In the past few years, I have noticed a stream of articles asserting that American physicians are performing or prescribing too many imaging procedures. The result of this excessive indulgence, assert many of the authors, is that the nation’s health care system is spending too much money on imaging; that many of the patients who undergo these procedures are getting false-positive results, which lead to more spending; and that most of the same patients are receiving too much unjustified ionizing radiation.
These articles range from pieces in radiology journals, to assertions in other medical publications, to news articles in the New York Times and one in Parade magazine last July. The same assertions also appear in several recent books alleging that imaging is one of the leading abuses in the overuse of expensive medical procedures.
Numbers justify some of these accusations. Charges for imaging procedures now account for a fifth of all physician payments for services to Medicare beneficiaries, and they are growing fast. Americans underwent some 66 million computed tomographic (CT) scans in 2005, an astounding increase over the past two decades. The number of nuclear scans, particularly for heart studies, competes with the number of CT scans for rapid growth. The sale of x-ray equipment to health facilities other than hospitals or radiology offices contributes to the generality that more than half of all imaging procedures outside of hospitals are performed by persons other than qualified specialists.
One spate of imaging, whole-body CT scans of the worried wealthy with no clinical indications, provoked denunciations from the US Food and Drug Administration and the American College of Radiology. Few of these nonreferred, medically unjustified examinations are covered by health insurers. But the medical follow-up they often provoke does add to health system costs.
From the 1930s, screening chest x-ray programs to detect tuberculosis were promoted by the US Public Health Service, the National Tuberculosis Association, and other health agencies as key to the successful national effort to stamp out tuberculosis in Americans. A few decades later, the promulgation of mammography as a primary screening technique contributed to the reduction in the death rate from breast cancer.
Some critics still allege that the acceptance of mammography is merely a factor of lead-time bias and that improved treatment rather than early diagnosis should be credited. Mammography is relatively simple and inexpensive compared to most other tests. It is covered by Medicare and most other health insurers. Its quality is guaranteed by federal and state laws governing mammography facilities.
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