Ordering of US Hospital Imaging Tests Remains the Same with or Without Knowing the Cost

In a study designed to determine if physicians who are informed of the precise cost of expensive medical testing such as magnetic resonance imaging (MRI) in advance would order less of them, US investigators found out that the answer is no.

In a report published online January 2, 2013, in the Journal of the American College of Radiology, the researchers discovered that revealing the costs of MRI scans and other imaging modalities up front had no impact on the number of tests doctors ordered for their hospitalized patients.

“Cost alone does not seem to be the determining factor in deciding to go ahead with an expensive radiographic test,” said the study’s senior author, Daniel J. Brotman, MD, an associate professor of medicine at the Johns Hopkins University School of Medicine (Baltimore, MD, USA), and director of the hospitalist program at The Johns Hopkins Hospital. “There is definitely an over-ordering of tests in this country, and we can make better decisions about whether our patients truly need each test we order for them. But when it comes to big-ticket tests like MRI, it appears the doctors have already decided they need to know the information, regardless of the cost of the test.”

Earlier studies suggest that much of the expense of medical imaging, laboratory tests, and prescription drugs is unknown or concealed from providers and patients at the time of ordering, leaving financial considerations chiefly out of the healthcare decision-making process and likely push up costs, Dr. Brotman noted.

Other studies have shown that clinicians ordered fewer laboratory tests in some cases when they were given the price right away. However, Dr. Brotman noted that imaging tests appear to be “a different animal.” There are built-in disincentives to ordering many major tests if they are not necessary, such as the potential danger of radiation used in some, Dr. Brotman noted. In addition to making physicians more sensitive to the costliness of unnecessary testing, he noted, they need to learn how to explain to patients why they may not need them.

For the study, Dr. Brotman and his colleagues identified the 10 imaging tests most frequently ordered for patients at The Johns Hopkins Hospital. Dividing the tests into two groups, they made sure prices were attached to one group over a six-month period, from November 2009 to May 2010. Dr. Brotman and his colleagues kept out the pricing data for the other group over the same time period. Prices are not typically shared with physicians or patients in most medical settings.

When the researchers compared the ordering rates to the rates from a six-month period a year earlier, when no costs were displayed at all, they found no considerably difference in ordering patterns. Dr. Brotman noted that he might have been worried if there was a large decrease in ordering expensive tests, as there are many instances when the expensive test is justified. For example, when a patient appears to have had a sub-acute stroke, an MRI is often justified “regardless of cost,” he said. “When a key diagnosis is needed in imaging, there are limited options for comparison shopping.”

That is not to say there are not times when physicians need to look more closely at whether too many imaging tests are being ordered, according to Dr. Brotman. Patients in a hospital intensive care unit (ICU), for instance, who are on a ventilator and not able to tell physicians how they are feeling may not need a daily chest X-ray to scan for potential problems. Dr. Brotman reported that there is evidence that outcomes are not compromised if radiographs are ordered only when the patient’s condition appears to be deteriorating. MRI scans are also ordered too frequently for lower back pain, according to Dr. Brotman.

“For too long, there has not been enough attention paid to the bottom line in healthcare,” Brotman said. This is not about allocating care to hold down costs, he noted, but about choosing tests a little more wisely. “There are financial consequences for the choices we make, and for too long we haven’t considered them,” he said.

Although price transparency did not influence the way physicians ordered imaging tests in his study, according to Dr. Brotman, financial considerations may play a role in other circumstances if tied to clinical evidence. For example, when clinical programs began to compare the amount of blood products used by surgeons, those who were using far more than their peers (and with similar patient outcomes) took notice and decreased their dependence on transfusions, which are not only costly but also carry risks. If a provider is ordering four times as many computed tomography (CT) scans as a colleague whose patients have similar outcomes, it could change the decision-making calculus for the better, according to Dr. Brotman.

“Cost transparency must be part of the solution to solving fiscal challenges in medicine,” Dr. Brotman concluded. “Providers have no idea how much they’re spending. Patients don’t know either. Having everyone understand more of the economics of health care is a great place to start cutting costs in medicine.”

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Johns Hopkins University School of Medicine