'Bending the Cost Curve' by Tackling Overuse of Diagnostic Imaging

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, examines how some communities are using evidence-based  guidelines to rein in a conspicuous source of health care overspending. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

If you look closely in Aligning Forces for Quality communities, you can see how local laboratories are grappling with some of the most vexing delivery issues in health care. And there is probably no more vexing issue than overuse of health services—an issue that has figured prominently in the health care debate as Congress and the president wrestled with the question of how best to control costs.

Dartmouth researchers have estimated that as much as 30 percent of health care spending is for care that doesn’t improve people’s health—and don’t just take their word for it. Thompson Reuters came out with a new study last October attesting to the reasonableness of this estimate.

Diagnostic imaging, especially when it involves lower-back pain, is one case drawing the attention of overuse detectives. Lower-back pain is the fifth-most-common reason Americans see a doctor, and the common use of expensive imaging technology to diagnose it has become controversial. For more than a decade, guidelines for treating lower-back pain have recommend delaying imaging use for most patients because their backs typically get better, and their pain often subsides, within a month. A recent study published in Health Affairs took a look at the relationship between the supply of MRI machines, and their use for lower-back pain. Surprise, surprise: The researchers found “a clear relationship between MRI availability and MRI use for low back pain patients.”

The areas with the largest growth in MRI availability also had the fastest-growing Medicare bills for imaging. Little wonder. At $2 million a pop, if you buy an MRI machine you either use it maximally or take a bath on the investment.

The Puget Sound Health Alliance in Seattle is trying to work both sides of the equation—doctors and patients. The Community Checkup, the name of the Alliance’s public report, scores practices on how often imaging is deployed for new lower-back pain patients—the fewer the scans, the higher the score.

Its Web site explains to potentially antsy patients that they should wait at least six weeks before having an X-ray, MRI or CT scan, much less injections or surgery, unless there is a red flag. And it urges doctors to use an imaging checklist to talk with patients about whether X-rays, MRIs or CT scans are needed.

In Minnesota, a broader look at imaging is under way. To combat overuse, several insurers had set up prior-notification programs for imaging tests that left both doctors and patients frustrated. The Institute for Clinical Systems Improvement stepped into the breach, and working with six medical groups developed protocols based on national guidelines for use.

HealthPartners, the Bloomington, Minnesota-based health plan, estimates it saved almost $6 million in 2008—double what it saved the year before—by requiring its doctors to consult the guidelines. The consultation is easy: The guidelines simply pop up on the computer screen when doctors order tests. The health plan agreed to leave the ultimate decision to its 600 doctors—once they have consulted the guidelines.

Meanwhile, Minnesota Community Measurement is now developing composite measure to report on imaging use at the clinic level. And the way it describes its effort says everything about the new language of local reform: “Use the power of measurement and transparency to accelerate and promote appropriate use of high-technology diagnostic imaging.”

It’s an affordable solution that communities around the country can easily replicate to solve a glaring, national problem.