If you watch TV, you may have seen a popular IBM commercial for Watson that points out magnetic resonance imaging (MRI) has increased by 10 percent a year. A 10 percent increase may seem like a reasonable trend, but a recent white paper from Lockton Companies titled “Red Herrings and Medical Overdiagnosis Drive Large-Loss Workers’ Compensation Claims,” reveals a 300% increase over the last decade. Unfortunately, those tests show that 90% of the common abnormalities discovered by MRIs result in over treatment. Maybe IBM’s famous Jeopardy winner is whispering something more to us – that we need to be aware of the red herring.
For healthcare and insurance professionals, the MRI statistic is old news, and not necessarily good old news. For at least two decades, imaging of the spine has been one of many diagnostics driving up medical costs. Although unit costs for MRIs are being controlled more effectively with many diagnostic ancillary providers, MRI is still an expensive test by itself and often leads to expensive overtreatment.
With our fascination for information and instant results, most people understandably want the detailed look inside their body MRI provides. We want to see what is going on, to determine the cause of our pain. The problem is that we don’t have enough data to distinguish between normal abnormalities and those that cause the pain non-conservative treatment can cure. So doctors recommend more treatment, from injections to surgery, due to this modern technology view into our bodies.
[When Knowing More Should Mean Doing Less]
Evidence-based algorithms show us that positive imaging results are the main finding supporting invasive care instead of conservative care. As an example, UR companies that follow evidence-based guidelines do not typically authorize payment for an MRI prior to least six weeks of conservative treatment. However, many industry participants dislike the “wait and see” during this conservative care period. After all, doesn’t the delay cause patients to think of themselves as victims of pain? Doesn’t the delay drive up indemnity costs? Doesn’t the delay just delay the inevitable?
So why wait six weeks? The word ‘wait’ is our problem. This is not a waiting period intended to make a patient wait for treatment. It is an important period of time intended to resolve a person’s pain through safe and effective conservative care.
Many people are simply waiting for the opportunity to “see what is going on.” Perhaps Watson is actually whispering to us – the growth in MRI usage is causing us to detect things we think need treatment, when it is actually distracting us from real, effective patient care. MRI can reveal incidental or common abnormal findings that may divert attention from the true pain source.
The MRI Problem is Much More Costly in Workers’ Comp than in Group Health
According to the National Council on Compensation Insurance (NCCI), the costs of treating injuries covered by workers’ compensation are consistently higher than for comparable injuries covered by group health. This correlates to both price and utilization, but more-so to utilization. Only physical therapy outpaces radiology in having higher utilization in workers’ comp than in group health.
While the higher costs and utilization are substantial, workers’ compensation systems carry a much heavier burden. In its white paper, Lockton Companies states, “…the proliferation of precise imaging has meant that workers are disabled longer than historical baselines.”
Systematic Cuts are Not the Answer
Some experts argue that the increase in imaging reflects improved patient care, while others say the costs associated with imaging are out of proportion to the benefits. According to health policy journal, Health Affairs, even if spinal imaging were decidedly more beneficial, the cost increases are not sustainable.
Health care payers, utilization review companies and regulators have tried to slow the soaring use of imaging. But their methods have tended to decrease imaging across the board instead of selectively reducing unnecessary tests. We need more patient outcome studies in order to better understand when MRI findings are most likely to benefit patients in the race to surgery.
Will Smarter MRI Prevent Unnecessary Treatment?
If a tree falls in a forest and no one is around to hear it, does it make a sound? False positive imaging is analogous to this philosophical question about observation and reality. If a patient has a bulging disk, but there’s no MRI to show it, is the disk causing the pain? The pain is real, but the reason for it may have nothing to do with the abnormality shown in the MRI.
The IBM commercial mentioned earlier notes that data is increasingly visual stating “In fact, a radiologist might view a thousand images to find one tiny abnormality in shape, contrast or movement.” It’s precisely that “one tiny abnormality” that has many experts concerned. Up to one third of individuals with no back symptoms have visible abnormalities on imaging studies.
According to IBM, the average person is likely to generate more than one million gigabytes of health-related data in his lifetime, and most of the data is discarded. Artificial intelligence may be as promising to healthcare as advertised if we are able to harness the use of the information. We need to find out what common abnormalities mean and stop automatically reacting to them with invasive care that has little potential to reduce pain.
Let’s do something about this red herring. We all have abnormalities (and pain) of some kind, and they do not all require treatment. Patient outcome studies of conservative care following “abnormal findings” could make imaging more beneficial in achieving accurate diagnosis that supports conservative care rather than just placing patients into a waiting period for aggressive care.