of prior authorization, increased cost sharing, and other policies appear to have contributed to the slowdown. A meaningful fraction of the reduction in use involved imaging studies previously identified as having unproven medical value. What has occurred in the imaging field suggests incentive-based cost control measures can be a useful complement to comparative effectiveness research when a procedure's ultimate clinical benefit is uncertain.

A framework for assessing the value of diagnostic imaging in the era of comparative effectiveness research.

In June 2009, the Federal Coordinating Council for Comparative Effectiveness Research submitted a report to the President and Congress in which the Council described the purpose of comparative effectiveness research (CER) as developing evidence-based information for interventions and determining under what circumstances an intervention is effective (1). With the enactment of the Patient Protection and Affordable Care Act, a Patient-centered Outcomes Research Institute (PCORI) was established to assist decision makers in making evidence-based health decisions through synthesis and dissemination of clinical CER of health interventions (2). Its founding has underscored a heightened need for health policy makers to consider the impact of health care technologies on final outcomes of interest--for example, functional status, quality of life, disability, major clinical events, and mortality (3-5).

Radiology benefit managers: cost saving or cost shifting?

PURPOSE: Radiology benefit managers (RBMs) are widely used by private payers to manage the utilization of imaging services through prior authorization, and they have been proposed for use in the Medicare program. The authors created a framework for evaluating the impact of key parameters on the ability of RBMs to lower costs and used decision-analytic modeling to simulate the net impact of RBMs on health care costs under uncertainty from a societal perspective. METHODS: The authors' model of a "typical" RBM's prior authorization process used base-case values for each parameter (utilization rate and costs for MR, CT, and PET imaging; physician and staff time spent in complying with RBM requirements; approval and denial rates; and RBM fees to insurers) drawn from published data and the experience of a large, academic institution. Different values were tested in the sensitivity analysis to account for uncertainty in the parameter estimates. A hypothetical 100,000-member private health plan with an imaging utilization rate of 135 per 1,000 members per year was assumed. RESULTS: Under the authors' base-case scenario, in which RBMs have no net impact on costs, they estimated that 28% ($182,066/$640,263) of the projected RBM-related savings are shifted to providers. RBMs were cost saving in 45% of simulations, and 95% of simulations fell between a cost decrease of $397,880 and a cost increase of $341,991. The probability of an initial approval by the RBM, the RBM's fee, and the imaging utilization rate and associated charges had the largest influence on the results. CONCLUSIONS: The authors' models shows that RBMs shift significant costs to physicians and that their net impact on societal costs depends on parameters for which supporting data are incomplete.

Understanding the medical and nonmedical value of diagnostic testing.

OBJECTIVES: To develop a framework for defining the potential value of diagnostic testing, and discuss its implications for the health-care delivery system. METHODS: We reviewed the conceptual and empirical literature related to the valuing of diagnostic tests, and used this information to create a framework for characterizing their value. We then made inferences about the impact of this framework on health insurance coverage, health technology assessment, physician-patient relationships, and public health policy. RESULTS: Three dimensions can effectively classify the potential value created by diagnostic tests: 1) medical value (impact on treatment decisions); 2) planning value (affect on patients' ability to make better life decisions); and 3) psychic value (how test information affects patients' sense of self). This comprehensive framework for valuing diagnostics suggests that existing health technology assessments may systematically under- or overvalue diagnostics, leading to potentially incorrect conclusions about cost-effectiveness. Further, failure to account for all value dimensions may lead to distorted payments under a value-based health-care system. CONCLUSIONS: The potential value created by medical diagnostics incorporates medical value as well as value associated with well-being and planning. Consideration of all three dimensions has important implications for technology assessment and value-based payment.

Trends in healthcare utilization among older Americans with colorectal cancer: a retrospective database analysis.

