MR imaging: reimbursement and costs – a European potpourri
he average total payment per MR imaging examination in the United States is US$ 650. According to the newspaper Washington Post, fees for a single scan in the Philadelphia area ranged from US$ 850 to US$ 1,100 in 1990. In Europe, reimbursement styles are different and spiced with typically European ingredients.
Let’s start traveling:
To reduce costs in the health system, the reimbursement institutions of the Swiss canton of Ticino have decided not to cover MR imaging at all. There is an agreement between the providers of medical services and the reimbursement institutions about payments but apparently someone in the bureaucratic system believed that not paying the bills would solve all problems of the cost explosion.
In France, average reimbursement is US$ 350 for the first 4,000 scans per year, per machine. The fee for any patient thereafter is US$ 65, contrast agent included. In other words, the reimbursement for the entire examination does not even cover the cost of the contrast agent. Because Paris is the navel of the world, reimbursement in the capital is higher than in the suburbs or provinces. The fee levels are also according to field strength: less than 0.3 T; between 0.3 and 1.0 T; and above 1.0 T.
Norway is the country with the highest cost of living in Europe. As with the United Kingdom and Sweden, the country has a socialized welfare system lacking competition in health services. Waiting lines for diagnostic and therapeutic procedures are long and painful for the patients and their relatives. Prices for MR imaging were artificially set in late 1986; reimbursement was set at US$ 540 for a head scan and at US$ 690 for a body examination. Reimbursement was then cut by 20% in 1992. The unofficial reason given for this action was that doctors used MR imaging for research, which cannot be paid for by the state health system.
Access to MR examinations in parts of the country is restricted: neurologists or other specialists cannot refer patients directly to MR imaging but have to refer them to a hospital neurologist in a policlinic who will then reevaluate the referral. According to its inventors, this system was introduced to reduce health service costs. However, in reality waiting times for patients get even longer and health expenditure increases.
In Germany, what is worth noting is not the actual reimbursement fees but the regulations controlling them. The Germans have set the rules for reimbursement with characteristic precision, scientifically backed by experts. Their latest system was published early in 1992 by the Kassenärztliche Bundesvereinigung (National Association of Statutory Health Insurance Physicians) the German institution that regulates reimbursement of private-practice physicians.
Reading these regulations for the first time, it occurred to me that they might have been written by a major German manufacturer of MR equipment to promote the sales of its machines. Upon a second reading, I revised my judgement. They have been written by somebody representing a lobby of high-field users with a woeful lack of knowledge about magnetic resonance.
In the future, the profitability of high-field MR imaging will likely decline on account of decreasing reimbursement and higher operating costs. Institutions operating mid-field machines with the same or similar qualitative diagnostic value and efficacy will have an easier time and the use of these machines should contribute to a balanced cost efficiency in the health system.
Germany is the most important country in Europe with respect to heavy medical equipment. It is a trendsetter not only for the rest of Europe but, partly, also for the rest of the world. The conditions for qualifications set by the Kassenärztliche Bundesvereinigung for running an MR machine could easily create an uncontrollable chain reaction leading to an absurd and wrong development, adding to the already high costs in the health system, hurting health spending and the credibility of this otherwise well-respected institution. For Germany the regulations mean that many of the existing MR machines have to be exchanged before the deadline of 1995 to comply with these regulations. Cost efficient machines and some of the upcoming niche machines are killed.
These examples basically show that the agencies responsible for reimbursement are helpless and try to hide this with more or less fruitless actions to prevent increasing spending in the health system. They depend on experts whose schemes sound good but are either inefficient or court the interests of small groups. The result is a number of arbitrary regulations with little or no relevance for MR imaging examinations and patients.
From the patients' perspective, the struggles of bureaucrats and administrators, the number of examinations deemed adequate per machine or the characteristics of the machine itself are unimportant. It is the expediency of the health service and the quality of medical performance that matter. This is what should guide the policies of reimbursement institutions.
It does not take special foresight to see that both the expediency of the system and the quality of care are directly dependent on adequate reimbursement. Unfortunately, experience has shown that health bureaucrats are willing to pay for machines but are reluctant to pay for their operation and the physicians’ skills. It is almost as if machines were being acquired for the purpose of wining the “country-with-the-most-machines” race on the one hand or “let’s-go-back-to-herbal-medicine” on the other, and not for the real purpose of providing a service to patients.
In this context, the first question should be how many MR imaging systems – high-field, medium-field, and low-field – are necessary to cover the needs of a given population in an economic way. The answer to this question could be supplied by free market laws of demand and supply or it could be determined by a conscientious analysis of needs and capabilities. An international effort with the latter in mind is under way. Its goals are to outline the appropriate medical use of MR imaging with respect to other available diagnostic techniques and to analyze the adequate use of MR imaging in the health system with regard to technology and costs.
It then falls to reimbursement agencies to determine adequate fees on the basis of real needs and costs. Of course, different machines create different costs. A possible solution could be a standard fee calculated for an average mid-field machine, with an extra fee for more expensive high-field machines limited to those cases where high-field examinations are really compulsory. The calculation should not be more than a simple mathematical equation where machine depreciation and running costs, personnel costs, necessary supplies such as contrast agents, and, last but not least, the radiologist’s fee are factors considered.