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Health Policy and Practice |
1 From the Research Department, American College of Radiology, 1891 Preston White Dr, Reston, VA 20191 (M.B., J.H.S.); and Department of Diagnostic Radiology, Yale University, New Haven, Conn (J.H.S.). Received September 26, 2003; revision requested December 8; final revision received March 17, 2004; accepted May 12. Address correspondence to M.B. (e-mail: mythreyib@acr.org).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSION REFERENCES |
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MATERIALS AND METHODS: Aggregated claims data from Medicare enrollees for all radiology procedures and from the Medical Expenditure Panel Survey (MEPS), a nationally representative survey of almost 25 000 Americans, for some radiology procedures, were used to calculate population-based utilization for the relevant age groups. Limited private insurer data also were obtained. All radiology utilization was measured and reported, irrespective of provider specialty. Average levels and percentiles of utilization were measured according to modality, and average annual rates of increase in utilization were compared across modalities, data sources, and regions. Rates of increase in utilization according to modality and state were compared for correlation with state characteristics and initial utilization levels.
RESULTS: In 2001, 4176 diagnostic and 274 therapeutic radiology procedures were performed per 1000 Medicare non–managed care enrollees. Nearly one-half of diagnostic procedures (n = 2057) involved radiography. The other half involved computed tomography (CT) (n = 391), magnetic resonance (MR) imaging (n = 114), ultrasonography (US) (n = 921), interventional radiology (n = 215), mammography (n = 221), and nuclear medicine (n = 249). On average, between 1998 and 2001, utilization per Medicare enrollee increased 16% per year for MR imaging and 7%–15% per year for CT, US, interventional radiology, and nuclear medicine, while that for radiography increased 1% per year. The proportion of diagnostic radiology procedures performed in ambulatory settings increased from 62% in 1992 to 68% in 2001. There was wide variation across states in utilization by Medicare enrollees. State totals for diagnostic radiology were 3038 in the 10th percentile and 4573 in the 90th percentile. In 1999, MEPS reported average utilization in ambulatory settings as follows: 64 MR imaging, 102 US, 73 mammographic, 326 radiographic, and 43 radiation therapy procedures per 1000 persons (all ages) in the U.S. population.
CONCLUSION: Utilization of high-technology modalities increased rapidly, while that of radiography was relatively stagnant. Variation in utilization among states and census regions was substantial.
© RSNA, 2005
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSION REFERENCES |
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSION REFERENCES |
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The Medicare files contain data about 100–130 million diagnostic radiology procedures that pertain to approximately 30 million enrollees for each year reported. Utilization levels were measured for each Current Procedural Terminology (CPT) code (2), state, and place of service (eg, inpatient hospital, emergency room). We (M.B., J.H.S.) applied a list used by the American College of Radiology to group CPT codes into modalities. The analysis includes the 70000 series of CPT codes, as well as the 90000 series for echocardiographic procedures, and includes procedures performed by all providers. With regard to interventional procedures for which a combination of surgery codes and radiology supervision and intervention codes was used, we (M.B., J.H.S.) counted claims only for supervision and intervention codes that were in the 70000s and did not count each surgery code independently, to avoid counting each procedure more than once.
The data were grouped according to modality, place of service, and state. (The District of Columbia and the counties of Maryland and Virginia that are included in the Washington metropolitan area all share the same geographic identifier; hence, numbers of claims for the District of Columbia, Maryland, and Virginia do not strictly correspond to the state geographic borders.) We (M.B., J.H.S.) included data only for the 50 states and the District of Columbia; data about procedures performed in Puerto Rico and the Virgin Islands were excluded. Our numbers for ambulatory radiology services include all nonhospital procedures, emergency room procedures, and hospital outpatient procedures. The overall total includes ambulatory care plus hospital inpatient care.
The number of enrollees eligible for services included in the Physician/Supplier Procedure Summary File for each year was obtained from the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) Web site (3) and was calculated as the number of Supplemental Medical Insurance enrollees minus the number of Medicare managed care enrollees as measured in July of each year (4). These are publicly available data that include total counts of Medicare beneficiaries enrolled in Part A, Part B, and managed care by county only; there are no patient identifiers.
