Medical imaging boom spurs cost debate.

L.A.'s major medical centers are undergoing a building boom in expanded and enhanced imaging facilities amid a continuing debate in health care circles about whether MRIs and other scanning equipment have been overused.

Tens of millions of dollars are being invested in the new machinery at Cedars-Sinai Medical Center, Good Samaritan Hospital, UCLA Medical Center and USC University Hospital, among others. With high-end magnetic resonance imaging sometimes costing patients more than $1,000, these services have become significant revenue producers for hospitals -- especially for outpatients.

"Imaging technology has been expanding almost at the same rate of Moore's law -- it's doubling every 18 months or so' said John Relic, who is overseeing the development of Good Samaritan's center. "And we are taking the position of making sure we provide the best technology available."

The pace of technological advancement has accelerated in recent years, with imaging machines capable of detecting many more diseases faster than ever. This has prompted unprecedented demand by both patients and doctors for the screenings.

But while the benefits are undeniable, there are questions about the necessity of many of the procedures, along with concerns that increasing the availability of such scanning will lead to unnecessary testing.

A recent report by the BlueCross BlueShield Association found that hospital outpatient costs, which include the provision of imaging services to patients who are not admitted, are the fastest growing component of skyrocketing health care costs.

"There is little doubt this is one of the contributing factors to an upward push in cost," said Dr. Michael Belman, a medical director at Blue Cross of California, a division of Well-Point Health Networks Inc. and the largest for-profit health insurer in California.

Belman said that when hospitals and other providers expand the availability of new technology, it tends to get used, whether it is needed or not. "Availability is the clear factor," he said.

'Cheating' death'

Dr. Barry Pressman, chair of the department of imaging at Cedars-Sinai, concedes that as much as 20 percent of all imaging may be unnecessary, but adds that those costs are outweighed by the benefits of making faster, more accurate diagnoses -- and thus making unnecessary expensive, invasive procedures. "There are cost savings in getting the patient through the system faster, and getting them back to work faster," he said.

Jim Lott, executive vice president of the Healthcare Association of Southern California, the region's hospital industry trade group, says the enhancement in imaging technology illustrates health care's basic paradox.

"In any other industry, the better you do the costs go down, but in our industry the goal is to cheat death, so the more we find out the more care we provide," he said. "It's a strange economic and it's unique to our industry."

CT scanners, the first of the new high tech imaging technologies, were first introduced in the early 1970s, but advances in another competing technology, the MRI threatened to make it superfluous. That was until major improvements came along in the latter half of the 1990s.

CT scans emit radiation and take pictures of "slices" of the human body that can differentiate blood, tissue, and bone. The first machines took only single slices, but the newest machines can take 16 images at a time. Manufacturers have learned how to build machines that can rotate the 2,000 pounds of X-ray equipment in a circle as fast as 0.4 seconds.

That provides, for example, stunningly clear pictures of arteries that have significantly advanced the diagnosis of coronary artery disease.

"The images are dramatically better, and if you are a busy clinician having to take care of a lot of patients part of your job is to collect as much valuable information as possible," said Dr. Dieter Enzmann, chairman of the radiology department at UCLA Medical Center.

MRIs, which pulse magnetic fields through the body, now use bigger magnets, while also taking advantage of advances in computer technology. Orthopedists love the technology because it provides clear images of minute tendon tears.

At Cedars-Sinai, imaging services were located on each floor of its inpatient medical tower until demand by outpatients led the hospital in 1995 to open a small, dedicated outpatient imaging center.

It couldn't keep up with growing demand, leading to the opening a few months ago of the three-story $90 million S. Mark Taper Foundation Imaging Center for both inpatients and outpatients. It includes five MRIs, six CT scanners, two PET scanners -- another even pricier technology -- as well as dozens of other pieces of equipment, from sophisticated ultrasound machines to digital X-ray units.

"You can't be a serious provider of health care in this country unless you have a first-class imaging center," said Lynne Roy, Cedars-Sinai's director of imaging.

Feeling the competition

UCLA first opened its outpatient imaging facilities a decade ago in buildings next to its main campus, and isn't planning any major renovations. But it is about to upgrade half a dozen CTs and MRIs over the next two years.

Frances Ridlehoover, chief operating officer of UCLA Health Systems, denies any response to the new center at Cedars-Sinai, which is often seen as its West Los Angeles rival. Instead, she said the hospital often upgrades its imaging equipment as advances in the technology accelerate.

Enzmann admits feeling pressure from Cedars-Sinai, but he argues there is nothing wrong with hospitals competing with each other to offer the best technology.

"Until someone outlaws competition for hospitals there will be different dimensions in which they compete and imaging happens to be a popular one," he said. "It's a general phenomenon with hospitals."

Not everyone is so sanguine about the growth of the use of imaging technology, especially as it affects rising health care costs.

Eric Gemmen, an economist with The Lewin Group, a health care policy research firm that worked on the BlueCross BlueShield study, said "the patient is concerned about whether or not they have the disease. They are not concerned about its effect on health care premiums overall."

The doctor, Gemmen added, "is worried about malpractice. If they run a test and detect something they are less likely to face a lawsuit than if they don't."

That's especially true in an outpatient setting, where hospitals are generally paid fees for every service they provide, either through negotiated contracts with commercial insurers, or through set fees established by the government for its Medicare and Medicaid programs.

"There certainly are incentives to promote the use of these services, because you do want to earn a return on what you've invested," said Paul Ginsburg, president of the Center for Studying Health System Change, a health care policy think tank. "And buying the equipment is a huge ticket."

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