Strategies for Managing

Imaging Utilization
Mark Bernardy, MDa, Christopher G. Ullrich, MDb,
James V. Rawson, MDc, Bibb Allen Jr, MDd,e, James H. Thrall, MDf,
Kathryn J. Keysor, BSg, Christie James, MSh, John A. Boyes, MD, MBAi,
Worth M. Saunders, MHAj, Wendy Lomers, CPA, MBAk,l,
Daniel J. Mollura, MDm, Robert S. Pyatt Jr, MDn, Richard N. Taxin, MDo,
Michael R. Mabry, MAp

Imaging represents a substantial and growing portion of the costs of American health care. When performed correctly
and for the right reasons, medical imaging facilitates quality medical care that brings value to both patients and
payers. When used incorrectly because of inappropriate economic incentives, unnecessary patient demands, or
provider concerns for medical-legal risk, imaging costs can increase without increasing diagnostic yields. A number
of methods have been tried to manage imaging utilization and achieve the best medical outcomes for
patients without incurring unnecessary costs. The best method should combine a prospective approach; be
transparent, evidence based, and unobtrusive to the doctor-patient relationship and provide for education
and continuous quality improvement. Combining the proper utilization of imaging and its inherent cost
reduction, with improved quality through credentialing and accreditation, achieves the highest value and
simultaneous best outcomes for patients.
Key Words: Utilization management, computerized order entry system, decision support, preauthorization,
prior notification, radiology benefit management company, RBM
J Am Coll Radiol 2009;6:844-850. Copyright © 2009 American College of Radiology

INTRODUCTION been driven by some negative factors, including the incom-

Annual spending on diagnostic imaging increased from
$220 to $419 per Medicare beneficiary between 2000 and
2006 [1]. More recently, there has been a flattening of the
rate of growth of imaging costs in the Medicare population.
Apart from increased use due to the positive role imaging is
playing in redefining medical practice through safer, less
invasive, and more accurate means of collecting diagnostic
information, this rapid growth of imaging costs has also
plete dissemination of appropriateness guidelines in the
medical community, the incomplete availability of patients’
imaging histories, leading to duplicate studies and unneces-
sary radiation exposure, inappropriate economic motiva-
tions, defensive medicine, and misguided patient prefer-
ences [1].
Many strategies have been used to try to manage or de-
crease the utilization of imaging. The characteristics of an
ideal approach require that it be transparent to all stakehold-

h
C.G. Ullrich is a member of the Optinet Advisory Panel of American Massachusetts General Hospital, Charlestown, Massachusetts.
i
Imaging Management and a member of the Diagnostic Imaging Advisory Mount Vernon, Washington.
Group of NC Blue Cross Blue Shield. J.H. Thrall is chairman of the board of j
Mid-South Imaging & Therapeutics, PA, Memphis, Tennessee.
Mobile Aspects and an equity partner. J.A. Boyes is a consultant with RadMe- k
Radiology Associates of San Antonio, PA, San Antonio, Texas.
trices. W. Lomers is a staff member of Radiology Associates of San Antonio. l
Advanced Medical Imaging Centers, FlexRad, San Antonio, Texas.
a
Conyers, Georgia. m
Russell H. Morgan Department of Radiology and Radiological Science,
b
Charlotte Radiology PA, Charlotte, North Carolina. Johns Hopkins University School of Medicine, Baltimore, Maryland.
c
Department of Diagnostic, Therapeutic and Interventional Radiology, Med- n
Chambersburg Hospital, Chambersburg, Pennsylvania.
ical College of Georgia, Augusta, Georgia. o
Crozer Chester Medical Center, Upland, Pennsylvania.
d
Birmingham Radiological Group, PC, Birmingham, Alabama. p
Radiology Business Management Association, Fairfax, Virginia.
e
Department of Radiology, Trinity Medical Center, Birmingham, Alabama. Corresponding author and reprints: Kathryn J. Keysor, BS, American Col-
f
Massachusetts General Hospital, Boston, Massachusetts. lege of Radiology, 1891 Preston White Drive, Reston, VA 20191; e-mail:
g
American College of Radiology, Reston, Virginia. kkeysor@acr-arrs.org.

