Overscanned or Overscammed?

Imaging scans.jpg

James Ridgeway, the Senior Washington Correspondent for Mother Jones magazine, wrote in a recent issue that one in ten Medicare dollars gets spent on patients with less than a month to live—a total that reaches a staggering $50 billion annually.

It would be palatable to the rest of us if we knew that that money was being spent towards palliative care efforts—efforts to make terminal patients, whatever their disease, more comfortable as they neared death.

Unfortunately a blockbuster paper has been published online in the Journal of the National Cancer Institute that argues otherwise. While never coming directly out and saying it, the study suggests that hospitals around the country are ordering very expensive imaging scans for elderly, stage IV terminal cancer patients—imaging scans that have neither diagnostic nor treatment value.

Imaging scans that aren't, as a general rule, ordered for younger patients with stage IV disease. Are these patients being over-scanned while the Medicare system is being over-scammed, or both?

High-Cost Imaging

In the paper's introduction, the researchers make note of the fact that diagnostic imaging is the fastest-growing category of Medicare-reimbursed services.

The Medicare Payment Advisory Commission has determined four types of high-cost imaging services:

  1. Computed tomography (CT)
  2. Magnetic resonance imaging (MRI)
  3. Positron emission tomography (PET)
  4. Nuclear medicine.

Little surprise that these four types of high-cost imaging services made up for nearly fifty percent of payments to doctors by Medicare in 2008. This might be acceptable if anywhere in the literature there was evidence that high-cost imaging was actually at all useful in patients with advanced disease who are not expected to live more than another month or two.

Research Findings

The researchers dug through the National Cancer Institute's SEER (Surveillance, Epidemiology, and End Results) database in order to find stage IV cancer diagnoses in Medicare patients from 1995 through 2006. They only looked at four cancer sites: breast, colorectal, lung, and prostate. They then looked at the Medicare billing by their doctors. According to their findings:

  • Almost 96 percent of patients diagnosed between 2002 and 2006 had undergone at least one of the high-cost imaging services prior to death.
  • On average, each patient had almost 10 scans.
  • Three out of four of those scans occurred afterdiagnosis, or during the continuing care phase.
  • One out of three patients underwent a high-cost imaging scan during the final thirty days of their lives.


The researchers responded to this data in their conclusion:

"These procedures represent a costly, yet underappreciated and understudied aspect of care in this vulnerable population. As our approach to their care evolves, it will be important to define the role of high-cost imaging to ensure that the maximum, in terms of both societal resources and patient quality of life, is achieved."

An accompanying editorial tried to defend the over-imaging abuses by arguing that in 2009 and 2010 the use of high-cost imaging had declined slightly, according to Medicare records. It further argues that use of high-cost imaging has increased in managed-care settings, where doctors might not be lured by the financial incentives to order such scans.

Why argue against any sort of hint of malpractice if you don't think it's a factor in the first place?


See the original study and the editorial yourself below. Both open as PDF files.


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