Radiation and Reimbursement Concerns Dog Diagnostic Imaging

May 2010, Vol 1, No 1 - ACCC Conference

Baltimore, MD—Although major technological advances continue in the diagnostic imaging arena, heightened concern over radiation overdoses, steep prices for equipment, and questions about whether the new technologies will be reimbursed pose challenges for the field.

Jason Launders, MScSo said Jason Launders, MSc, a medical physicist and expert on computed tomography (CT) at the ECRI Institute in Plymouth Meeting, Pa. He presented an overview of the state of diagnostic imaging at a session of the Association of Community Cancer Centers’ (ACCC) 36th Annual National Meeting.

As diagnostic imaging technology has evolved, so too has the thinking about its place in patient care. “As we move more and more into chronic disease management, diagnostic imaging is really becoming part of the whole continuum of care,” he said, including screening, initial diagnosis, initial treatment strategy, therapy guidance, and subsequent treatment strategy. 

But this expansion of the role of digital imaging over the past decades has necessarily led to cost increases. So how we’re paying for imaging “needs to be rethought,” Mr Launders said, because “as we all know, it’s unsustainable.”

Clinical and Cost Concerns

Lawsuits filed against Cedars-Sinai Medical Center and General Electric (GE) allege dangerous radiation overdoses of patients undergoing CT scans. “A class action lawsuit really changes everyone’s perspective,” pointed out Mr Launders. “This is huge, almost like a turning point in diagnostic radiology, because I don’t think there has been a major legal case before on too high a dose.” 

GE, Siemens, Toshiba, and Philips are all marketing equipment that lowers dosage by 50%—but at $500000, the equipment is expensive. “This is an area of some concern, because most patients are going to be denied the low-dose technology,” Mr Launders argued.

“Slices really aren’t the question,” said Mr Launders. “The real question today is how low can you get that dose?”

In addition to radiation-lowering technological developments, there have been a number of advances in CT scanning, including dual-energy technology, which streamline the identification of distinct anatomy. But CT also faces growing concerns, with payers pushing back on reimbursement because of cost.

According to Mr Launders, the high cost of CT means the equipment will increasingly only be available at larger providers. “I can see that most of the advanced CT is only going to be available in major centers in years to come because the cost of the technology—we’re now talking $2.5 million for a top-of-the-range CT scanner.”

Another major change that continues to sweep the diagnostic imaging community is the growth of digital devices. “Sixty percent of all mammography units in this country are now digital,” said Mr Launders. “The digital mammography vendors are saying that basically the market [for nondigital equipment] has disappeared. Very few devices are being sold. Maybe that will start Pushing the price down below the half million mark, which is where they’re at now.”

Mr Launders said that although reimbursement for full field digital mammography is now higher, patients must be seen more quickly, in 5- or 10-minute time slots. And although digital mammography is only of proven benefit to a subset of women, it will nonetheless displace the less costly film.

“You can’t provide digital mammography and screen field mammography in a workload,” he argued. “You can’t say beforehand, ‘You don’t meet the criteria for digital, therefore we’re going to use film.’ I think the days of film are going to be over. The high price of digital mammography has to come down; otherwise screening mammography could be under threat. It’s just going to become too expensive.”

Tomosynthesis is another developing mammography technology (not yet approved by the US Food and Drug Administration) that raises many of the same issues. Tomo synthesis provides a lower radiation dose, and is especially adept at seeing through overlying anatomy. “We’re talking about a DVD worth of data per patient to be stored almost forever, every year,” Mr Launders remarked. “The problem is there’s no reimbursement specific to it.” Clinical trials are ongoing; Mr Launders ventured that “I think tomosynthesis will be the future of mammography, because it will leave normal mammography in the shadows.”

Mammogram interpretation may be improved by computer-aided detection (CAD), and the technology is making rapid inroads, despite spotty reimbursements. “I think CAD will become invisible in the workplace,” said Mr Launders. “It will be built into the workstations [and] it will be such a time saver for any radiologist.”

Positron emission tomography (PET) has also been bolstered by the addition of time-of-flight information. Time of flight dramatically shortens the time necessary for a PET scan, lowering its price—but is itself still very expensive. Nevertheless, Mr Launders suggested that “despite the high cost of the equipment, in a few years—or very soon—PET will be so useful in so many cases, especially in oncology, that when you can afford to add a PET scanner, you will add time of flight.” In addition, he noted that hybrid imaging “is on the rise,” including PET/CT and single photon emission computed tomography/CT. Magnetic resonance/PET has also generated interest, but is still in very early stages of development.

Technological innovation is moving ahead, but Mr Launders emphasized that both reimbursement and radiation dosing will likely be coming down in the future.