844 © 2009 American College of Radiology

0091-2182/09/$36.00 ● DOI 10.1016/j.jacr.2009.08.003

ers, practical (as unobtrusive as possible in the normal work
processes of providers), efficient, consistent, and educa-
tional. The system should allow the opportunity for further
development, such as using data to guide the further con-
tainment of unnecessary utilization. Strategies that offer the
best return in the long run will be data driven and result in
the continuous education of providers and patients. They
will be designed to fit within the framework of normal
patient care processes. Providing decision support on the
basis of evidence-based utilization guidelines, such as the
ACR Appropriateness Criteria® at the point of computer
order entry, meets these criteria. The ideal scenario for the
health care system will be the marriage of an effective utili-
zation management system with the delivery of associated
imaging services that meet equally rigorous quality stan-
dards.
DRIVERS OF INCREASED IMAGING
UTILIZATION
To define the ideal method, or methods, to control the
unnecessary utilization of imaging, it is important to
understand the positive and negative factors underlying
the trend toward more imaging. On the positive side is
the prospect of achieving better, faster diagnoses using
contemporary, noninvasive imaging methods, some-
times in place of more invasive and expensive procedures
(Table 1). This is overwhelmingly the most important
factor in the rapid rise of imaging utilization. It has come
from the needs of all medical disciplines and affects pa-
tients with a wide spectrum of diseases and conditions.
However, in some instances, the rapid integration of ad-
vanced medical imaging into clinical practice has exceeded
the ability of the medical community to discern the most
appropriate imaging studies for their patients’ clinical cir-
Table 1. Imaging studies that replaced other
examinations
Prior Evaluation Current Clinical
Technique Practice
Surgical breast biopsy Image-guided breast
biopsy
Pneumoecephalography CT and MR brain
Surgical drainage of Image-guided
abscess percutaneous
drainage
Exploratory CT abdomen and pelvis
laporaotomy
Diagnostic angiography CTA and MRA
Venography for DVT Venous ultrasound
Myelography and CT MRI
Note: CTA ⫽ computed tomographic angiography; DVT ⫽ deep
venous thrombosis; MRA ⫽ MR angiography.
Bernardy et al/Strategies for Managing Imaging Utilization 845
cumstances. Additionally, because patients often receive
care from multiple physicians and at different facilities, du-
plicate examinations are performed because ordering physi-
cians do not have access to patients’ complete imaging his-
tories. Also on the negative side of the ledger are factors such
as inappropriate economic incentives for providers, defen-
sive medicine by providers, and misguided patient prefer-
ences. Finally, the aging US population is also a prevailing
factor contributing to increasing imaging utilization. Older
individuals are expected to use more of all medical services,
including imaging.
Most of the increased utilization in imaging is appropri-
ate and adds value to the care of patients [2]. In addition to
improved diagnostic capabilities, imaging is used for surveil-
lance in many diseases, allowing earlier diagnosis, interven-
tion, and changes in therapy when necessary. Many profes-
sional societies have developed best practices or clinical
algorithms that reflect that imaging is a key feature in the
workup of numerous clinical situations [3,4]. However, ap-
propriateness and comparative effectiveness guidelines have
not been uniformly disseminated to the medical commu-
nity, leading to some inappropriate use of medical imaging.
Physician ownership of advanced imaging equipment
provides an economic incentive for increased imaging utili-
zation. The in-office ancillary services exception to the
“Stark” conflict-of-interest legislation allows “ordering”
physicians to provide advanced imaging services (CT, MRI,
and PET) in their offices [1]. The ownership of advanced
imaging equipment by nonradiologists has dramatically in-
creased over the past 10 years because of the ability of self-
referring physicians to increase their own revenue by shift-
ing examinations away from independent imaging centers
and hospitals. Although not all of this imaging is inappro-
priate, it is clear from multiple studies that the utilization of
imaging by many ordering physicians increases when they
have ownership interest in imaging equipment [5-7].
In the work of Gazelle et al [8], the average likelihood of
image utilization for 8 medical scenarios was greater than 2
to 1 when there was a financial incentive compared with
when the referral was not financially motivated. In percent-
age terms, this equates to 100% more imaging being per-
formed under conditions of self-referral. To deny this reality
is to deny normal human economic behavior. We are not
aware of any credible studies showing “neutral behavior” or
unchanged ordering habits among physicians after purchas-
ing advanced imaging equipment.