For comparison of trends between 1992 and 2001, we (M.B., J.H.S.) used the data stratified according to modality that are reported in Burkhardt and Sunshine (1) for procedures performed in an ambulatory setting and for total procedures.
Medical Expenditure Panel Survey Data
The Medical Expenditure Panel Survey (MEPS), a nationally representative survey conducted by the federal government’s Agency for Healthcare Research and Quality, was used as a source of data about selected radiology procedures (magnetic resonance [MR] imaging, ultrasonography [US], mammography, radiography, and radiation therapy) performed in 1996 and 1999. The MEPS data are public-use data available for download from the Internet, and beneficiaries are not identifiable. (For more information, readers may visit the MEPS Web site at www.meps.ahrq.gov.)
The MEPS is a complex sample survey that contains responses from 22 601 persons in 1996 and 24 618 persons in 1999, including both elderly and nonelderly respondents, and with responses weighted to make results representative of the national population. The number of events (ie, visits to a physician’s office, emergency room, or outpatient hospital department) that involved radiology was relatively small for some types of events. (In 1996 and 1999, the numbers of radiation therapy events were approximately 600 and 1000, those of MR imaging events were approximately 800 and 1500, and those of radiography events were approximately 6700 and 7700.) The weights in the sample allowed us (M.B., J.H.S.) to calculate nationally representative average utilization per person.
Data from the MEPS are based on responses from persons living in the 50 states and the District of Columbia, and data about medical events are for ambulatory care only, including that provided in physicians’ offices, hospital outpatient departments, and emergency rooms. Respondents are told to maintain event logs, and attempts are made to verify these logs with the reported medical providers.
MEPS data include demographic information about the respondents, information about the medical event, statistical weights for each person and each survey design–specific sampling cluster, and stratum identifiers to enable calculation of nationally representative statistics. To protect confidentiality, information about the respondent’s state of residence is not available; MEPS data do, however, indicate the census region (Northeast, Midwest, South, or West) in which the respondent resides.
Private Insurers
We (M.B., J.H.S.) also obtained limited information about utilization by commercially insured patients, primarily nonelderly, from two sources. A medical imaging management company (MedSolutions, Franklin, Tenn) provided data from a number of private insurers across the country for utilization of computed tomography (CT), MR imaging, and nuclear medicine for 2000 and for trends since 1996. These outpatient data came from several managed care firms and represent a total of 127 million member-months over a 5-year period (1996–2000) (Poenitske A, personal communication, September 4, 2001). While these data are not nationally representative, they provide a useful indication of the managed care experience of some private payers.
The other source of information about utilization by commercially insured patients was an HMO in the northeastern United States. We (M.B., J.H.S.) obtained data about utilization of CT, MR imaging, and US per 1000 enrollees in this HMO for 1993–1998 (Moskowitz H, personal communication, 2001), during which time enrollment in the HMO ranged from approximately 100 000 to more than 160 000 (5).
The information cited for each private payer was given to us in aggregate (as procedure counts per beneficiary, for each modality, for each region). There were no patient identifiers. All the data that we received are presented in this article in the same form in which we received them; therefore, the data we obtained are available to everyone who has access to this publication.
Statistical Analyses
All statistical calculations and analyses were performed by the two authors. We used the Medicare data for 2001 to calculate national average utilization per 1000 non–managed care enrollees according to modality. To demonstrate the level of variability across states, several percentile measures of state-level utilization were calculated for each modality.
We calculated mean utilization per 1000 persons from the MEPS while taking into account the sample design, including clustering and stratification, and applying appropriate weights to calculate average utilization and standard errors.
Mammography is performed almost entirely in women, and the appropriate measure for utilization of mammography therefore is the number of procedures per 1000 women; however, state-level counts of Medicare enrollees according to sex at birth are not available. (The only counts available include enrollees of both birth sexes.) Therefore, we reported utilization of mammography as we did that of all other modalities, as number of procedures per 1000 persons among MEPS respondents and Medicare enrollees, with men and women combined. Approximately 60% of all Medicare enrollees (6) and 50% of persons younger than 65 years (7,8) are women.
