The New England Journal of Medicine has called medical imaging one of the “great medical developments of the past thousand years” (1)—and even in the last 10 to 15 years, we have seen technological advances that have completely changed the way we deliver patient care on a daily basis. For cardiology in particular, noninvasive imaging is now central to clinical practice and research, irrespective of the disease entity or the area of interest of the cardiologist.

The cardiac care team now has a wide range of noninvasive imaging techniques that enable them to provide earlier and more accurate diagnosis and better quality care. Echocardiography, nuclear imaging, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) enable us to image the beating heart and its structures in three dimensions; evaluate cardiac function, valvular disease,and the anatomy and physiology of the coronary arteries; and even detect the early stages of atherosclerosis. In short, noninvasive techniques allow us to more clearly see various aspects of disease that used to remain obscure even with riskier, costlier, more invasive procedures. From early detection of disease to guidance of therapies in hybrid operating suites, imaging is now ubiquitous and essential.

Despite the benefits of medical imaging, it is not without cost. Policymakers at the state and national level, as well as private payers, have expressed concern over the years about the rising volume of imaging because of the increase in healthcare costs associated with this growth. Their response has been to seek control over who can perform imaging tests and where, through administrative protocols or state and federal laws.

The largest federal effort to regulate office-based medical imaging occurred as part of the Deficit Reduction Act of 2005 (DRA). This law cut payments for many office-based imaging services by requiring that payment for the technical component of an imaging service be charged at either the hospital outpatient prospective payment system (HOPPS) rate or the physician fee schedule amount, whichever is lower. Other cuts to imaging payments stem from drastic revisions to the practice expense methodology and changes with the ongoing review of “potentially misvalued” services in the Resource-Based Relative Value Scale. Today, further reductions in imaging reimbursements are being considered as a possible way to offset other Medicare payments. The significant reduction in reimbursement of cardiovascular imaging that has occurred in the past 5 years is in large part behind the observed migration of cardiologists from private practice to employment by hospitals and health care systems.

On the payer front, some of the nation's largest insurers have contracted with radiology benefit managers (RBMs) to limit the growth of imaging. Under the RBM model, providers must get prior authorization to perform an imaging test in order to be reimbursed. A June 2008 General Accounting Office (GAO) report recommended that the Centers for Medicare and Medicaid Services (CMS) examine the feasibility of this approach (2). Such an approach may reduce utilization in the short term but it unquestionably burdens the time and resources of the care team, payers, and the healthcare system. Furthermore, experience suggests that measures aimed at limiting costs through administrative oversight too often end up denying care to patients who really need it, and not reducing costs in the long run as much as shifting money away from the providers of care.

States have also been a battleground on imaging issues. Lawmakers and other interest groups have pushed legislation to completely ban in-office imaging or place arbitrary limits on reimbursement for nonradiologists. In July 2008, the American College of Cardiology (ACC) Arizona Chapter played an instrumental role in defeating a bill (S.B. 1224) that would have frozen in-office medical imaging for nuclear medicine and certain advanced imaging modalities at 2008 levels. In all states, the threat of legislation that limits access to in-office imaging remains and the College, working with local chapters, continues efforts to educate lawmakers on the benefits of in-office medical imaging, including the timeliness of diagnosis and treatment, convenience to patients, efficiency, and cost-effectiveness of care.

In truth, many factors have led to a greater reliance on imaging besides their ability to provide clinicians more accurate and detailed information about physiological conditions. Changing patient demographics (metabolic syndrome, aging, atrial fibrillation, and so on) have arguably increased the need for the kinds of information readily provided by imaging. Greater patient awareness also contributes to the demand for imaging technologies, because some patients want state-of-the-art care, while others want the certainty that seems to be promised by technology. The fragmentation of care contributes to repeated tests when previous studies are unavailable; the threat of lawsuits leads many physicians to practice, consciously or subconsciously, defensive medicine and rely on technologies as an objective means to ground decisions that inevitably require fine judgment; the demise of the physical examination and its replacement by an imaging test is also a factor for the specialist and generalist. Unfortunately, we must also face the fact that the greater availability of these technologies combined with fee-for-service incentives can sway physicians toward greater reliance on imaging than if the tests were still difficult, invasive, and costly.

In recognition of the complex mix of motives that has led to an increased use of imaging modalities, the medical community has taken on the responsibility of identifying gaps in care and providing solutions focused on ensuring quality and appropriate use of technologies. Today, the ACC is widely credited by payers, members of Congress, and other stakeholders for working to address a perceived problem and taking proactive efforts to ensure quality, cost-effective care.

The development of appropriate use criteria (AUC) is one of the cardiovascular community's most significant contributions. AUC define when and how often it is reasonable to perform a given procedure or test. When systematically implemented, AUC can be used to assess patterns of care in an effort to understand and improve the rate of clinically appropriate imaging tests, while reducing clinically less appropriate tests. By providing physicians their imaging utilization, AUCs also engage the providers in shared responsibility for judicious use of imaging services and can effect appropriate change in behavior better than that observed with changing reimbursement.

The first AUC document for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) was released in October 2005. Since then the College has continued to refine the process by introducing an early review of proposed clinical scenarios, using larger expert panels, basing AUC on more comprehensive lists of clinical scenarios, and improving ongoing coordination with clinical guidelines and other ACC policy documents. To date, the ACC Foundation has developed, in collaboration with subspecialty societies, AUCs for echocardiography, cardiac radionuclide imaging, CCT, CMR, and peripheral arterial and venous ultrasound among others. Currently under development in the realm of imaging are documents on ultrasound use in pediatric patients and multi-modality imaging use in heart failure, chest pain, and stable ischemic heart disease.