Finally, some have suggested that radiologists are a cause
of inappropriate imaging utilization because they recom-
mend unnecessary additional studies. There are no credible
studies demonstrating that this is a significant factor in the
overall growth of imaging utilization. In fact, there is evi-
dence to the contrary. Lee et al [9] determined that only 8%
of follow-up or repeat imaging was associated with radiolo-
gists’ recommendations in a large study encompassing
846 Journal of the American College of Radiology/ Vol. 6 No. 12 December 2009
⬎100,000 examinations. The vast majority of these were
appropriate recommendations for disease surveillance or
workup of unsuspected clinically significant conditions.
Defensive medicine occurs when physicians’ decision
making is influenced by their perceived risk for litigation
from their interactions with patients. In this context, imag-
ing studies may be ordered primarily to demonstrate order-
ing physicians’ care and thoroughness; they are used to
exclude unlikely but dangerous diagnoses. Defensive medi-
cine is universal. A survey of 900 providers by the Massa-
chusetts Medical Society in 2008 found that 22% of x-ray
examinations, 28% of CT scans, 27% of MRI scans, and
24% of ultrasound examinations were ordered for defensive
reasons [10]. Unfortunately, this increased utilization often
does not benefit patients, but it does add substantial costs.
Patients’ expectations and preferences also motivate im-
aging utilization. Increased patient awareness of advanced
imaging leads some to expect and even demand imaging
evaluations of their clinical concerns. This awareness is a
mixed blessing driven by the media, direct-to-consumer
marketing, the Internet, and self-help books. Effective
and proper patient education can be difficult to define,
let alone achieve. Physicians who fail to image these pa-
tients risk losing them from their practices. Insurers that
refuse payment may be viewed as greedy or obstructive.
Patients’ preferences also matter. For example, a recent
study of colon cancer screening indicated that almost
40% of the surveyed patients would refuse optical
colonoscopy but were willing to undergo CT colonogra-
phy (unpublished data presented to CMS by Brooks
Cash, March 3, 2009).
STAKEHOLDERS AND THE IMPACT OF
INCREASED UTILIZATION
Although patients have the biggest stake in having the most
appropriate imaging examinations performed, there
are many other stakeholders, often with opposing incen-
tives (see Figure 1). Medical equipment manufacturers,
physicians, and hospitals have incentive to perform im-
Fig 1. Stakeholders and funds flow in health care.
aging studies, while payers for health care generally have
incentive to control costs or raise premiums to be profit-
able. Ironically, almost all of the stakeholders are paying
for health care, and yet the increase in the utilization of
imaging services affects each stakeholder in very different
ways. The challenge is to align stakeholder incentives
with the best outcomes for patients.
EDUCATION AND STANDARDIZATION OF
ORDERS FOR IMAGING
There is sometimes a lack of knowledge on the part of
ordering physicians, who want to do what is best for their
patients but do not understand which imaging study is best
suited to confirming or excluding the diagnosis in question.
This may result in an inappropriate study being ordered and
performed and often a recommendation from the radiolo-
gist for a more appropriate follow-up study. Appropriate
management of the utilization of medical imaging should
begin with how physicians are trained to use medical imag-
ing to benefit their patients. Although the integration of
imaging utilization training into medical school and resi-
dency training is beyond the scope of this review, appropri-
ate utilization should become a major focus of medical stu-
dent or resident training in specialties outside of image-
intensive specialties. However, it must be recognized that
many practicing physicians have not received any formal
training in the appropriate use of advanced medical imag-
ing. To diminish inappropriate utilization and provide ed-
ucation to ordering physicians, order sets and clinical path-
ways are now being used in some locales to standardize care,
including the appropriate utilization of imaging and other
resources. Although order sets were initially used to stream-
line prevailing practice, the focus began to shift from stan-
dardizing individual or local practices to standardizing prac-
tices within a profession. Professional societies, such as the
ACR, have produced standards and guidelines to define
standard practices [11]. As evidence-based medicine and
patient safety programs grew, the best-practice guidelines
used in some locales moved from a consensus basis to data-
driven algorithms that crossed specialties and disciplines.