BACKGROUND: Analyses of utilization trends (cost drivers) allow us to understand changes in colorectal cancer (CRC) costs over time, better predict future costs, identify changes in the use of specific types of care (eg, hospice), and provide inputs for cost-effectiveness models. This retrospective cohort study evaluated healthcare resource use among US Medicare beneficiaries diagnosed with CRC between 1992 and 2002. METHODS: Cohorts included patients aged 66+ newly diagnosed with adenocarcinoma of the colon (n = 52,371) or rectum (n = 18,619) between 1992 and 2002 and matched patients from the general Medicare population, followed until death or December 31, 2005. Demographic and clinical characteristics were evaluated by cancer subsite. Resource use, including the percentage that used each type of resource, number of hospitalizations, and number of hospital and skilled nursing facility days, was evaluated by stage and subsite. The number of office, outpatient, and inpatient visits per person-year was calculated for each cohort, and was described by year of service, subsite, and treatment phase. Hospice use rates in the last year of life were calculated by year of service, stage, and subsite for CRC patients who died of CRC. RESULTS: CRC patients (mean age: 77.3 years; 44.9% male) used more resources than controls in every category (P < .001), with the largest differences seen in hospital days and home health use. Most resource use (except hospice) remained relatively steady over time. The initial phase was the most resource intense in terms of office and outpatient visits. Hospice use among patients who died of CRC increased from 20.0% in 1992 to 70.5% in 2004, and age-related differences appear to have evened out in later years. CONCLUSION: Use of hospice care among CRC decedents increased substantially over the study period, while other resource use remained generally steady. Our findings may be useful for understanding CRC cost drivers, tracking trends, and forecasting resource needs for CRC patients in the future.

The association between hospital outcomes and diagnostic imaging: early findings.

PURPOSE: Resource use variation across the United States prompts the important question of whether "more is better" when it comes to health care services. The aim of this study was to examine correlations between the use of 4 common imaging modalities (CT, MR, ultrasound, and radiography) and in-hospital mortality and costs. METHODS: Using clinical and utilization data for 1.1 million inpatient admissions at 102 US hospitals during 2007, two hospital-specific, risk-adjusted imaging utilization measures for each modality were constructed that controlled for patients' demographic and clinical characteristics and for hospital characteristics were constructed for each modality. First, logistic regression was used to estimate the odds that each type of imaging service would be provided during an admission. Second, the mean number of services per admission was estimated using output from a two-part ordinary least squares model. Hospital-specific, risk-adjusted inpatient mortality and total hospital costs were also computed, and correlations between the imaging utilization measures and the mortality and cost outcome measures were then assessed using Pearson's correlation coefficients (P < .05). The correlation analyses were weighted by hospital admission volume. RESULTS: Hospitals in which patients were more likely to receive imaging services during admissions had lower mortality, even after controlling for potential confounders. Correlation coefficients were -0.2 for all modalities (P = .02-.05). Weaker correlations existed between mean services per admission and mortality, while costs trended insignificantly higher with greater utilization. CONCLUSIONS: This study lays the foundation for further exploration of the relationship between resource use and the clinical and economic outcomes associated with imaging utilization.

Cost-effectiveness of magnetic resonance guided focused ultrasound for the treatment of uterine fibroids.

OBJECTIVES: The aim of this study is to evaluate the cost-effectiveness of Magnetic Resonance Guided Focused Ultrasound (MRgFUS) compared with alternative treatments for uterine fibroids in the United States. METHODS: We used techniques of decision analysis and data from secondary sources to develop and estimate an economic model of the management of uterine fibroids among premenopausal women. Patients in the model receive treatment with MRgFUS, uterine artery embolization (UAE), abdominal myomectomy, hysterectomy, or pharmacotherapy. The model predicts total costs (including subsequent procedures) and quality-adjusted life-years (QALYs) for each treatment strategy over a lifetime horizon, discounted at 3 percent, from a societal perspective. Data on treatment efficacy and safety were obtained from published and unpublished studies. Costs (2005 US$) were obtained from an analysis of a large administrative database and other secondary sources. Lost productivity costs were included in the base-case analysis, but excluded in a sensitivity analysis. RESULTS: UAE was associated with the most QALYs (17.39), followed by MRgFUS (17.36), myomectomy (17.31), hysterectomy (17.18), and pharmacotherapy (16.70). Pharmacotherapy was the least costly strategy ($9,200 per patient), followed by hysterectomy ($19,800), MRgFUS ($27,300), UAE ($28,900), and myomectomy ($35,100). Incremental cost-effectiveness ratios (cost per QALY gained) were $21,800 for hysterectomy, $41,400 for MRgFUS, and $54,200 for UAE; myomectomy was more costly and less effective than both MRgFUS and UAE. Results were sensitive to MRgFUS recurrence rates, MRgFUS procedure costs, and assumptions about quality of life following hysterectomy. CONCLUSIONS: Our findings suggest that MRgFUS is in the range of currently accepted criteria for cost-effectiveness, along with hysterectomy and UAE.

