Body Scanner Boom : MRI Is a Wonder, but Cost Is an Issue

Like taco stands, they popped up across Southern California in the second half of the 1980s. They mushroomed in the basements of hospitals and rolled across freeways in giant trailers to do duty in the parking lots of hospitals that rented them by the day.

“Imaging centers” have been one of the hottest new businesses in Los Angeles in recent years, fueled by a powerful and pricey medical technology called magnetic resonance imaging, or MRI.

Today, despite increasing cost constraints, the MRI explosion continues in a medical technology race across the nation, and particularly in Southern California.

Patients are slid into the giant, oven-like MRI machines like so many hundreds of thousands of loaves of bread; out come remarkable computerized images of their brains, hearts and knees. Out also come high profits for doctors who have invested in the machines and who, critics charge, fill them sometimes needlessly with their own patients.

The use and abuse of the fledgling technology are especially acute in Southern California, which some call the MRI capital of America. The area is home to hundreds of 10-ton MRI scanners and, critics allege, to millions of dollars of unnecessary tests.

To be sure, when used properly, MRI is a phenomenally fruitful technology that has significantly improved the quality of medical care. It is painless and non-invasive.

MRI, which uses computers to reconstruct images based on radio waves bounced off the body, is free of the side effects of X-ray radiation. By replacing the knife with magnets, radio waves and computers, MRI helps in the diagnosis and treatment of brain tumors, spine injuries and cancer by making the body’s insides as visible as a medical school model--without surgery, and virtually without risk.

Such diagnostic power does not come cheap. An estimated $6 billion to $10 billion was spent on MRI procedures nationwide last year, just one part of increased technology contributing to the country’s growing annual health costs.

Perhaps more than any new technology, MRI shows that there is no easy answer to stemming the tide of billions of dollars a year the country spends on high-tech medicine. The fundamental problem is that better technology, especially when it aids early diagnosis, often ends up raising society’s overall health bill even as it improves quality of care, say economists.

While it is clear that profits help drive the proliferation of medical equipment--including a nearly 10-fold increase in MRI scanners in California since 1985--that same market motivation also drives lifesaving innovation by both doctors and manufacturers. And the restrained use of technology that many argue would be good for society is not what many Americans want when it comes to the lives of their own families.

MRI machines have blossomed in California in part because, like Florida--but unlike many other states--it does not regulate the proliferation of technology. As a result, the state has 370 MRI scanners--25 times more than all of Canada, which has a similar population.

“Considering the number of MRIs in Orange County, Los Angeles, San Diego and San Francisco, you’d think coastal California would fall off into the ocean from the weight,” says Jim Baumgartner, head of national accounts sales at General Electric, America’s largest maker of MRI equipment.

On a map of the United States in Baumgartner’s Milwaukee office, the jumble of pins representing customers for the $2-million machines in Los Angeles doesn’t even fit on the footprint of the city. Meanwhile, vast reaches of the U.S. map are bare, and the highly regulated Northeast is sparsely studded.

Not surprisingly, a recent study by the private Center for Health Policy Studies found that California Medicare recipients get 50% more MRI scans per person than the national average. It estimated that physician ownership of facilities accounted for 270,000 to 450,000 extra scans a year.

The United States has far more machines per capita than most advanced nations. Only Japan, where doctors often own their own machines and profit from their use, rivals the United States in its appetite for MRI machines.

While some people grumble that they’ve had apparently useless MRI scans, others whose lives have been saved by MRI have no doubt that the $800- to $1,200-a-scan cost is worth it.

Shirley Teal spent a year and a half in agony not only from pain and numbness on the right side of her face, but from the inability of her doctors to find a cause for it. Thousands of dollars in tests, including X-rays, ultrasound and computed tomography scans, showed nothing. Finally, she was slid into an MRI tube in San Gabriel, and after she endured half an hour of the banging noise familiar to thousands who have used the machine, her doctors had the answer.

The scan of Teal’s head showed that she had a tumor on a nerve behind her eye--just a hair’s breadth away from invading her brain. Based on the MRI image, doctors operated to remove the malignant tumor, and three years later Teal is healthy.

“I have no doubt MRI saved my life,” she says, and her doctors agree. To her, MRI was not too expensive. “How can you put a value on human life?” she asks.

Such success stories have also led to a search for expanded MRI uses. MRI of the spine has largely replaced the painful and sometimes dangerous myelogram, a technique for diagnosing spine troubles that requires a dye to be injected into the spinal fluid. It can cause excruciating headaches.

MRI also is useful for diagnosing soft tissue in the extremities and is gaining popularity for diagnosing knee problems. In some cases, MRI of the knee can replace arthroscopy, a surgical procedure that involves inserting a tiny scope into the joint to guide both diagnosis and surgery.