Such standardized systems allow physician education at the
time of order entry and provide the means to order the
appropriate test for the presenting clinical complaints with-
out necessarily having had extensive experience with the
current imaging techniques, sensitivity, and specificity in
that clinical scenario [12].
MANAGING IMAGING UTILIZATION
A number of methods have been used to manage imaging
utilization, with the aim of minimizing or reducing unnec-
essary imaging studies, especially higher cost advanced im-
aging examinations (Table 2). Some methods focus on de-
creasing utilization by restricting access using various

Table 2. Methods to reduce inappropriate
imaging
Method Example
Order entry/decision University of Florida
support systems Health Center,
Massachusetts General
Hospital, Minneapolis
Area Imaging
Accreditation ACR, MQSA, IAC
programs
Network strategies CareCore, NIA, etc
Radiology benefit NIA, AIM, Med Solutions,
management HealthHelp
Unit cost reduction Deficit Reduction Act,
bundled payments
Note: AIM ⫽ American Imaging Management; IAC ⫽ Intersoci-
etal Accreditation Commission; MQSA ⫽ Mammography Qual-
ity Standards Act; NIA ⫽ National Imaging Associates.
means, while others focus on ordering the correct study
through education and feedback. Controlling approval and
providing feedback at the time of ordering are common
approaches. Managed care organizations attempted to use
preapproval programs to control utilization in the early
1990s and received significant public criticism [13,14]. Uti-
lization management systems may also include physician
and provider profiling, prior notification requirements or
preauthorization processes, network strategies, and unit-of-
service payment reductions.
Order Entry and Decision Support Systems
Computerized provider order entry and decision support
systems that provide immediate feedback about appropri-
ateness at the time of ordering are an education-focused
method of utilization management. Standardized indica-
tions are directed at each modality, symptom, and body part
through the use of examination-specific “pick lists.” An “ap-
propriateness” score is presented to the requesting physi-
cian, along with scores for other imaging modalities that
might be selected for the same indications. For examina-
tions receiving very low scores, various barriers to ordering
can be implemented. Physicians’ performance with respect
to appropriateness is tracked over time and compared with
that of their peers. Alerts about duplicative scans can avoid
unnecessary patient radiation and other examination risks.
This is a time-efficient and cost-effective process that can be
used in inpatient, outpatient, and emergency care settings.
The primary conceptual difference between decision
support and prior authorization by a radiology benefit man-
agement (RBM) company, described below, is that decision
support advises the ordering physician on the individual
case and evaluates the ordering physician across the spec-
trum of cases, rather than simply serving as a gatekeeper.
Bernardy et al/Strategies for Managing Imaging Utilization 847
This is an educational process that does not disrupt patient
care workflow or disrupt the physician-patient relationship.
The radiology department at Massachusetts General
Hospital has designed an order entry system with deci-
sion support on the basis of the ACR Appropriateness
Criteria. Their 7-year experience showed a reduction in
the quarterly compound growth rate of 2.75% for out-
patient CT, 1.2% for outpatient MRI, and 1.3% for
outpatient ultrasound during steady growth of clinic vis-
its [15]. This approach can also be applied to inpatients
and emergency room patients.
Computerized provider order entry with decision sup-
port has proven to be an effective approach to imaging
utilization and should be explored further. It has a number
of characteristics that are highly desirable and works in a
completely transparent manner. It is completely reproduc-
ible, unlike the results of phone conversation– based prior
approval systems. Computerized provider order entry with
decision support is also highly practical because it fits di-
rectly into the workflow of a physician’s office. It is efficient
and provides continual education because each episode of
ordering results in immediate feedback to the provider. The
approach is suited to further development because it collects
data about ordering patterns, permitting focused review and
updating of criteria as well as allowing identification and
management of outlier behavior.
Prior Notification
Prior notification is a strategy used by several large national
payers (eg, UnitedHealthcare, Humana). Prior notification
seeks to educate ordering physicians on the best imaging
study given the reported clinical indications on a case-by-
case basis. The ordering physician maintains the ability to
order an imaging study contrary to the advice of the health
plan should they believe it is indicated. Health plans using
this approach believe that prior notification encourages phy-
sicians to select the most appropriate studies on the basis of
individual patients’ clinical circumstances [16]. Almost all
health plans using prior notification have emphasized their
desire to collaborate with physicians rather than simply
deny or limit imaging services. Physician profiles may be
part of their notification programs, creating a form of peer
pressure to be conservative in using imaging resources.