Resource use and cost of diagnostic workup of women with suspected breast cancer.

We estimated resource use and costs associated with a diagnostic workup for suspected breast cancer among Medicare beneficiaries. Using Medicare claims data, we found that the average cost of a diagnostic workup for suspected breast cancer--whether it eventuated in a breast cancer diagnosis or not--was $361, and did not vary by presentation (signs/symptoms or screening mammography). In the aggregate, we estimate that Medicare spends approximately $679 million annually on diagnostic workups for women with suspected breast cancer, and that false positive mammograms result in diagnostic costs of approximately $250 million.

Lifetime and treatment-phase costs associated with colorectal cancer: evidence from SEER-Medicare data.

BACKGROUND & AIMS: This study provides detailed estimates of lifetime and phase-specific colorectal cancer (CRC) treatment costs. METHODS: This retrospective cohort study included patients aged 66 years and older, newly diagnosed with CRC in a Surveillance Epidemiology and End Results (SEER) registry (1996-2002), matched 1:1 (by age, sex, and geographic region) to patients without cancer from a 5% sample of Medicare beneficiaries. The Kaplan-Meier sample average estimator was used to estimate observed 10-year costs, which then were extrapolated to 25 years. A secondary analysis computed costs on a per-survival-year basis to adjust for differences in mortality by stage and age. Costs were expressed in 2006 US$, with future costs discounted 3% per year. RESULTS: Our sample included 56,838 CRC patients (41,256 colon cancer [CC] patients and 15,582 rectal cancer [RC] patients; mean +/- SD age, 77.7 +/- 7.1 y; 55% women; and 86% white). Lifetime excess costs were $29,500 for CC and $26,500 for RC patients. Per survival year, stage IV CRC patients incurred $31,000 in excess costs compared with $3000 for stage 0 patients. CRC patients incurred excess costs of $33,500 in the initial phase, $4500/y in the continuing phase, and $14,500 in the terminal phase. RC patients had lower costs than CC patients in the initial phase, but higher costs in both the continuing and terminal phases. CONCLUSIONS: Excess costs associated with CRC are striking and vary considerably by treatment phase, cancer subsite, and stage at diagnosis. Interventions aimed at earlier diagnosis and prevention have the potential to reduce cancer-related health care costs.

Uterine fibroid treatment patterns in a population of insured women.

OBJECTIVE: To profile women treated for uterine leiomyomas who are covered by commercial insurance from large, self-insured employers in the United States. DESIGN: Retrospective, observational study. SETTING: Inpatient, outpatient, and prescription drug experience of women with employer-sponsored insurance in the United States. PATIENT(S): Data were obtained from the MarketScan insurance databases for 1999 through 2004 and weighted to represent the population of women with employer-sponsored health insurance in the United States. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The proportion of women with clinically significant leiomyomas was determined in each year, based on inpatient and outpatient medical claims with diagnostic codes indicating leiomyoma. Patient characteristics, comorbidities, prescription drug treatments, and surgical interventions were profiled in 2004. RESULT(S): Approximately 1% of women had clinically significant leiomyomas. Comorbid genital or menstrual conditions were common and much more prevalent for women with leiomyomas. Of women with leiomyomas, 18.4% received no surgical or prescription drug treatment, whereas 16.8% received only surgical treatment, 22.4% received only prescription drug treatment, and 42.4% received both. Hysterectomy was the most common surgical treatment. CONCLUSION(S): Generalizing from this sample, we estimate that 443,445 women with employer-sponsored insurance in the United States had clinically significant leiomyomas in 2004.

