Despite a Highmark program that takes aim at the heightened use of diagnostic imaging exams in Western Pennsylvania, the number of MRI machines in the region still rivals the number found in all of Canada.
Officials at Highmark Inc. say they are still happy with the program and that high utilization of exams will be addressed more directly in the program's next phase. The region's dominant health insurer next year will require pre-authorization of expensive tests including MRI, or magnetic resonance imaging.
For the past year, Highmark has asked imaging companies to meet certain quality standards in order to be included in its provider network. The process has resulted in just a slight decrease -- from 126 to 117 -- of MRI facilities in the network, some of which might operate more than one machine.
The 29 counties where Highmark operates in Western Pennsylvania are thought to be home to about 140 MRI machines, whereas the 32 million people living in Canada share 151 MRIs.
"From the very beginning, we did not see [this phase] as having a direct impact on cost because we never really assumed the numbers would drop -- we felt it would be possible for all the practitioners to meet or exceed our guidelines," said Dr. Carey Vinson, a vice president at Highmark. "We are planing to start pre-certification for MRI, CT and PET scans ... and that will have more direct impact on cost."
Scans let doctors look inside the body to observe everything from a growing cancer to brain functions, but the growing cost of diagnostic imaging is of concern nationally.
This year alone, the total tab could reach nearly $100 billion for all types of diagnostic imaging, including pricey scans that are best known by their abbreviations -- MRI, CAT (for computerized axial tomography) and PET (for positron emission tomography).
While most agree the machines have improved care, there have been costly side effects. Poorly conducted tests can require wasteful second exams, while other scans initiate an expensive search for a disease that's never found.
A federal advisory committee recommended in January that Medicare change the way it pays for such imaging tests with an eye toward saving money.
The Pennsylvania Health Care Cost Containment Council found that during 2003, about 120,000 MRIs were performed in Pennsylvania. The machines cost about $2 million each and $800,000 a year to operate, according to the council.
A typical PET costs about $2,000, an MRI costs about $700 to $900 and a CAT scan is about $500 to $700, according to National Imaging Associates, a New Jersey company working with Highmark.
Highmark worked with the imaging company from 1999 through 2001 on a pre-certification program that cut utilization of expensive scans by 15 percent to 20 percent, said Vinson. The insurer stopped the program on the belief that physicians would continue to follow guidelines on when tests should be ordered.
But that might have been naive, Vinson said, because utilization of the costly tests returned to previous levels within a matter of months.
"If mechanisms aren't put in place, the costs go up," he said. "And if the costs go up, the payers either reduce coverage for employees or just drop coverage. We have to do what we can to get costs under reasonable control."
Christopher Snowbeck can be reached at firstname.lastname@example.org or 412 263-2625.