May 6, 2010 in Health Policy
What is “MRI Abuse”? This is when the health care provider orders MRIs (Magnetic Resonance Imaging) in excess or for the wrong reasons. There are many causes of MRI abusive behavior but most evolve out of a significant misunderstanding of how to properly utilize this diagnostic tool. MRI imaging has a high sensitivity to detect anatomic abnormalities, does not expose the patient to high doses of radiation like a CAT scan, and is non-invasive and widely available. It is these advantages that leads to multiple erroneous assumptions on the part of way too many providers.
- MRI will usually yield a correct diagnosis.
- MRI will usually rule out a serious condition.
- MRI is the BEST of all imaging studies.
- MRI will usually help direct further evaluation efforts and lead to the correct treatment.
- MRI is without risks.
- The costs for an MRI don’t matter.
Even if MRIs were cheaper than aspirin (each scan is well over $1,000) and even if they were 100% safe (gadolinium IV contrast can cause nephrogenic systemic sclerosis in rare cases), they would still not be the definitive end-all, be-all, gold-standard imaging and diagnostic modality of all time.
Other than the excessive costs involved, there are significant downsides to a very sensitive test. For one, MRIs can pick up many abnormal findings that can often confuse the clinical picture. Are these findings incidental and harmless and not related to the problem at hand? Or are the findings related but harmless or unrelated but potentially harmful and in need of further evaluation? Sensitive testing undertaken without a clear clinical question in need of being answered is a problematic setup and likely to raise more questions and worries and lead to more testing (often invasive testing with increased associated costs and risks).
One of the worst cases of MRI abuse I have ever witnessed involved a middle aged patient who presented with some rather vague but worrisome pain. The patient’s exam was benign and routine blood tests and an ultrasound were normal. Because the pain appeared to be improving, we decided to see how it progressed over the next several weeks before deciding what to do next.
In the mean time, the patient ended up being seen by a mid-level practitioner for several visits on follow up (don’t ask me how this happened) who, when told about the mild and improving pain, proceeded to order MRIs of the chest, abdomen, pelvis, lumbar spine, the thoracic aorta, and the renal arteries, all of which were negative for any significant findings.
By the time the patient got back to see me after several months, the pain had resolved – as we hoped it would – and she was doing very well. I reviewed her prior extensive “magnetic therapy” in amazement. It was not at all clear from the mid-level practitioner’s progress notes as to why all of these MRIs were ordered but despite this lack of documentation, the patient reported that the health insurance company had paid the complete MRI bill. The total cost for this work up was well in excess of $10,000.
It’s evident that there remain huge gaps in utilization and cost review processes of insurance companies. It’s also evident that health care providers who don’t have the training, experience, or time to bother with the concepts of cost containment, resource utilization management, and standards of care (which usually call for the simplest and cheapest test to start the evaluation process) are the ones most likely to go for the “shotgun” method of diagnostic medical practice.
This is very bad omen since primary care is headed is towards an ever larger percentage of care being provided by mid-levels and both mid-level providers and physicians are being forced by dropping reimbursement rates to see more and more patients. All of this is going to translate into worse medical resource utilization and higher costs and a big part of it will be MRI abuse.