ER Imaging Overutilization: CT Scans in 36% of Visits!!

This video provides an in-depth exploration of the significant issue of emergency room (ER) imaging overutilization in the United States, highlighting its financial implications and contributing factors. Dr. Eric Bricker begins by sharing a personal anecdote about a $5,000 CT scan that constituted 83% of his total ER bill, immediately establishing the immense cost burden associated with advanced imaging in emergency settings. He then presents compelling statistics, revealing that out of 150 million annual ER visits, 50% involve some form of imaging, with 36% including a CT scan and 2.5% an MRI – figures that have surged over 300% in the last decade.

The presentation delves into the various factors driving this overutilization, categorizing them into patient demographics (middle-aged or older, drug use, non-English speaking), patient psychology (anxiety, specific expectations), physician behavior (malpractice avoidance), and systemic issues. A particularly insightful point is the practice of non-ER physicians sending patients to the ER for imaging to circumvent prior authorization hurdles or administrative delays, effectively turning the ER into a "24/7 Advanced Imaging Center." The video also contrasts the fee-for-service model, prevalent in most of the US, with capitated models like Kaiser in California, demonstrating how financial incentives directly influence imaging rates.

Dr. Bricker critically analyzes the failure of the Centers for Medicare & Medicaid Services (CMS) to implement the Appropriate Use Criteria (AUC) program, a decade-long effort mandated by Congress to reduce imaging overutilization. Despite a law passed in 2014, CMS was unable to fully implement the program, eventually pausing it in 2024, partly due to a significant exemption for emergency departments. This highlights the challenges of health policy implementation. Finally, the video offers a proven solution: employers and Medicare Advantage plans have successfully reduced ER utilization and associated imaging by up to 30% within a year by providing patients with 24/7 access to primary care through on-site, near-site, direct primary care clinics, or virtual visits, offering a viable alternative to the ER for non-emergent issues.

Key Takeaways:

• Significant Cost Burden of ER Imaging: Advanced imaging, particularly CT scans, can account for a disproportionately large percentage of an ER visit's total cost, as illustrated by an example where a CT scan was 83% of a $3,000 allowed amount.
• High Prevalence of Imaging in ERs: Approximately 50% of the 150 million annual ER visits in America involve some form of imaging, with 36% including a CT scan and 2.5% an MRI.
• Dramatic Increase in Advanced Imaging: The utilization of CT scans and MRIs in ERs has increased by over 300% in the last 10-15 years, transforming ERs into de facto "24/7 Advanced Imaging Centers."
• Multiple Factors Drive Overutilization: Key drivers include patient demographics (older age, drug use, non-English speaking), patient anxiety/expectations, physician's fear of malpractice lawsuits, and requests from non-ER physicians seeking to bypass prior authorization or administrative delays.
• Financial Models Impact Imaging Rates: Fee-for-service models are associated with higher rates of advanced imaging in the ER compared to capitated models (e.g., Kaiser, group HMOs) where providers bear financial risk.
• Failure of Regulatory Intervention: The CMS's Appropriate Use Criteria (AUC) program, mandated by Congress in 2014 to curb imaging overutilization, failed to be effectively implemented over a decade and was ultimately paused in 2024, demonstrating the difficulty of policy change in healthcare.
• ER Exemption from AUC: A major loophole in the AUC program was the exemption of emergency departments, allowing ER doctors complete discretion in ordering imaging without decision support tools or financial penalties.
• ER as a High-Volume Outpatient Imaging Center: With 86% of ER visitors going home, the ER often functions as an expensive, high-volume outpatient imaging center rather than solely for true emergencies.
• Effective Solution: 24/7 Primary Care Access: Employers and Medicare Advantage plans have achieved up to a 30% reduction in ER utilization (and associated imaging) within one year by providing patients with 24/7 access to primary care through on-site, near-site, direct primary care clinics, or virtual visits.
• Importance of Alternative Care Pathways: Offering accessible primary care alternatives helps divert non-emergent cases from the ER, reducing unnecessary advanced imaging and overall healthcare costs.

Tools/Resources Mentioned:

• Electronic Medical Record (EMR): Mentioned in the context of decision support tools for Appropriate Use Criteria.
• Decision Support Tool: A hypothetical tool within EMRs for guiding appropriate imaging orders.

Key Concepts:

• ER Imaging Overutilization: The excessive and often unnecessary use of diagnostic imaging (like CT scans and MRIs) in emergency departments.
• Appropriate Use Criteria (AUC): Specific guidelines developed by healthcare policy makers and researchers to determine when it is medically appropriate to order certain diagnostic tests, particularly advanced imaging.
• Protecting Access to Medicare Act of 2014: The federal law that mandated the implementation of Appropriate Use Criteria for advanced diagnostic imaging services under Medicare.
• Fee-for-Service: A payment model where providers are paid for each service they perform, which can incentivize higher utilization of services.
• Capitated/Group HMO: A payment model where providers receive a fixed amount per patient per period, regardless of the services provided, which can incentivize cost control and appropriate utilization.
• On-Site, Near-Site, Direct Primary Care Clinics: Models of primary care delivery that offer convenient and often 24/7 access to primary care physicians, serving as alternatives to ER visits for non-urgent conditions.