Imaging overuse: What care cascades may cost you

When clinicians perform a low-value test “just to be safe,” it often leads to follow-up tests and procedures. These so-called “care cascades” expose patients to potential physical and financial harms. Previous research on cascade events show that they are incredibly common; thirty percent of physicians report that they experienced cascades without a meaningful outcome on a monthly basis.

Low-value imaging for back pain

One of the most commonly overused tests is imaging for low back pain. Back pain is extremely prevalent– impacting an estimated 577 million people worldwide– and is the leading global cause of disability. In the face of so much pain and discomfort, it’s tempting for doctors and patients to try tests and procedures, even when they are not proven to improve outcomes. Imaging for uncomplicated low back pain tops the list of most commonly overused services in the Medicare population, impacting 9% of beneficiaries and wasting $263 million in 2018.

Unfortunately, the cost of the initial test is only the beginning. In a recent article in the Journal of General Internal Medicine, Dr. Ishani Ganguli at the Harvard Medical School and colleagues examined the prevalence and cost of cascade events resulting from imaging overuse from back pain.

They looked at about 6,000 people within Massachusetts’ Blue Cross Blue Shield plan who received an inappropriate X-ray or MRI for low back pain from 2017-2019. Compared to others who were eligible for imaging but who didn’t receive it, those who had low-value imaging were more likely to have follow-up office visits, lab tests, and surgeries.

Those who had a low-value MRI were 14 percentage points more likely to have a cascade event compared to those with no initial imaging.

After six months, those who had an MRI were 14 percentage points more likely to have a cascade event, and those who had an X-ray were 9 percentage points more likely, compared to those with no initial imaging. Results were adjusted for differences in patient age, risk, and other characteristics.

The cost of cascades

Total costs and out-of-pocket costs were both much higher for patients that had low-value imaging. Among those who had a low-value MRI, total spending on cascades was $1050 greater and out-of-pocket cost was $298 greater six months after the MRI, compared to those who did not get any imaging.

Patients with a high-deductible health plan who received low-value imaging spent $513 more out-of-pocket on cascade events than patients who did not receive imaging.

Patients with a high-deductible health plan who received low-value imaging were exposed to even higher costs, spending $513 more out-of-pocket on cascade events than patients who did not receive imaging.

Your experience may vary…

The Journal of General Internal Medicine shows how costs can skyrocket due to care cascades, even for patients with commercial insurance. However, another recent study demonstrates that the cost of imaging can vary extremely based on which insurer you have and to which hospital you go.

In the journal Radiology, John (Xuefeng) Jiang from the Department of Accounting and Information Systems at Michigan State University and colleagues examined the price variation of common scans at more than 2,000 hospitals. They found that even at the same hospital, prices for thirteen common imaging tests varied by 3.8 times depending on the insurer. Prices for head CT were the most variable, with the highest price being 5.2 times the lowest at the same hospital. The median price of MRI for low-back pain was $1,426, but the price at the same hospital varied nearly five-fold depending on the insurer.

The suffering caused by back pain undoubtedly puts pressure on clinicians to offer unnecessary tests. But both doctors and patients should be aware that these tests given “just to be safe” actually create more harm for patients — both physical and financial.