Prior Authorization
Prior authorization (sometimes referred to as precertifica-
tion) is a more stringent process for imaging utilization
management that has been used by insurance companies
and the RBM companies they have hired. Prior authoriza-
tion requires an ordering physician to obtain authorization
from the insurance company or its designee before a study is
performed in order to receive payment for the service. The
ordering physician is required to contact a center and obtain
authorization on the basis of the proprietary guidelines,
848 Journal of the American College of Radiology/ Vol. 6 No. 12 December 2009
purportedly built from the ACR appropriateness guidelines
but often including proprietary clinical algorithms [17].
Unfortunately, these programs are not using the ACR Ap-
propriateness Criteria as envisioned by the College, as they
seem to ignore the comparative effectiveness, function, and
educational value of these criteria. Prior authorization pro-
grams introduce barriers to patient care by introducing a
layer of administrative complexity that creates additional
costs and administrative burdens for referring physicians,
hospital outpatient and freestanding imaging centers, and
radiology groups [18]. Prior authorization can also delay the
provision of appropriate health care to patients if authoriza-
tion is not obtained at the time the examination is requested
by the referring physician. Payment denials are often based
on procedural “errors” rather than a lack of medical neces-
sity [19]. Some of these programs are intentionally burden-
some to discourage utilization. Because of its somewhat
cumbersome structure, prior authorization functions only
in the outpatient setting. Few physicians find this process
“educational” beyond learning how to game these systems
to get requested examinations authorized.
The RBM companies claim to improve the quality of pa-
tient care while saving health plan partners millions of dollars a
year. However, the effectiveness of prior authorization is not
uniformly accepted. The Medicare Payment Advisory Com-
mittee, in its 2005 report to Congress, wrote that prior autho-
rization was costly and ineffective in controlling imaging utili-
zation [20]. In a follow-up 2008 report, the Government
Accountability Office opined that prior authorization by RBM
companiescouldbeusefulincontrollingimagingutilization.In
responding to that report, the US Department of Health and
Human Services pointed out that “there is no independent
data—other than self-reported—on the success of RBMs in
managing imaging services” [1]. Furthermore, the effectiveness
of the algorithms used by RBM companies in maintaining the
quality of care has not been validated for the Medicare popula-
tion, in which the prevalence of disease is higher than in the
general population, and delays in diagnosis associated with ob-
taining prior authorization could cause detrimental outcomes
due to the frequent comorbid conditions in Medicare patients.
In a recently published variation of preauthorization, imag-
ing studies not meeting the RBM company’s preauthorization
criteria were referred to an academic neuroradiologist for review
with the referring physician. After consultation, an additional
29% of these studies were performed or changed to more ap-
propriate examinations. This study also demonstrates the bur-
densome nature of preauthorization programs. Thirty-seven
percent of studies not meeting the RBM company’s preautho-
rization criteria were initially withdrawn because the referring
physician did not immediately call to review; however, 36% of
these were ultimately performed. It was not stated whether the
delays resulted in any adverse outcomes [21].
Although there may be savings to insurance compa-
nies associated with preauthorization programs, these
dollars do not leave the health system. The savings are
a cost shift to other stakeholders in health care, such as
additional staff members in doctors’ offices and hos-
pitals [22].
Network Strategies
Network strategy efforts tend to focus on examination cost,
quality, or a combination of these factors. Accreditation is a
system to ensure that when an examination is performed, it
is done properly. UnitedHealthcare and others use accredi-
tation as a significant factor in profiling providers for net-
work inclusion or payment [23]. Some plans profile provid-
ers strictly by cost with little regard to quality and then
actually divert patients to these facilities, sometimes over the
objections of the treating physicians and patients; quality
and continuity of care are ignored in such cases (Omega
Diagnostic Imaging, PC v CareCore National, LLC et al ).