What are the total costs of surgical treatment for uterine fibroids?

OBJECTIVE: To investigate the direct and indirect costs of uterine fibroid (UF) surgery. METHODS: Data were obtained from the MarketScan Commercial Claims and Encounters databases for 1999-2004. Our sample included 22,860 women with insurance coverage who were treated surgically for UF and 14,214 women who were treated nonsurgically for UF. Medical care costs and missed workdays were divided into baseline (1 year prior to surgery) and postoperative (1 year after surgery) periods. For a subsample of women, we calculated average annual costs 3 years before and after their surgery. RESULTS: Of patients electing surgery, 85.9% underwent hysterectomy, 7.6% myomectomy, 4.9% endometrial ablation, and 1.6% uterine artery embolization (UAE). Women undergoing UAE incurred the highest medical care costs in the operative year ($16,430 unadjusted, $20,634 adjusted for confounders), followed by hysterectomy ($15,180 unadjusted, $17,390 adjusted), myomectomy ($14,726 unadjusted, $18,674 adjusted), and endometrial ablation ($12,096 unadjusted, $13,019 adjusted). Women treated nonsurgically incurred costs of $7,460 unadjusted and $8,257 adjusted during the year after they were diagnosed with UF. Three years after surgery, patients treated with hysterectomy had the lowest annual costs. Missed workdays in the year after surgery were high, resulting in significant losses to employers in the magnitude of $6,670-$25,229, depending on treatment, values assigned to missed workdays, and whether the analyses adjusted for confounders. CONCLUSIONS: UF surgical treatment costs were high. Absenteeism and disability were important components of the cost burden of UF treatment for women, their employers, and the healthcare system.

The direct and indirect cost burden of clinically significant and symptomatic uterine fibroids.

OBJECTIVE: To estimate direct medical costs and indirect (productivity related) for women age 25 to 54 who had clinically significant and symptomatic uterine fibroids (UF). METHODS: We compared direct medical expenditures among 30,659 women who had clinically significant and symptomatic UF to expenditures among an equal number of matched controls who did not. We also compared indirect costs for a sub-sample of 910 employed women in each group. Regression analyses controlled for demographic and casemix factors. RESULTS: Mean 12-month direct medical costs for women with UF were $11,720 versus $3257 for controls, and mean 12-month indirect costs for women with UF were $11,752 versus $8083 for controls. Differences were statistically significant (P<0.0001). CONCLUSIONS: UF is a costly disorder and merits thought as interventions are considered to improve women's health and productivity.

Agreement between insurance claim and self-reported hospital and emergency room utilization data among persons with diabetes.

As part of a retrospective evaluation of a diabetes management program, the agreement between self-reported and insurance claim data on hospitalization and emergency room utilization was examined. Data agreement on hospitalization or emergency room visits between the two collection modes was evaluated through the use of simple agreement proportions and the kappa agreement statistic. A total of 1,230 participant responses were studied. The proportions of patients with hospitalization or emergency room visits were indistinguishable between the self-reported and medical claims data, and kappa statistics also indicated good-to-excellent agreement between data sets. The percentages of participants whose self-reported hospitalization and emergency room utilization exactly matched data derived from insurance claims were high (89.1% and 87.2%, respectively). Furthermore, the kappa statistics of agreement for the number of hospitalizations (0.6366) and emergency room visits (0.5390) indicate good agreement between self-reported and insurance claim data. The results of this study suggest either self-reported or insurance claims data can be used to evaluate the impact of health care interventions on hospital or emergency room utilization.