The private payer data were simply tabulated in the form in which we received them, with no further statistical analysis. We measured the compound average annual rate of increase in Medicare-reported utilization per 1000 enrollees for 1992–1995, 1995–1998, 1998–2001, and 1992–2001. Rates were calculated by using numbers reported in Burkhardt and Sunshine (1) for 1992 and numbers that we calculated for 1995, 1998, and 2001. We calculated compound annual rates of increase in utilization per 1000 persons for MEPS between 1996 and 1999, and we tabulated rates based on the managed care data across years for which annual rates of increase were available. With regard to the single HMO, we used the utilization level for each year for which we had these data to calculate compound average annual rates of increase in utilization.
We also measured procedures performed in an ambulatory setting as a proportion of all diagnostic radiology procedures reported in Medicare data for 1992 and 2001. We compared levels and trends in utilization between Medicare data and MEPS data for persons aged 65 years or older.
Data from the MEPS and data from MedSolutions with regard to privately insured persons were separable according to region, and Medicare data were grouped according to state within the four U.S. census regions. (The regions in the MEPS data are consistent with the census regions. The regions in MedSolutions data, however, do not strictly correspond to the census regions: Texas and Oklahoma are included in the West in MedSolutions data but in the South in the census data.) We compared utilization by MEPS respondents younger than 65 years to that by MedSolutions customers, and that by MEPS respondents aged 65 years or older to that by Medicare patients according to census region. In some instances, data for these comparisons were not available for identical years, and we compared data with a displacement of 1 year.
To analyze variations in utilization across states, we sorted states into quartiles of utilization per 1000 persons and mapped these state quartiles. In addition, we calculated correlation coefficients for comparisons between, on one hand, the number of procedures per 1000 Medicare enrollees in each state in 2001 and, on the other hand, the numbers of Medicare providers in that state, radiologists in that state, Medicare providers per person in the state population, radiologists per person in the state population, and persons in the state population. We also performed linear regression analyses by using state-level utilization per 1000 Medicare enrollees as the dependent variable and by using combinations of the other state-level variables as independent variables. We then performed a stepwise regression analysis to determine which of the state-level statistics were most predictive of the variation across states in radiology utilization per 1000 Medicare enrollees. The state population data for 2001 were obtained from the Web site of the U.S. Census Bureau (www.census.gov), data about Medicare providers (counts according to state in September 2002) came from the Web site of the Centers for Medicare and Medicaid Services (www.cms.hhs.gov), and the numbers of radiologists in each state were obtained from the American Medical Association (9).
With regard to Medicare utilization levels and rates of increase across modalities and states, we calculated correlation coefficients for the 1995 level with the 1995–1998 rates of increase and coefficients for the 1998 level with the 1998–2001 rates of increase.
Finally, we calculated coefficients of variation for utilization per 1000 Medicare enrollees in 1995, 1998, and 2001 across states and for each modality.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSION REFERENCES |
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According to data from the 1999 MEPS, utilization of MR imaging and mammography per 1000 persons 65 years or older was, on average, about three times that per 1000 persons younger than 65 years (Table 2). Among those aged 65 years or older, utilization of radiography (in MEPS data, counted as "x-rays") was two and a half times, and utilization of US was nearly one and a half times, the level among those younger than 65 years. As the standard errors in Table 2 show, the uncertainty of utilization reported in MEPS among those aged 65 years and older is large because MEPS is a sample survey in which each respondent, on average, represents more than 11 000 persons. For radiation therapy, standard errors were particularly large because fewer than 1% of respondents underwent radiation therapy.
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In the state-level analysis, we found that a high utilization per 1000 Medicare enrollees in any year was strongly correlated with a low compound average annual rate of increase in utilization per 1000 enrollees in the ensuing years. There was a statistically significant and strongly negative correlation between the number of procedures per 1000 enrollees in 1998 and the average annual rate of increase in utilization of procedures per 1000 enrollees in the ensuing 3-year period from 1998 to 2001 (Pearson correlation coefficient = –0.951) and between the number of procedures per 1000 enrollees in 1995 and the annual rate of increase in utilization of procedures per 1000 enrollees in the ensuing 6-year period from 1995 to 2001 (Pearson correlation coefficient = –0.947). In almost all modalities, the variability in utilization across states decreased during 1998–2001 and 1995–1998.