Other plans use some combination of quality and cost pro-
filing to encourage a value-spending approach. Such efforts
range from advisory to compulsory in their design and func-
tion. As health savings accounts become more common,
patients are also demanding more cost and quality informa-
tion from their plan administrators. Some RBM companies
have extended into at-risk agreements with insurers, creat-
ing a situation in which the RBM companies’ profit (or loss)
is directly tied to their denial rates [24]. Patients enrolled in
these plans are rarely honestly informed about such incen-
tive arrangements.
Ensuring Quality: Accreditation Programs
and Practice Guidelines
The ACR’s accreditation programs were first established in
1963 and are continuously expanded and updated to remain
current with new technologies. There are currently 9 accredita-
tion programs: mammography, radiation oncology, ultra-
sound, stereotactic breast biopsy, MRI, breast ultrasound, nu-
clear medicine, CT, and PET. The ACR accreditation
programs are based on the ACR Practice Guidelines and Tech-
nical Standards, which are created through a thorough consen-
sus process and are approved by the Commission on Quality
and Safety as well as the ACR Board of Chancellors, the ACR
Council Steering Committee, and the ACR Council. Many of
these guidelines are collaborative efforts with other medical
specialty societies [25].
ACR accreditation is an educationally focused evaluation
of practices as well as a peer-reviewed assessment of image
quality and radiation safety. Qualifications of personnel,
equipment performance, and the effectiveness of quality
control and assurance measures as well as outcomes data are
also evaluated in the process. Facilities that achieve accredi-
tation meet a high standard of service, and as such, reim-
bursement programs that require accreditation from pro-
viders who provide imaging services promote quality
practice and patient care.

The focus on quality and the potential to reduce or elim-
inate inappropriate utilization by facilities that do not meet
the rigorous standards of accreditation is what has led some
payers, such as UnitedHealthcare, to require facilities to be
accredited to receive reimbursement for certain imaging
procedures. The Mammography Quality Standards Act
(MQSA) was passed in 1992 and established minimum
standards for performance and interpretation of mammo-
grams [26]. By 1994, 9.5% of the 10,000 mammography
sites existing before MQSA had closed because they could
not meet the new standards [27]. Changes in MQSA in
1997 required written communication of results to patients.
Because only accredited mammography programs are reim-
bursed, this new patient safety enhancement almost imme-
diately reached 100% compliance. The Medicare Improve-
ments for Patients and Providers Act of 2008 mandates
accreditation for advanced diagnostic imaging services, in-
cluding MRI, CT, nuclear medicine, and PET, by January
1, 2012 [28].
Unit Cost Reduction
It has been argued that advanced imaging studies are
overvalued and that the unit cost must be lowered to
reduce utilization. The Deficit Reduction Act of 2005
lowered the unit price of the technical fee in the Medicare
Physician Fee Schedule to the lower of the Medicare Fee
Schedule or HOPPS payment [29]. Unit cost reductions
mandated by the Deficit Reduction Act reduced spend-
ing on imaging per Medicare beneficiary by 10.5% but
did not significantly affect utilization. The growth of
tests subject to the HOPPS caps was almost 4 times
higher than that of those not subject to the HOPPS cap
[30]. Self-referral situations are very likely to respond in
this manner when unit prices decrease.
DISCUSSION
A review of the criteria for appropriate imaging utilization,
the drivers of imaging utilization, and the current methods
of utilization management allows the analysis and optimi-
zation of strategies to eliminate the inappropriate uses of
medical imaging. Ordering physicians have the pertinent
clinical information to make the best decisions for their
patients, and that knowledge can be supplemented with
evidence-based comparative effectiveness guidelines that
can be accessed at the time of order entry. The ideal method
is an evidence-based educational process to ensure that the
correct imaging study is chosen for the current clinical sce-
nario and in similar scenarios in the future. Programs that
intervene at the time of decision making without obstruct-
ing clinical workflow have the highest likelihood of accep-
tance by the ordering physicians. A computerized order
entry system with decision support for medical imaging
based on standardized comparative effectiveness criteria
Bernardy et al/Strategies for Managing Imaging Utilization 849
such as the ACR Appropriateness Criteria is best suited to
transfer these goals into clinical practice. Providing a stan-
dardized, evidence-based guide to ordering imaging studies
should help mitigate defensive medicine practices. Integra-
tion with portable electronic health records will make pa-
tients’ prior imaging histories available at the time of order
entry, eliminating duplicative examinations. Establishing
mandatory accreditation and credentialing for imaging pro-
viders can further enhance quality and patient safety. Ac-
creditation will ensure that the imaging study ordered is
performed in a way that the expected diagnostic yields are
obtained. Utilization management strategies should include
measures to ensure and improve quality, diminish defensive
medicine, and eliminate financially motivated imaging. If
these are accomplished and imaging is used appropriately,
cost savings will follow.