The good news is that medical imaging growth has declined since 2006. A recent report by the Medical Imaging and Technology Alliance for MedPAC (3) found that:

• •spending on imaging services per Medicare beneficiary has declined by 16.7 % since 2006, while spending on nonimaging services has increased by 21.3% over the same period.
• •per-beneficiary use of imaging services has declined by 5.1% since 2009, while use of advanced imaging services has decreased 6.6 %.
• •total spending on imaging services represents a smaller share of overall Medicare spending (9.3%) than at any point in the past decade and has shrunk by 28.4% since 2006.

Cardiovascular imaging has seen similar trends to overall medical imaging, with slowing of imaging utilization even prior to 2005 (Figure 08_gr1). Advanced new imaging modalities (CCT and CMR) continue to constitute a small fraction (0.1% to 1%) of conventional echocardiography and nuclear imaging. Factors that contributed to the decrease in utilization and slowing of the growth of medical imaging include the DRA, more awareness of cost and utilization, RBMs, AUC by professional societies (particularly ACC and ACR), and more recent evidence incorporated into AUCs on the need for fewer serial studies in stable patients (4).

Accreditation of laboratories is another important contributor to improvements in quality and appropriate use of imaging. As of January 2012, under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), providers of the technical component for advanced diagnostic imaging services (nuclear, CT, and CMR) must be accredited by a designated accreditation organization. Facilities are evaluated based on criteria that include standards for qualifications of medical personnel who furnish the technical component; qualifications and responsibilities of medical directors and supervising physicians; procedures to ensure that the equipment used meets performance specifications; standards that require the suppliers have procedures in place to ensure the safety of both advanced diagnostic imaging providers and patients; and, lastly, standards that require the establishment and maintenance of a quality assurance and quality control program.

The ACC was a strong proponent of the MIPPA provision, believing that accreditation provides an independent evaluation and validation of imaging facilities that allows laboratories to be held to a level of accountability and quality for the patient care they provide. It also can help reduce inappropriate imaging as the Inter-Societal Accreditation Commission has incorporated AUCs in their evaluation criteria.

In recent years, the ACC initiated the national “Imaging in FOCUS” (FOCUS), a self-directed, quality improvement software and interactive community, to help providers better understand their imaging practices, identify areas for improvement, and incorporate AUC at the point of care. It has proven successful in reducing overuse of imaging. Unlike RBMs, which have been criticized by health care providers for delaying or denying necessary imaging studies, creating unsustainable administrative burdens, basing decisions on inconsistent rules and practices, and lacking clinical guideline transparency, FOCUS is transparent, grounded in AUC, and provides opportunities (and in some cases incentives) for improved AUC adherence.

Preliminary data from the FOCUS group showed that with the use of such an approach, physicians in 30 different practices were able to decrease significantly the proportion of SPECT MPI tests not meeting appropriate use, from 11% to 5% in a cohort of more than 1000 studies (5). A recent study of 472 patients with suspected coronary artery disease found that the use of a real-time, multimodality decision-support tool, like the one used in FOCUS, led to a reduction in inappropriate testing from 22% in the first 2-month period to 6% in the last 2 months (6). Similarly, a significant impact of a continuous quality improvement initiative was seen on the utilization of coronary CT angiography (7).

As a result of these successes, the College is working to expand FOCUS beyond health plans and the current case-review tool to offer an ongoing subscription service directly to hospitals and practices that would integrate AUC decision support directly into electronic health records for all noninvasive cardiac imaging. The subscription service will allow practices to track AUC on a continual basis and then use the information as part of a quality improvement module that will offer MOC Part IV credit and meet laboratory accreditation quality review standards. There are potential opportunities to help eligible providers meet Physician Quality Reporting System (PQRS) requirements. There is also growing interest on the part of health plans and practices in incorporating FOCUS into alternative payment programs such as accountable care organizations (ACOs) and episode or global-based payment models.

There is no doubt that imaging modalities will only continue to improve technologically and enhance our ability to diagnose and treat patients earlier in the course of a disease. While we continue to develop many genetic markers of disease in addition to other measurable risk factors, imaging provides the actual phenotype, which can conceivably be detected at an even earlier stage with molecular imaging. On the other hand, scientists are busy trying to develop low-radiation tracers and new CT techniques to address safety concerns and reduce radiation exposure.

With advancement in digital technology and miniaturization, imaging will run the gamut from high-end large equipment to handheld imaging devices. The latter will proliferate for bedside diagnosis with ultrasound and other technology; the smaller, more compact designs will not only be less expensive to produce, but allow more physicians to take advantage of technology and use it at the point of care. Healthcare payment models will likely encourage their utilization for greater efficiency. The potential opportunities for international distribution to developing countries are great.

With a more cost-conscious and value-driven healthcare system, there is a new imperative for medical imaging. Novel technologies need ultimately to show a positive effect on patient care and outcome. With the availability of many modalities for imaging, there is confusion as to their best utilization. Rather than risk arbitrary cuts imposed by administrative processes far removed from the needs of the patient, we as physicians need to continue taking the lead in comparative research to assess the most effective uses of imaging to diagnose and manage common cardiovascular disease. This would also reduce the layering of multiple modalities, for considerations of both safety and cost. Ultimately, our driving concern is to achieve the triple aim of quality care, reasonable cost, and the health of the population.

Medical imaging is integral to the practice of cardiovascular care. I'm proud of the College and its members for being at the forefront of this continuously developing field and working to make sure that patients reap the benefits of advances in imaging technology in a transparent, evidence-based manner.