Radiation and Reimbursement Concerns Dog Diagnostic Imaging

May 2010, Vol 1, No 1

Baltimore, MD—Although majortechnological advances continue in the diagnostic imaging arena, heightenedconcern over radiation overdoses,steep prices for equipment, andquestions about whether the newtechnologies will be reimbursed posechallenges for the field.

So said Jason Launders, MSc, amedical physicist and expert on computedtomography (CT) at the ECRIInstitute in Plymouth Meeting, Pa. Hepresented an overview of the state ofdiagnostic imaging at a session of theAssociation of Community CancerCenters’ (ACCC) 36th AnnualNational Meeting.

As diagnostic imaging technologyhas evolved, so too has the thinkingabout its place in patient care. “As wemove more and more into chronic diseasemanagement, diagnostic imagingis really becoming part of the wholecontinuum of care,” he said, includingscreening, initial diagnosis, initialtreatment strategy, therapy guidance,and subsequent treatment strategy.

But this expansion of the role ofdigital imaging over the past decadeshas necessarily led to cost increases.So how we’re paying for imaging“needs to be rethought,” Mr Launderssaid, because “as we all know, it’sunsustainable.”

Clinical and Cost Concerns

Lawsuits filed against Cedars-SinaiMedical Center and General Electric(GE) allege dangerous radiation overdosesof patients undergoing CTscans. “A class action lawsuit reallychanges everyone’s perspective,”pointed out Mr Launders. “This ishuge, almost like a turning point indiagnostic radiology, because I don’tthink there has been a major legal casebefore on too high a dose.”

GE, Siemens, Toshiba, and Philipsare all marketing equipment that lowersdosage by 50%—but at $500000,the equipment is expensive. “Thisis an area of some concern, becausemost patients are going to bedenied the low-dose technology,” MrLaunders argued.

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

In addition to radiation-loweringtechnological developments, therehave been a number of advances inCT scanning, including dual-energytechnology, which streamline theidentification of distinct anatomy. ButCT also faces growing concerns, withpayers pushing back on reimbursementbecause of cost.

According to Mr Launders, the highcost of CT means the equipment willincreasingly only be available at largerproviders. “I can see that most of theadvanced CT is only going to be availablein major centers in years to comebecause the cost of the technology—we’re now talking $2.5 million for atop-of-the-range CT scanner.”

Another major change that continuesto sweep the diagnostic imagingcommunity is the growth of digitaldevices. “Sixty percent of all mammographyunits in this country arenow digital,” said Mr Launders. “Thedigital mammography vendors aresaying that basically the market [fornondigital equipment] has disappeared.Very few devices are beingsold. Maybe that will start Pushingthe price down below the half millionmark, which is where they’re at now.”

Mr Launders said that althoughreimbursement for full field digitalmammography is now higher, patients must be seen more quickly,in 5- or 10-minute time slots. Andalthough digital mammography isonly of proven benefit to a subset ofwomen, it will nonetheless displacethe less costly film.

“You can’t provide digital mammographyand screen field mammographyin a workload,” he argued.“You can’t say beforehand, ‘You don’tmeet the criteria for digital, thereforewe’re going to use film.’ I think thedays of film are going to be over. Thehigh price of digital mammographyhas to come down; otherwise screeningmammography could be underthreat. It’s just going to become tooexpensive.”

Tomosynthesis is another developingmammography technology (notyet approved by the US Food andDrug Administration) that raisesmany of the same issues. Tomo synthesis provides a lower radiationdose, and is especially adept at seeingthrough overlying anatomy. “We’retalking about a DVD worth of dataper patient to be stored almostforever, every year,” Mr Laundersremarked. “The problem is there’s noreimbursement specific to it.” Clinicaltrials are ongoing; Mr Launders venturedthat “I think tomosynthesis willbe the future of mammography,because it will leave normal mammographyin the shadows.”

Mammogram interpretation maybe improved by computer-aideddetection (CAD), and the technologyis making rapid inroads, despite spottyreimbursements. “I think CAD willbecome invisible in the workplace,”said Mr Launders. “It will be builtinto the workstations [and] it will besuch a time saver for any radiologist.”

Positron emission tomography(PET) has also been bolstered by theaddition of time-of-flight information.Time of flight dramatically shortensthe time necessary for a PET scan,lowering its price—but is itself stillvery expensive. Nevertheless, MrLaunders suggested that “despite thehigh cost of the equipment, in a fewyears—or very soon—PET will be souseful in so many cases, especially inoncology, that when you can afford toadd a PET scanner, you will add timeof flight.” In addition, he noted thathybrid imaging “is on the rise,”including PET/CT and single photonemission computed tomography/CT.Magnetic resonance/PET has alsogenerated interest, but is still in veryearly stages of development.

Technological innovation is movingahead, but Mr Launders emphasizedthat both reimbursement and radiationdosing will likely be comingdown in the future.

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