What Should We Do Now?
Many doctors will probably say that CT scans have allowed us to diagnose disease, monitor treatment, and prolong life in ways never before possible. We certainly do not want to throw the baby out with the bathwater. The problem is that radiation isn’t good for you, and so for a variety of reasons – cost savings, health promotion, ease of access, interest in using the Cadillac of imaging – CT scans are being used when they don’t necessarily need to be.
The solution to the problem of scanning is of two types:
- Make sure that scans’ health value is being weighed against potential risk and that cost is not the main priority in this calculation.
- Limit the scans’ radiation.
Given the competing interests and priorities of our health care system’s various stakeholders, these solutions lead to a whole bunch of questions:
Who Bears the Burden of Proof?
Are we going to ask insurers to prove that CT scans are not worth the radiation risks?
Or ask doctors and researchers to prove that they are?
Or ask patients to take responsibility for their own health care and override the doctor’s orders?
What role should government play?
Here’s one example of how it’s happening now:
Both private insurers and Medicare in the case of Pulmonary CT scans have begun to examine whether these scans are being over-prescribed. Medicare paid for roughly 70,000 heart CT scans in 2006, at a total price tag of $40-$50 million. Because private insurers generally seek to lower their medical payments in order to boost profits and shareholder value, if Medicare reduces its payments for procedures or services it deems ineffective, insurers are typically soon to follow.
Medicare in this case concluded, however, that not enough data exist about the long-term effects of such scans to limit coverage of them. Particularly not in the face of doctor groups like the American College of Cardiology and the American College of Radiology who hugely support the scans for their relative ease of use and diagnosis compared to traditional angiographs. Pressure from scan manufacturers may have also helped tip the scales in their favor.
But insufficient evidence proves nothing. There is still the potential of discovering that frequent scans are a risk not worth whatever diagnostic benefits they offer. Who is going to make sure more evidence is collected and weighed?
Who Weights Short-Term vs. Long-Term Costs?
Insurers are seeking to institute more pre-authorization requirements for these scans to limit how often they’re prescribed. Doctors in the field are concerned that insurer efforts to cut costs might hamper the actual practice of medicine if insurers promote or mandate less effective or more invasive tests because they’re cheaper. And if other methods failed to adequately diagnose the problem, the CT scan would still be needed.
Who Is Guaranteeing the Patients’ Best Interests?
Doctor specialty groups are supporting attempts to put in place advanced accreditation requirements for both the machines and the doctors running them, as well as published criteria for their use.
But do doctors have credibility on this issue?
An April 2008 study has found that that there have been steady increases in referrals for imaging scans among patients with private insurance. Why? Mainly due to physicians who self-refer for these tests – have their patients receive the scan in their office. Federal law created monetary incentives for these kinds of self-referrals in order to promote patient convenience. The unanticipated outcome has been doctors going so far as leasing imaging center’s facilities in order to make money on scanning.
Even doctors with the best of intentions and regular experience with CT scans are woefully uninformed. A 2004 study found that only 9% of emergency department doctors and only 47% of radiologists knew that CT scans increased the lifetime risk of cancer. Only 22% of the ER doctors and 13% of radiologists got it right: CT scans provide a radiation dose 100-250 times higher than a chest X-ray. The majority of ER doctors and radiologists selected the multiple choice answer that scans provided 2-10 times the radiation dose of a chest X-ray.
Who is Monitoring the Adoption of Even Newer Technologies?
New technologies are now being offered with different schools of thought on their value. Who will decide if and how they are used?
Proton therapy centers help target nuclear radiation therapy for cancer with the aims that only the diseased part of the body is exposed to the harmful x-rays. Critics say that the minor evidence of proton therapy’s advantage over X-rays does not make it worth its tremendous cost.
Michigan is seeking to block 4 of its hospitals from spending $100 million each to build their own centers, forcing them to collaborate on the construction of just one for the whole state .
Is this supposed health-promoting measure just another battle in the hospital arms race?
To borrow a phrase from Dr. Strangelove, perhaps we should learn to stop worrying and just love the MRI. These scans use magnetic fields, not radiation, to examine the human body and produce definitive images. Of course they take longer, are more expensive, and 1 in 10 people can’t use them for various reasons, such as metal in parts of their body or being unable to deal with the lengthy stillness and enclosure MRIs require. (Open MRIs prevent claustrophobia but their images are less clear.)
CT is the prescribed diagnostic standard for many diseases and injuries, but preference for the MRI is growing in an increasing number of situations, and evidence on others is still being collected.
In a 2004 survey, almost all the patients (93%) reported that CT scans’ risks and benefits had not been outlined to them.
Be aware of the potential hazard of x-ray radiation to the body.
Ask your doctor why he or she is recommending a CT scan and, if a scan is really necessary, whether an MRI and/or an ECG (an echocardiogram, which uses sound waves) or even a sonogram (which uses sonar) is a possible substitute.
The amount of radiation in a scan can be adjusted. However there is still a gap – between what the doctor orders and what the radiologists and their techs execute – that the patient can’t easily navigate.
Again, this should be more of a concern for people who have to get scanned semi-regularly.
- Patients who need frequent scans to monitor problems like recurring kidney stones, cystric fibrosis, and cancer treatment should have a clear discussion with their doctors weighing the risks and benefits.
- For people at risk for colon cancer, while a “virtual colonoscopy” – a CT scan of the lower abdomen – may seem preferable to the discomfort and unpleasantness of a traditional colonoscopy, the repeated exposure to radiation may not be worth the risk.
And whether this is your first scan or your 50th, always have your doctor go over with you the current criteria for whether a CT scan is appropriate for you.
Note from WhatIf:
We have tried to make sense for you of a complex issue of importance to us all. This has been a difficult topic to present because though scan usage is wide, conclusive research on scan radiation is limited and contradictory. So health care providers and insurance companies are making decisions based upon both financial cost and on their ease of use in diagnosing and monitoring health care problems that doctors know are serious. It’s something to keep in mind when being asked as a consumer to take responsibility for your own health as well as when thinking about the ways in which our health care system could be improved.
This article was written by Emily Cleath.