Cardiovascular imaging has advanced at breakneck speed over the past five years. With the steadily improving capability to image the cardiovascular system has come the appreciation that imaging is not an end in itself, but must lead to more effective and appropriate therapy in order to be clinically justified. Current economic challenges are particularly relevant to healthcare and will have major influence on further technical development and clinical application of advanced cardiovascular imaging modalities.
In 2006, we predicted that clinical use of cardiac imaging would continue to expand and evolve, but at a slower pace than in previous decades, primarily because of economic challenges but also related to a healthy emphasis on developing a more robust and discriminating evidence base for appropriate usage of multiple, high-technology imaging modalities that provide overlapping, sometimes redundant diagnostic and prognostic data. This prediction was accurate in 2006 and is likely to remain true for the next five years.
Although there is no doubt that cardiac imaging has been one of the most useful developments in medicine over the past 50 years, it is also true that enthusiasm for this remarkable technology has led to sometimes uncritical, widespread adoption and too-frequent instances of over usage. We, physicians, our institutions and even our patients, have embraced new and rapidly advancing, highly sophisticated technology without enough critical assessment of its incremental impact on eventual patient outcome—does the patient actually feel better or live longer? This ultimate goal can be clouded by an understandable desire to make a complete and accurate diagnosis, avoid claims of malpractice and deliver the most ‘modern’ care, in competition with other institutions and physicians in the community. These influences are compounded by our medical payment system, which is largely run on a fee-for-services basis. This system provides incentives to hospitals, clinics, and physicians to perform more and more services, with insufficient emphasis on the true value these services impart to the patients for whom they are rendered. This is by no means an exclusive problem related to imaging, or to physician-owned imaging services, but these are easy targets.
As we noted five years ago, this ‘perfect storm’ of increasing usage of sophisticated and expensive medical services has resulted in extreme economic pressure being placed on the entire healthcare system and imaging in particular. Insurance companies continue to tighten payment policies by requiring pre-authorization for many procedures, including echocardiography, as well as more expensive magnetic resonance imaging (MRI), computed tomography (CT), and nuclear imaging procedures. Payments for imaging procedures have been reduced, particularly for independent imaging facilities and physician in-office services. This pressure will continue. Fairly or unfairly, the Medicare Payment Advisory Commission (MedPAC) and Centers for Medicare and Medicaid Services (CMS) are targeting physician in-office imaging services for reduced reimbursement if not outright banning. Reimbursement and profit margins for imaging services will continue to contract, with cuts extending next to hospitals, which currently receive favorable payments for outpatient imaging, compared with independently provided services.