The average rate of increase in radiography and MR imaging utilization for those aged 65 years and older among MEPS respondents in 1996–1999 is similar to the corresponding average annual rate of increase among Medicare enrollees for the overlapping period of 1995–1998 (Table 5). We found a decrease in reported utilization of US in MEPS data, in contrast to a fairly rapid increase in utilization reported in Medicare data. While the average rate of increase in mammography utilization appears to differ between the two sources, the 95% confidence intervals for the MEPS averages are so large that the differences are not statistically significant. Similarly, although the average rates of increase in utilization differ between MEPS respondents who are 65 years old or older and those who are younger than 65 years, the differences are not statistically significant because of the large standard errors in the MEPS estimates.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSION REFERENCES |
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The Medicare data indicate that the total number of radiology procedures per 1000 enrollees increased at a compound annual average rate of almost 5% between 1998 and 2001. Population aging is responsible for an approximately 0.5% increase annually (10), but, on the other hand, relative value units per procedure are increasing approximately 1.5% annually (11), which means that utilization in relative value units per age-standardized Medicare enrollee is increasing by approximately 6% annually. This is a rapid increase, and it implies almost a doubling of per capita utilization every decade. This increase in utilization, which is sometimes attributed to technologic progress, is a measure of the increasing power of radiology to help patients.
While the benefits to patients seem clear, increased utilization entails a major problem for radiologists. If we add to the approximately 6% annual increase in utilization per age-standardized person an approximately 0.5% increase to account for overall population aging and an approximately 1% annual increase to accommodate the increasing numbers in the U.S. population, we must conclude that the total radiology workload is increasing by approximately 8% annually. In contrast, the number of radiologists in practice is estimated to increase by approximately 1.5% annually (12). It seems that radiologists must either continue to manage a rapidly increasing work load (11)—possibly through adoption of technologic advances such as three-dimensional "fly-through" viewing of cross-sectional images and computer-aided detection—or see a greater portion of the radiology work load devolve to other specialties, as is already happening with nuclear cardiology (13). Indeed, it is most likely that both trends will continue to develop quite rapidly.
States with a large total population and large numbers of radiologists and Medicare providers have higher radiology utilization per 1000 Medicare enrollees. Strangely, there generally are no similar correlations between utilization per 1000 Medicare enrollees and resources per capita (for example, physicians per 100 000 persons in the state population or per 1000 Medicare enrollees), although such correlations would be more expected. We do not know the reason for this odd pattern, but geographic differences in utilization have been widely noted (14). Also, while we have found some correlations, the results of regression analysis show that these variables, even in combination, do not explain more than 20% of the geographic variation in utilization. The correlations do not explain the underlying mechanism that drives utilization.
With regard to utilization according to modality, there are negative correlations between the rate of increase for a modality and the age of that modality (ie, how long the technology has been available). Increase in the utilization of radiography, by far the longest-available modality, has essentially stopped, a fact that suggests that utilization of modalities eventually plateaus. At the other extreme, MR imaging is the newest modality and the one for which utilization is increasing most rapidly, which indicates that modalities grow (as a percentage of radiology utilization) especially rapidly in their early stages. For most modalities, we found that the variability in Medicare utilization across states has decreased over time, which is consistent with the notion of a plateau in utilization. We noticed a similar plateau for all modalities combined, as well: States with high utilization in the early 1990s experienced low rates of increase in utilization for the rest of the decade. We do not have enough information to identify the mechanisms that cause these correlations. Presumably, states and modalities with high utilization in 1992 were those in which equipment penetration and, possibly, provider influx occurred earlier than elsewhere, and once these were in place, there was not as much room for rapid increase in utilization. Conversely, states with low initial utilization experienced a more rapid increase in utilization through the 1990s, since it was relatively easy to expand equipment use and physician employment.
