Medicare pays only about 20% of typical charges and radiation can be reduced by 90%.
The literature is absolutely packed with compelling articles and studies indicating that we order way too many CT scans.
Too many head CTs for trauma and headaches and dizziness. Too many CT pulmonary angiograms in low-risk PE patients who haven’t even had a d-dimer performed. Too many coronary CT studies in individuals with extremely low risk of CAD. Too may abdominal scans in patients with abdominal pain. Too many pan scans for trauma patients without reasonable indications.
There are two reasons many believe we should be ordering a lot fewer CTs – cost and radiation.
The cost of a CT is actually quite nominal – the charge, however, is an entirely different matter. Regarding cost, there is the cost of the tech, the cost of the radiologist, the amortized cost of the machine (to include routine maintenance, tube replacements and the like) and the allocated overhead costs applied to cover the general expenses of running the hospital.
Let’s use Medicare reimbursement rates. Most hospitals claim that Medicare covers only about 70% of its costs, but, obviously, Medicare doesn’t agree. Table 1 shows data from the John C. Lincoln Health Network in Arizona (www.jcl.com/hospitals/average-pricing-information/ct-scans). Two things are apparent – a big disconnect between their charges and what Medicare pays and in the chart below that its noted that their charges seem to be substantially lower than the average claimed in the chart listing average charges by city.
On the Internet site www.comparecatscancost.com they present the data shown in table 2 to show the huge local and regional differences in the average charge for a CT scan.
One of the things I never really understood was how the hospitals and radiologists got away with charging separately for an “abdominal” scan and a “pelvis” scan. Seriously, this is like charging for a reading of the left lung separately from the right. And the hardest part, we had to choose which study we wanted in assessing a patient with abdominal pain – an abdominal scan or a pelvic scan. Naturally we chose both, incurring significantly more cost for whoever was going to pay for the study. In 2011, Medicare wised up and now the reimbursement code for hospitals have been combined for these two studies as has the radiologists fees with the new codes being much less that the prior separate codes.
It can be seen based on Medicare rates that their reimbursement to hospitals for even the most expensive CT scans per- formed in the ED are between $200 and $500. What about reimbursement for an extremity study? According to a chart of 2014 Medicaid reimbursement (not Medicare), a lower extremity or upper extremity CT scan gets the hospital paid $152. In contrast, a plain X-ray of an ankle gets reimbursed at $30.56. But that’s just an ankle. What if there was a CT charge for just an ankle? It would likely have to be lower than $152. How close Medicaid hospital payments are to Medicare payments I couldn’t determine.
The bottom line – CT charges can be much lower than they currently are and, as such, could start approaching costs of plain films. Given that the visual detail seen on CT scans is far superior to that of plain films, the trade-off between costs and quality may warrant the expanded use of CT in selected cases. Now, if only CT radiation doses were less.
But wait! To the rescue comes a paper by Patrick McLaughlin, FFR RCSI and colleagues (I don’t know what these initials mean but I’m sure they’re important). Dr. McLaughlin’s paper, summarized below, reaffirms that the number of mSv that we think people get when they have chest and abdominal scans can be a fraction of what is currently routine. For example, the papers that we have been following indicated that a chest CT for PE or CAD is about 10 mSv, as is an abdominal CT. We’ve be told that this is the equivalent of 500 chest x-rays. And, as a result, fatal cancers will develop in 1 in 2,000 patients. But in our recent interview with Peter Viccellio, MD, on Emergency Medical Abstracts regarding his study of CT angiography in low-risk chest pain, he noted that their average radiation dose for a CT coronary angiogram was down to 4.5 mSv. Dr. McLaughlin’s paper describes using CT radiation doses that are lower than those for plain radiographs in some cases!
The problem with this new information is that it may open the floodgates for ordering even more CT scans. Now both reasons for restricting the use of CT scans could go away substantially – charges and radiation dose. It actually looks like the radiation dose factor will be easier to fix than the issue regarding charges. But, at least for Medicare and Medicaid patients, where the reimbursement is a fraction of the usual charges, it is less of an issue for physicians. And, perhaps there will be an expansion in the use of CT into the areas more typically reserved for plain films – musculoskeletal imaging.
Listen to the May issue of Emergency Medical Abstracts (EMAOnline.org) for an interview with the lead author of the study, Doctor Patrick McLaughlin.
3 Comments
Perhaps Medicare is dictating what should be charged, but if the Hospital charged what they reimbursed wouldn’t Medicare be obligated then to lower the reimbursement by thirty percent? Bearing that in mind, why doesn’t the ordering physician not also charge to displace their own malpractice expenses as most of us read our own CT while the radiologist sleeps?
What to do? Do less CT’s and risk missing those subtle but life-threatening conditions, then getting sued? We all know that even the best physical exams can miss a PE, appendicitis, small brain hemorrhage,or infarcts etc…
As always, Dr. Bukata cuts through the nonsense and brings common sense to bear. He is a gem.