I previously wrote about how I feel like we are in the “Era of Ancillary Services” for the physician. The New York Times recently ran an interesting article about cardiologists and the unnecessary CT-angiography scan. At the heart of the issue is that among cardiologists the CT-angiography scan (basically a 3-dimensional X-ray of the heart showing how much vessels are occluded) is controversial in its actual preventive utility.

Medicare, in its effort to cut costs, has balked at reimbursing for these scans. However, many cardiologists continue to order these tests because they make money (up to half of the income of some cardiologists) and patients demand the scans. Last year 150,000 of these scans were done at a cost of more than $100 million. All data trends indicate that their use is increasing significantly.

In the best case, having a CT-angiography that reveals significant occlusion of vessels may indicate the need to increase medications or undergo a procedure to unblock coronary arteries. In the worst case, having a CT-angiography can reveal that there are no blockages in a healthy and asymptomatic patient.

What is interesting about this issue is that the economic and political lobby for CT-angiography is extremely strong and was able to get Medicare to back down from their coverage reversal. Obviously, cardiologists, who may own the machines or have a financial interest in the machines, are going to fight all they can to keep this industry alive. Some people feel that the lobby is driven by capitalism under the guise of “improving patient care.” It is the rare cardiologist that refuses to order scans, own scans, or have financial interests in scanning facilities. Most other cardiologists feel that they might as well own or else they will be leaving money on the table.

At the heart of the issue though is whether these scans affect the actual outcome of the patient. There is very little evidence to suggest that it affects or does not affect patient outcomes. There are many patients in whom asymptomatic disease has been detected. There are also symptomatic patients where the scan confirms what previously was a sound clinical diagnosis based on history and examination.

It does not appear that CT-angiography is going away. The demand is just too high from patients and the lobby is too strong. This is yet again another example where the utilization of healthcare and the discovery of medical advancement are incongruent with the payment and reimbursement mechanism in this country.