The share of ambulatory settings among Medicare-reported diagnostic radiology procedures increased from 62% in 1992 to 68% in 2001, in keeping with the general health care trend away from the hospital inpatient setting. In part, this trend is due to new techniques, such as laparoscopic surgery, that permit speedier patient discharge or movement of procedures to outpatient settings. In addition, pressures from the payment system—for example, the incentive incorporated in Medicare reimbursement according to diagnosis-related groups to discharge patients as rapidly as feasible—are almost certainly also partly responsible.
Comparing Medicare results in this study to earlier results from 1992 that were reported in Burkhardt and Sunshine (1), we found that the average annual rate of increase was lower between 1992 and 1995 for all modalities except interventional radiology than it was through the rest of the 1990s. It is interesting that although all the Medicare enrollees in the study were in the fee-for-service category, the trends in utilization parallel the intensification and easing of managed care constraints: The period of 1992–1995 was one of increasingly restrictive managed care, and the years after 1995 saw an easing of managed care restrictions (15).
The Medicare data for utilization of mammography indicate a rate of increase of 7.4% per year between 1995 and 2001, but use of screening mammography increased much faster, at about 16.5% per year in 1995–2001 (the most recent years for which we have data about screening mammography as a category distinct from diagnostic mammography). Breen et al (16) analyzed the National Health Interview Survey data for screening mammography, and their numbers translate into an average annual rate of increase of about 5.6% for women aged 65 years or older between 1992 and 1998, which is closer to the 5.9% increase in utilization per year in 1992–1998 for all mammography (screening and diagnostic) reported in Medicare data. Since utilization of Medicare-reported screening mammography increased significantly faster than did that of diagnostic mammography, the rates reported by Breen et al are substantially different from the ones we found for women aged 65 years and older. It is possible that self-reported definitions are not always accurate and may understate rates of increase, but it is also possible that with Medicare having instituted coverage for screening mammography, providers have changed practice styles to substitute screening mammography for what earlier would have been classified as diagnostic mammography.
It was reported in an issue brief from the Center for Studying Health System Change (15) that with managed care losing its hold in the past few years, and with loosening of restrictions by employers and insurers, health care utilization and costs have increased rapidly overall. In this study, not only did we find an increase in the utilization of radiology by Medicare enrollees, but our limited managed care data also indicate a much more rapid increase in utilization than that indicated by the Medicare data. The findings by the Center for Studying Health System Change suggest that our managed care data, despite limitations, may reflect some of this upsurge.
Limitations of the Data
The individual information resources we used differ substantially from each other. It is understandable that data from an individual payer such as the single HMO might differ from national averages. Moreover, it is likely that the managed care organizations that contacted us with their data did so because they experienced unusually high rates of increase in utilization. Therefore, these data might well not be nationally representative.
Even data from relatively large nationally representative surveys such as the MEPS are not particularly congruent with corresponding data for the same population from administrative databases such as that of the Medicare administration. The differences in reported levels of utilization between MEPS and Medicare could simply be definitional. In the Medicare data, we identified procedures by their CPT codes, and we used an American College of Radiology list to identify the modalities to which each CPT code pertains. In surveys such as the MEPS, the modalities are self-defined and may cover more or fewer services than those we identified in the Medicare data. As we had expected, because national utilization did not match across sources, we did not find agreement in absolute levels of regional utilization reported across sources.
Conclusion
Overall, the data show that utilization of high-technology modalities such as MR imaging and interventional radiology increased rapidly through the 1990s, while utilization of radiography stayed at about the same level. As noted, however, there are substantial differences in utilization among census regions and states. Presumably, smaller geographic areas may show even larger differences. Thus, national, regional, and state data are informative but should not be taken as rigid norms for a practice or for a locality.
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FOOTNOTES |
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Authors stated no financial relationship to disclose.
Author contributions: Guarantors of integrity of entire study, M.B., J.H.S.; study concepts and design, M.B., J.H.S.; literature research, M.B., J.H.S.; data acquisition and analysis/interpretation, M.B., J.H.S.; statistical analysis, M.B.; manuscript preparation, definition of intellectual content, editing, revision/review, and final version approval, M.B., J.H.S.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSION REFERENCES |
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