Danilo Espinola is a busy doctor who seldom sees a patient. Instead, he spends most of his time in a half-darkened room at Advanced Radiology's imaging center in Pikesville, peering at amazingly detailed scans on a computer screen as he searches for malignancies or other abnormalities.
Less than a decade ago, the technology - positron emission tomography - was primarily a research tool shunned by insurers. But once Medicare and private insurers decided to cover the diagnostic test, usage shot up.
In the past five years, the number of PET scans increased 400 percent, according to consulting firm IMV Limited.
Now more than a million PET scans are done a year, at about $2,500 apiece. Espinola reads 20 to 25 scans in a typical day, a rate that would yield more than $1 million a year in billings.
Both patients and doctors are grateful for the new technologies that allow images that were unimaginable even a few years ago. And as the capabilities expand rapidly, it holds even more promise.
But that progress comes at a price.
Though the humble and inexpensive X-ray still has its uses, more and more patients are undergoing high-end scans that can cost thousands of dollars to assess everything from bone density to brain atrophy to rotator cuff injuries.
The upshot: Imaging has nudged out drugs as the fastest growing component of rising medical costs, increasing as much as 20 percent a year.
The overall cost of diagnostic imaging is estimated at well over $100 billion annually in the United States. That's about a nickel of each health spending dollar.
That's gotten the attention of insurers, who have put up more hurdles and imposed more controls, creating hassles for doctors and patients alike. Sometimes they refuse to pay at all.
Dorothy Jewell, 72, of Mount Washington, a retired nurse, has had cancer surgery on her lung and on her hip.
After a blood test last fall showed a possible cancer marker, her oncologist ordered a combined PET and computed tomography (CT or CAT) scan.
When she called Medical Imaging of Baltimore to make the appointment, she was told Medicare wouldn't pay for the test because she had had one less than six months before.
"It was just a shock to me," she said. "I feel they shouldn't limit doctors in any way to do what they think is right for the patient."
Unlike some other patients, Jewell's anxiety was limited to several hours. The imaging center got her on Medicare's registry of cancer patients, guaranteeing payment, and she got the scan without delay.
But private insurers have instituted tighter controls, especially as they have see their imaging bills escalate.
Diagnostic imaging is "one of the most visible and costly technological advances over the last 25 years," according to a report by the national Blue Cross and Blue Shield Association.
(The term "imaging" is often used rather than "radiology," since some of the techniques don't use radiation.)
Medicare's payments to doctors for imaging had "by far the highest growth rate" of medical bill categories studied, doubling between 2000 and 2005, according to Medicare's Office of the Actuary.
When CareFirst BlueCross BlueShield did a detailed analysis of its claims to look for cost drivers - examining 1,300 trends by ZIP code, market segment and type of service, "diagnostic radiology came to the top," said Michael Fierro, associate vice president for health care informatics for CareFirst.
CareFirst pays about $300 million a year for diagnostic imaging, nearly 7 percent of its $4.5 billion in medical claims.
The bill has risen as use of sophisticated - and expensive - technologies have proliferated. Magnetic resonance imaging (MRI) typically costs $700 to $900; computed tomography $500 to $700, and PET and other forms of nuclear medicine, in which a patient is given a radioactive material, $2,000 and up.
80% of cost increase
These high-end imaging procedures now account for 60 percent of radiology costs and 80 percent of cost increases, estimates Dr. Thomas Dehn, executive vice president and chief medical officer of National Imaging Associates, one of the country's largest radiology benefits management firms.
Propelling the surge in usage is the quantum leap in the capabilities of MRI, CT and PET over the quarter-century they have existed, said Dr. Donald Rucker, vice president and chief medical officer for Siemens Medical Solutions USA, a major manufacturer of imaging equipment.
"People look at them historically as cameras into the body," said Rucker, who is also on the faculty of the University of Pennsylvania medical school. "It's actually a very sophisticated computer system."
Vast increases in the speed and power of computers have enabled radiologists to assemble more tiny slivers of an image, taken from different angles, into clear, three-dimensional pictures - a far cry from the old flat X-ray images that look like Halloween skeletons. Doctors can even, with a flick of a computer mouse, in effect turn an organ around to look at all sides.
"When I started, to scan a neck took 20 minutes," said Dr. Jonathan S. Lewin, chief of radiology at Johns Hopkins. "Now, it takes a second."
This isn't just a matter of convenience; it's a vital breakthrough because it allows scans that that couldn't be done before because the patient, or organ such as the lungs or heart, couldn't hold still long enough.
Dr. Elliot Fishman, a CT whiz at Hopkins - he was just voted the country's top radiologist by readers of Medical Imaging magazine - said the CT scanners of just two or three years ago took 16 views, or slices, at a time; now that's quadrupled.
"With 16-slice, in the best of hands, 60 to 70 percent of the time you were able to get good study," Fishman said. "With 64-slice, 95 percent-plus of studies are perfect."
Calling up an image from an 11-year-old who had collapsed on a playground, Fishman showed how the coronary artery was being pinched as the heart beat.
The diagnosis led to a fix by relocating the blood vessel. "With a 16-slice, there's no chance we could do this," he said.
It's not stopping with 64-slice, of course. There are 128-slice scanners now on the market, at about $2.5 million each, with 256-slice machines on the near horizon.
Like CT scanners, MRI machines have gained in visual power, with faster computers and larger magnets.
Dr. Tania Walton reads breast MRIs, a use of imaging that has burgeoned in the last three years as the newer machines became able to detect tiny tumors.
At Advanced Radiology's Pikesville office, she shows an image from a patient who thought she felt something in her breast, but had a negative mammogram. The more sensitive MRI showed a small growth.
"It's going to save her life," Walton said.