CONCLUSIONS
A review of existing practices shows that providing physi-
cian education at the time of order entry using computer-
ized order entry with decision support is a solution that is
educational, transparent, efficient, practical, and consistent.
Combined with an electronic imaging history to eliminate
unnecessary duplicate studies and the elimination of incen-
tives that lead to unnecessary imaging either from defensive
medicine or conflicts of interest, this strategy could com-
pletely eliminate inappropriate imaging utilization. Facility
accreditation will ensure that imaging studies are high qual-
ity and provided in a safe environment for patients. Al-
though there are numerous alternatives for managing the
costs associated with medical imaging, the choice of strategy
will ultimately depend on whether the goal of the stake-
holder is to merely reduce the number of imaging examina-
tions performed, reduce costs, or increase the likelihood that
the appropriate examination is ordered and inappropriate
utilization is eliminated. The choice of strategies may vary
on the basis of the perspective of the various stakeholders;
however, the perspective of patients must be paramount in
the decision-making process.
REFERENCES
1. US Government Accountability Office. Medicare Part B Imaging ser-
vices: rapid spending growth and shift to physician offices indicate need
for CMS to consider additional management practices (GAO-08-452).
Available at: http://www.gao.gov/new.items/d08452.pdf. Accessed Sep-
tember 22, 2009.
2. Lichtenberg FR. The quality of medical care, behavioral risk factors, and
longevity growth (NBER working paper no 15068). Available at: http://
www.nber.org/papers/w15068. Accessed June 30, 2009.
3. Qaseem A, Snow V, Barry P, et al. Current diagnosis of venous throm-
boembolism in primary care: a clinical practice guideline from the Amer-
ican Academy of Family Physicians and the American College of Physi-
cians. Ann Fam Med 2007;5:57-62.
4. Manning K, Tepfer B, Goldklang G, Loyd R, Garimella P, Halkar R.
Clinical practice guidelines for the utilization of positron emission tomog-
850 Journal of the American College of Radiology/ Vol. 6 No. 12 December 2009

raphy/computed tomography imaging in selected oncologic applications:
suggestions from a provider group. Mol Imaging Biol 2007;9:324-32.
5. Kouri BE, Parsons RG, Alpert HR. Physician self-referral for diagnostic
imaging: review of the empiric literature. AJR Am J Roentgenol 2002;
179:843-50.
6. Hillman BJ, Joseph BA, Mabry MR, Sunshine JH, Kennedy SD, Noether
M. Frequency and costs of diagnostic imaging in office practice: a com-
parison of self-referring and radiologist referring physicians. N Engl J Med
1990;332:1604-8.
7. Levin DC, Rao VM. Turf wars in radiology: updated evidence on the
relationship between self-referral and the overutilization of imaging. J Am
Coll Radiol 2008;5:806-10.
8. Gazelle GS, Halpern EF, Ryan HS, Tramontano AC. Utilization of
diagnostic medical imaging: comparison of radiologist referral versus
same-specialty referral. Radiology 2007;245:517-22.
9. Lee SI, Saokar A, Dreyer KJ, Weilburg JB, Thrall JH, Hahn PF. Does
radiologist recommendation for follow-up with the same imaging modal-
ity contribute substantially to high-cost imaging volume? Radiology
2007;242:857-64.
10. Massachusetts Medical Society. MMS survey examines defensive medicine.
Available at: http://www.massmed.org/AM/Template.cfm?Section⫽
Search8&template⫽/CM/HTMLDisplay.cfm&ContentID⫽27696. Ac-
cessed June 29, 2009.
11. American College of Radiology. American College of Radiology guidelines and
standards. Available at: http://www.acr.org/SecondaryMainMenuCategories/
quality_safety/guidelines.aspx. Accessed June 29, 2009.
