As more patients sample from the alphabet soup of MRI, CAT and PET scans to diagnose ailments, insurers are alarmed at how the growing appetite is fattening health-care costs.

	Online Graphic: MRIs See a graphic that shows the use of MRIs by country in 2002.

A federal advisory committee recommended this month that Medicare change the way it pays for such imaging tests with an eye toward saving money. The effort follows that of many private insurers, including Highmark Blue Cross Blue Shield, that also are trying to rein in a sector of health-care spending that for some is growing faster than medication costs.

This year alone, the total tab could reach nearly $100 billion for all types of diagnostic imaging, whose acronyms stand for the more tongue-twisting names of magnetic resonance imaging, computerized axial tomography and positron emission tomography. While most agree that advancements in the technology 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.

In the background is the unanswered question of whether some regions have too many of these expensive machines. The 29 counties where Highmark operates in Western Pennsylvania are home to about 140 MRI machines, for example, while the 32 million people living in Canada share 151.

"We've got to get medical costs under control, and imaging has gotten way out of hand," acknowledged Dr. Mark Goodman, president of the Allegheny County Medical Society. But until the Highmark program is fully implemented, "We won't know if it saves money, cuts repeat imaging or if it's inconvenient for patients," he said.

While the costs to patients of scans vary, 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. 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.

Scans let doctors look inside the body to observe everything from a growing cancer to brain functions. Use of the machines has exploded partly because they can both improve care and save money, said Robin Strongin, spokeswoman for the National Electrical Manufacturers Association, a trade group that represents makers of the machines.

PET scans can eliminate as much as half the surgeries for terminally ill lung-cancer patients who won't benefit, Strongin said, while CAT scans can reduce unneeded surgeries and hospitalizations for patients suspected of appendicitis.

Angioplasty guided by MRI images costs a fraction of open heart surgeries, she said, and the procedures virtually eliminate hospital stays.

"Those are real savings experienced by real people as well as employers, providers, disability programs and government agencies," Strongin said.

But use also has grown in part because patients know the machines are out there and sometimes demand the latest technologies, some say. Doctors don't always have an incentive to say "no," considering the prospect of lawsuits as well as their own financial interests. One survey by National Imaging Associates found that more than 20 percent of imaging studies were performed by the physician who ordered the test.

Highmark pays more than $500 million per year for outpatient imaging, including MRI, CAT and PET scans. The company's payments for advanced imaging services have increased more than 20 percent annually in each of the last three years.

Highmark has begun asking doctors who perform tests outside hospitals to meet certain quality guidelines, and even then, doctors will need prior authorization from New Jersey-based Highmark before they can perform certain MRI, CAT and PET studies. While Highmark officials recognize the cost implications of imaging, they say they don't know whether the new program will actually reduce spending.

"We're just looking for the quality of the service to be appropriate," said Dr. Carey Vinson, Highmark's medical director for quality management. "But we want to make certain that we are not creating barriers for our patients to get these procedures."

The Medicare Payment Advisory Committee started looking at the issue more than a year ago, after noting that use of CAT and MRI scans for certain health problems was growing 15 percent to 20 percent per year. Total spending for imaging services in Medicare was $6.5 billion in 2000, the latest year available.

The advisory committee recommended that the U.S. Department of Health and Human Services set standards for all providers who bill Medicare for performing diagnostic imaging services. It also called on the government to reduce payments for single scans performed on contiguous body parts, which traditionally have been billed as two separate scans.

It used to be that abdominal and pelvic CAT scans, for example, had to be performed separately because machines were slower, said Vic Panza, a senior vice president with National Imaging Associates, which advised the Medicare advisory committee. Newer machines, however, can take images of both areas with one scan, Panza said, so his company sometimes recommends bundling and reducing the overall payment.

While the savings per bundled exam amounts to only $100 or so, Panza noted that abdominal and pelvic CAT scans were among the most widely used. "When you look at it on a national or regional level, it's millions of dollars," he said. "If [Medicare] does it, the private insurance carriers will follow suit."

Before making the recommendations, the advisory committee studied whether Medicare recipients who received more scans, including people in Pittsburgh, had better outcomes. They found that increased use of imaging services was not associated with improved survival for heart attack, colon cancer and hip fracture patients.

That's not surprising to Dr. Jack Wennberg, director of the Center for Evaluative Clinical Services at Dartmouth Medical School.

Scanners are used in the diagnosis of so many patients that it is difficult to measure when and where they provide clear health benefits, Wennberg said. But in general, increased spending on technology results in more tests being performed, not better outcomes for patients, he said. Indeed, some studies have shown just the opposite.

"People in high-cost, high-capacity regions have worse outcomes than those in low-cost, low-capacity regions," Wennberg said.

Yet high-technology regions are rushing to buy the latest technology: PET/CAT scanners, which combine the functions of both machines so that doctors can view the anatomy and function of tissues. Pennsylvania's U.S. senators helped secure $1 million in last November's omnibus spending bill for a new PET/CAT scanner at a Pittsburgh hospital.

"The decision to create additional resources is not an unadulterated good," Wennberg said. "While the constituents who receive the equipment might be happy, the costs will be born ultimately not by the hospitals but by the voters of Pennsylvania."

But the flip side of all this is that many Pennsylvanians can get scans more promptly than, say, Canadians.

The Ville Marie PET/CT Centre of Montreal is currently making headlines by operating one of the first privately operated machines in the country. People are willing to pay $2,500 Canadian dollars for a scan out of their pockets because otherwise they would have to wait months, said Steve Stein, director of operations with the company.

"The wait list for a PET scan at a hospital is three or four months," Stein said. "When you're told that, and you have cancer, that's a lifetime."