As was the case with new, costly blockbuster drugs, no one questions whether the new technology is helping patients, and even saves lives. In some cases, it also saves money.
Better imaging, for one, has vastly reduced the need for expensive exploratory or unneeded surgery.
PET scans during cancer treatment can show whether it's working, allowing doctors to adjust dosages or to halt ineffective chemotherapy or radiation treatments, which have highly unpleasant side effects.
A 2004 study in the academic journal Stroke, published by the American Heart Association, found that doing CT scans of all stroke patients produced lower overall costs and better patient outcomes than selective scanning or no scanning at all.
Although more is spent on scanning, the authors wrote, that's offset by making an earlier diagnosis and getting the patient treated more quickly.
Similarly, CT scans in cases of abdominal pain have virtually eliminated unneeded appendectomies, which used to account for a third of those operations, said Rucker, the Siemens executive.
But while the value of much high-end imaging is clear, there are also cases - as with blockbuster drugs - where unneeded scans are ordered, or where a less costly alternative would have sufficed.
Estimates of the number of inappropriate scans vary.
Fierro, the CareFirst data analyst, looked at MRI tests of the brain, a large and growing category. Reviewing records on 250 cases, Fierro said, CareFirst found proper documentation of the need for the brain scan in 80 percent.
National Imaging Associates estimated several years ago that as many as 30 percent of imaging studies were not needed or not the correct test, although NIA believes the number may have declined as insurers have tightened the approval process.
Several hypotheses are offered as to why too many tests, or the wrong tests, could be ordered: physician worry about malpractice suits; patient demand for the latest, best exam; doctors who aren't up to date on the rapidly-developing technology, and doctors who profit from tests because they own imaging equipment.
"With the malpractice situation, the rules of the road for physicians, quite understandably, are, 'When in doubt, do the test,' " said Karen Ignagni, president and chief executive officer of America's Health Insurance Plans, the trade association for health insurers.
As with popular medications, patient demand can sometimes drive use of imaging tests. "Your buddy just got a shoulder MRI and you want to get one," said Dehn, of the radiology management firm.
Some equipment manufacturers have begun advertising directly to consumers, although not nearly to the degree that pharmaceutical companies promote their products.
Much of the focus on inappropriate use stems from potential conflicts of interest .
Studies over the years have looked at so-called "self-referral" - doctors who own their own machines or otherwise benefit financially from tests.
Published research ranges from a 1992 article in Journal of the American Medical Association, which found that self-referring doctors order two to six times as many scans as doctors who don't benefit financially, to a study published last month in the online edition of the journal Health Affairs reporting that nearly a third of MRI scans and about a fifth of CT and PET scans, involved "self-referral."
Maryland law, which is more stringent than federal statutes, prohibits self-referral, but there has been a running legal battle about how the law should be interpreted and what exceptions it permits.
Court cases and an administrative proceeding pitted some non-radiology specialists against insurers. Rulings have gone both ways, and one case is pending.
Some insurers have attempted to rein in imaging costs in the simplest way possible - paying lower rates.
Medicare imposed lower rates this year - not an across-the-board cut, but by limiting certain fees. The cuts are projected to trim Medicare spending on imaging by 1 percent - but that's worth $8.1 billion over 10 years.
CareFirst set lower rates for a variety of doctors in July, hitting radiology particularly hard.
Doctors to lose pay
Dr. Robert Stroud, Advanced Radiology's chief executive, estimates that the CareFirst cuts alone will trim income for each of Advanced's 60-plus partners by about $18,000 a year.
(The median compensation for diagnostic radiologists is $419,148, according to a survey by the Medical Group Management Association.)
While rate cuts can hold down costs for insurers, they don't do anything to distinguish between appropriate tests - those that can save money and lives - and unneeded ones.
National Imaging Associates offers a service that evaluates whether physicians are following guidelines when ordering tests and works with doctors on a "correction plan" if needed.
Mostly, however, radiology benefits managers such as NIA exercise cost control through prior authorization - requiring doctors to get approval for high-end tests such as PET.
"You have $2,500-to-$3,000 buying decisions made literally in a matter of seconds," said Dehn, of NIA. "What we're doing is slowing down the physician in the office."
A study conducted in Israel, published in November in the Journal of the American College of Radiology, found that use of CT scans dropped by about a third after the introduction of pre-authorization based on American College of Radiology guidelines. MRI use dropped by 9 percent with pre-authorization over the same two-year period.
Dehn said 80 percent of requests reviewed by his company are approved by an initial screener. The other 20 percent "go to peer-to-peer" - an NIA physician talking, or exchanging correspondence, with the doctor ordering the test.
In the end, Dehn said, 5 percent of requests are denied, and another 5 percent are dropped by the doctor or patient after questions are raised.
The process doesn't always go as smoothly as Dehn suggested, according to radiologists and to doctors who make referrals for imaging.
Dr. Gary I. Cohen, director of the cancer center at Greater Baltimore Medical Center in Towson, said the authorization process is tedious.
"You fill out a form. Then the company sends you a form letter. You have to fill out another form, then the people from your office have to call, " he said.
In the end, Cohen said, only "a small percentage" of patients don't get the imaging tests they need, but the process can tie up members of his office staff. "I've seen them sitting on the phone for half an hour," he related.
If a patient shows up without a needed authorization, said Stroud, of Advanced Radiology, "Each one of these companies does this pre-authorization schtick another way.
"We try to scramble to get them authorized. If we can't, we usually end up postponing the test. The patient doesn't get the care, and we have a scanner sitting around."
The fairly small percentage of denied payment - is small comfort to patients anxiously awaiting a test. "When the sample size equals one," said Stroud, "you want your test and you want it now."