These broadening uses of the technology--which are now extending to cardiology, gynecology and urology--mean that the country’s MRI bill is bound to go up, even as the procedure reduces to some extent the money spent on other tests.

The growing use of MRI raises difficult questions about costs and service. Most evidence indicates that people with traditional “fee-for-service” insurance tend to get more MRI scans than those in health maintenance organizations.

Among the nearly 2 million people insured by Blue Cross of California’s Prudent Buyer plan, which pays doctors for each procedure they do, one in every 38 is expected to get an MRI this year. At Kaiser Permanente, by contrast, where doctors have no financial incentive to order MRI scans, only one member in a hundred gets a scan in the course of a year. The two groups may not be comparable because the patient population may have different age and other characteristics, but the trend is clear.

In MRIs, as with any medical procedure, “at HMOs you err on the side of doing too little. . . . With (fee-for-service) practice, you err on the side of doing too much,” says Rob Lufkin, a radiologist who also is an associate professor at UCLA’s medical school.

Nobody knows whether more is better--or worse. There is no definitive research to show what level of MRI use leads to longer or better lives for patients.

Fans of MRI argue that the reason Southern Californians have a bigger MRI bill than other regions is that they are getting cutting-edge medicine. Critics say it is the entrepreneurial spirit of doctors here that is driving excessive utilization.

A positive aspect of the glut of MRI machines here is that many facilities update their machines frequently because of competition to attract doctors. Another is that competition has been driving down prices per scan in some areas.

Patients also tend to get new procedures sooner than in many parts of the country. Southern California is a leader, for example, in new orthopedic uses of MRI. Industry sources say there are probably several reasons: a large sports-minded population that gets a lot of injured knees; a good supply of MRI machines with time slots to spare; a large number of hospitals competing for patients, and an unusually high proportion of doctors to population.

Because of Los Angeles’ reputation as a hotbed of MRI use, GE frequently relies on feedback from doctors here to develop new ways of using their machines. Recently, Frank Shellock, a physiologist for Tower Imaging, a Westside MRI center, visited GE’s headquarters to brainstorm with computer and marketing experts on ways to include the new uses in future scanner and software designs.

Dr. Jerrold Mink, director of Tower Imaging, says his center, a practice shared by 14 radiologists, makes enough money to fund about half a million dollars in research each year. And that, he argues, is good for patients.

But the booming California MRI environment has also created some potentially unsavory practices, most doctors agree. Many don’t like the telemarketing that pushes MRI services directly to people with no particular complaints. Others question the ethics of centers that use brokers to bring in workers’ compensation patients to keep the machines full.

But the biggest ethical debate is over whether physicians such as neurologists, orthopedic surgeons and internists should be allowed to own MRI machines.

Radiologists and many reformers argue that these “referring” doctors shouldn’t own scanners: They say that when a neurologist owns an MRI and can profit from it, he will often order more scans than necessary. (Radiologists, by contrast, don’t order scans but carry out orders made by other doctors.) Radiologists back legislation introduced by Assemblywoman K. Jacqueline Speier ((D-South San Francisco) to limit non-radiologist physician ownership.

“Study after study shows self-referral (by doctor-investors) increases the number of procedures and the cost of those procedures,” Speier says.

A national study published in the New England Journal of Medicine found that doctors with a financial interest in imaging facilities ordered more than four times as many exams and charged significantly higher fees than doctors without such interests.

Now, doctors are often able to gain $50 for every $100 they invest in an MRI scanner, says Jean Mitchell, a professor at Florida State University who did a study on market forces behind MRI.

“I am an economist, and I have never heard of a business making this kind of money in the first two years of operation,” she says.

But doctor-owners say that while some centers may be profiteering, most don’t make anywhere near that level of return. They say radiologists are just protecting their turf and that prohibiting all referring doctors from owning MRIs is punishing everyone for the sins of a few bad apples.

Dr. Ronald Rich, a neurosurgeon, says many doctors like himself invested in MRI scanners because they wanted to improve patient access and control quality. Back in 1984, when 86 doctors decided to get together to buy a scanner in Santa Monica, there was none in the area and local hospitals weren’t willing to invest in one, he says.

Rich says the general partners in the Medical Imaging Center of Southern California, himself included, have not yet made back the $250,000 each invested in the center. They do not, he says, order excess scans in order to make money.

The neurosurgeon argues that doctors should be trusted to make decisions that are best for the patient. Conflict of interest is not limited to use of high-tech machines. He notes that doctors have been accused of ordering surgeries or followup visits for profit reasons too.

“If you can’t trust your doctor to recommend the best place to get a scan, how can you trust him to do surgery on you?” he asks.