12. Demmerle C, Glaudemans J. Diagnostic imaging: spending trends and
the increasing use of appropriateness criteria and accreditation. Washing-
ton, DC: Avalere; 2008.
13. Levine J. Critics say HMOs hiding facts to save bucks. Available at:
http://www.cnn.com/US/9605/31/hmo.backlash/index.html. Accessed
July 3, 2009.
14. Hinman A. Are HMOs the wrong prescription for patients? Available at:
http://www.cnn.com/HEALTH/9704/02/nfm.hmo/index.html. Accessed
July 3, 2009.
15. Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH.
Effect of computerized order entry with integrated decision support on
the growth of outpatient procedure volumes: seven-year time series anal-
ysis. Radiology 2009;251:147-55.
16. UnitedHealthcare. Radiology notification. Available at: https://
www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId⫽
71a436d4b6e32110VgnVCM100000c520720a____. Accessed June
29, 2009.
17. Iglehart JK. Health insurers and medical imaging policy—a work in
progress. N Engl J Med 2009;360:1030-7.
18. Casalino LP, Nicholson S, Gans DN, et al. What does it cost physician
practices to interact with health insurance plans? Health Aff 2009;May:
w533-43.
19. Duszak R. Deauthorization: the insidious new payer trick. J Am Coll
Radiol 2006;3:713-5.
20. Medicare Payment Advisory Commission. Report to the Congress: Medi-
care payment policy. Available at: http://www.medpac.gov/publications/
congressional_reports/Mar05_EntireReport.pdf. Accessed September
22, 2009.
21. Friedman DP, Smith NS, Bree RL, Rao VM. Experience of an academic
neuroradiology division participating in a utilization management pro-
gram. J Am Coll Radiol 2009;6:119-24.
22. Sakowski JA, Kahn JG, Kronick RG, Newman JM, Luft HS. Peering into
the black box: billing and insurance activities in a medical group. Health
Aff 2009;May:w544-54.
23. UnitedHealthcare. Imaging accreditation. Available at: https://
www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId⫽
dda436d4b6e32110VgnVCM100000c520720a____. Accessed June
29, 2009.
24. AllBusiness. Magellan Health Services to convert radiology management
contract with Empire Blue Cross Blue . . . . Available at: http://www.
allbusiness.com/services/business-services/4302265-1.html. Accessed
June 29, 2009.
25. American College of Radiology. Accreditation. Available at: http://www.
acr.org/accreditation.aspx. Accessed June 29, 2009.
26. Mammography Quality Standards Act of 1992. Pub L No 102-539. As
amended by the Mammography Quality Standards Reauthorization Act
of 1998, Pub L No 105-248, Title 42, Subchapter II, Part F, Subpart 3, §
354 (42 USC 263b), certification of mammography.
27. Destouet JM, Bassett LW, Yaffe MJ, Butler PF, Wilcox PA. The ACR’s
mammography accreditation program: ten years of experience since
MQSA. J Am Coll Radiol 2005;2:585-94.
28. Medicare Improvements for Patients and Providers Act of 2008, Pub L
No 110-275, Subtitle C, Part I, § 135, imaging provisions.
29. Deficit Reduction Act of 2005, Pub L No 109-171, § 5102(b), 120 Stat.
4, 39-40 (2006).
30. US Government Accountability Office. Medicare: trends in fees, utiliza-
tion, and expenditures for imaging services before and after implementa-
tion of the Deficit Reduction Act of 2005 (GAO-08-1102R). Available at:
http://www.gao.gov/new.items/d081102r.pdf. Accessed September 22,
2009.

To access the article and take the exam, log in to www.acr.org and click on the CME icon
located next to the JACR cover. Follow the instructions and answer 3 questions to
complete the requirement for CME. Claim the credit and print your CME certificate
online. Note: CME for ACR members is free, however you will need to click on the “Buy Now”
button and proceed through the shopping cart process in order to receive the credit.
The American College of Radiology is accredited by the Accrediation Council for Con-
tinuing Medical Education to provide continuing medical education for physicians. The
American College of Radiology designates this educational activity for a maximum of 1
AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with
the extent of their participation in the activity.