David C. Levin, MD, unleashed a powerful tool for radiology in the form of newly crunched data illustrating the role of self-referral in the rapid growth of high-tech imaging. Presenting on Recent Trends in Utilization of the Major Imaging Modalities at the RBMA 2007 Summit in St Louis, MO, Levin used data gathered from a variety of sources, including Medicare Part B data and the Blue Cross Blue Shield (BCBS) Medical Cost Reference Guide, to underscore the startling differences in the utilization growth rates of high tech imaging performed by radiologists and that performed by self-referring physicians.

“If you are looking at growth in private office imaging, the increases are occurring primarily among the nonradiologists and that is something you have to keep in mind when you go out and talk to the payors and the hospital administrators,” Levin told attendees.

Medicare Part B data from David C. Levin, MD, Thomas Jefferson University imaging utilization workgroup.

Levin provided attendees with a bit of background: Back in 2004, the BCBS Medical Cost Reference Guide projected the total imaging pie to amount to 475 million examinations by 2008, a number that may prove to be conservative. Around that time, government officials began to note that imaging was distinguishing itself as the growth leader when the Medicare program’s cumulative growth in physician services was assessed, with a 45% growth rate between 1999 and 2003. By 2005, imaging accounted for 14% of Medicare spending.

Although radiology continues to produce the lion’s share of examinations performed on high tech imaging modalities—MRI, CT, and PET—radiology’s utilization growth rates have been extremely modest when compared to the growth rates of self-referring physicians. (It should be noted that Dr. Levin’s Medicare data is from 1999 to 2004 and does not include the growth in self referral that has during the past three years.)

Using Medicare Part B data (2000 – 2004), Levin offered the following facts about CT utilization:

• Utilization of CT in the Medicare population grew from slightly more than 300/1000 beneficiaries in 2000 to about 473/1000, a 49% growth rate, in 2004.
• Radiologist utilization of CT in the Medicare population grew 53% between 2000 and 2004 (from under 300/1000 to about 450/1000.
• Nonradiologist utilization of CT in the Medicare population grew 92% between 2000 and 2004 (from a little more than 6/1000 to just under 12/1000)
• Independent diagnostic testing facility (IDTF) share of the Medicare CT market grew 338% between 2000 and 2004 (from less than 2/1000 to less than 8/1000)

Using the same Medicare data, Levin revealed the following about MRI examination trends:

• Overall utilization of MRI in the Medicare population grew from under 100/1000 in 2000 to more than 150 in 2004
• Radiologist utilization of MRI examinations in the Medicare population grew by 68% between 2000 and 2004 (from about 80/1000 to just under 140/1000)
• Nonradiologist utilization of MRI examinations in the Medicare population grew 119% between 2000 and 2004 (from less than 4/1000 to nearly 8/1000)
• IDTF share of the Medicare MRI market grew 175% from 2000 to 2004 (from about 5/1000 to just less than 14/1000.

Levin said the same data showed that nonradiologists were not involved in PET imaging through 2004:

• Radiologist utilization of PET in the Medicare population grew by 1240% between 2000 and 2004 (from less than 1/1000 to almost 8/1000
• IDTF market share of PET grew from 0 to nearly 1/1000 between 2000 and 2004.

Growth in In-Office MRI Between 200 and 2005
Levin dug into the Medicare Physician Supplier Procedure Summary Master Files to explore who is billing for in-office MRI imaging, and shared the growth rates with the audience:

Radiologists: 80%
Orthopedists: 408%
Neurologists: 170%
PCPs: 250%
Internal Medicine subspecialists (excluding cardiologists): 2100%

Because PCPs are not known to purchase MRI scanners, Levin speculated that they possibly are be participating in lease arrangements with scanner owners.

Levin concluded his talk with a review of the utilization patterns in extremity angiography, primarily lower extremity. Levin pointed out that radiologist usage of diagnostic catheter angiography plummeted by 31% between 2000 and 2004, while their use of MRA and CTA during the same period increased 835%. The growth of total extremity angiography, including all modalities (DCA, CTA, and MRA) was relatively flat for radiologists at 3% growth. “This is a substitution of a noninvasive cheaper technology for a more expensive invasive technology. That’s a healthy trend,” he said.

By contrast, DCA by surgeons and cardiologists soared 70% between 2000 and 2004, as did their use of total extremity angiography, including DCA, MRA, and CTA (34% increase for cardiologists/176% increase for surgeons). “Now that we have these noninvasive less expensive technologies like MRA and CTA how do cardiologists and vascular surgeons justify their progressive increasing use of catheter angiography?” asked Levin. “The answer is, you can’t justify it. This is outrageous when you think about it.”