Digital imaging for conventional radiologic examinations: Impact of economic incentives

Digital Imaging for Conventional Radiologic Examinations: Impactof Economic Incentives Alain Taieb, MD 1, Robert Lavayssiere, MD 1, ATssa Khelifa, PhD 2, Monique Marichez, MD 1

he French heahh system relies on two fundamental principles: solidarity (universal financial coverage for the whole populat!0n) and freedom (free ichoice by patients and free prescription by physicians). These principles ~zome at the price of significant financial support from citizens and strict limitations on physicians' fees by the administration and the single-payer system (Social Security). In addition, the French health system has divided the provision of care for Short-term hospitalization into two separate units that differ in both function and financial support. One unit is a public system that is controlled directly by the state, operates under a global budget, and employs physicians on a fixed salary. The other system consists of private clinics under a tariff convention with Social Security. These clinics are reimbursed according to activity (day costs) and operating room charges. Physicians are paid on a fee-for-service basis, using .a national nomenclature and key-letters system (i.e., conversion factors). In 1991, radiology charges in private practice accounted for 2% of overall health expenses. In an attempt to limit these costs, the government agreed (in exchange for some other concessions) to increase reimbursement (by an extra 60 francs per examination) for digital imaging in conventional radiology. The purpose of this study was to show the effect of such an economic incentive on the French radiology market.

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MATERIALS AND METHODS For the period 1989 to 1994, we gathered market information on annual sales, equipment prices, and market share evolution from a variety of sources (Ministry of Heahh, Social Security, medical equipment trade unions, medical photographic trade unions, and individual equipment manufacturers). Furthermore, between November 1994 and February 1995, an inquiry on radiologic investment in private practice was conducted by the Centre de Sociologie et de Ddmographie M6dicales in Paris, the results of which will be published in La Revue du Mddecin Radiologtte.

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From and IDepartment of Imaging, Saint Joseph Hospital, Paris, France; and 2Caisse Nationale d'Assurance Maladie des Travailleurs Salaries, Pads, France. Address reprint requests to A. Taieb, MD, Department of Imaging, Saint Joseph Hospital, 185 rue Raymond Losserand, 75674 Paris Cedex 14, France.

Acad Radio11996;3:$80-$83 9 1996, Association of University Radiologists

Vol. 3, Suppl. 1, April 1996

E C O N O M I C INCENTIVES FOR DIGITAL IMAGING

RESULTS

The following data, obtained as just described, are analyzed to show the effect of an economic incentive on the market.

has occurred in sales of laser imagerS. In France, DPSI sales (2.1 billion francs) now represent approximately 7% of the total imaging market , including sonography. Films

Remote-Control Units

Before 1991, the annual market for remote-control radiofluoroscopic units (RFUs) in France (Table 1) was approximately 260 units (almost two thirds of the European market). After the government measures in the radiology nomenclature in 1991 (minus 6-9~ of professional income), a decrease in overall sales of RFUs was expected. However, an immediate increase in sales of digital units was observed (three times more than in 1990). During the two following years, the total number of units sold increased (8% and 28%, respectively), as did the number of: digital systems sold (90~ and 76%, respectively). Now, !more than one of every two RFUs purchased is dig!tal. The price of these units decreased dramatically (30-40~ within 4 years), and the price decrease was accompanied by a substantial improvement in equipment :qua!ity (i.e., high-definition image intensifier systems and high-definition television [1,249 lines] for fluoroscopy instead of standard equipment). Within 6 years, the mean age of RFUS decreased from 12 years to 10 years. In addition, some radiologists purchased "addon" digital systems to upgrade their units (accounting for an estimated 10-40 systems sold each year).

France is the world's third largest consumer of film. Between 1989 and 1994, the market increased by 1% a year (Table 2), with an interesting and important shift in the type of film purchased. Sales of laser-type film multip!ied 12-fold and n o w represent 25% of total sales. A shift in market share occurred during the same period. The leader lost 20% of market share, the second-place firm consolidated its position, and the company supplying most of the DPSI units captured 1820% of the total market, almost doubling its share. Private Practice Inquiry Data

About 44% of radiology groups are now equipped with digital ?conventional" imaging, 22% have image intensifiers, 15% have DPSI, and 6~ have both types of equipment (Table 3). Investment in n e w equipment is directly related to the size of the radiology practice--less than 30% of radiologists who practice alone invested in n e w equipment, whereas up to 63% of practices with more tl{an four meml~ers bought new equipment.

TABLE 2: Film Sales in Millions of Square Meters

Digital Phosphor Storage Imaging

In 1989, only five digital phosphor storage imaging (DPSI) units were installed in France (Table 1). In 1992, 1993, and 1994, annual sales rose to 98, 140, and 105 units, respectively. Except for Japan, France now has more units than any other market. From 1991 to 1993, only one company was Selling these units; two other firms have since joined the business. A parallel increase

Year

Analog

Digital

Total

1989 1990

14.6 14.5

0.3 0.5

14.9 15.0

1991

14.4

1.0

15.4

1992 1993 1994

13,9 13.4 12.2

1.6 2.3 3.7

15.5 15.7 15.9

TABLE 1: Annual Number of Units Sold in France Remote-Control Unit

DPSI Unit

Year

No. of Units

No. of Units with Digital Systems

Add-On Systems

No. of Units

1989 1990 1991 1992 1993 1994

275 270 230 250 320 220

6 20 57 104 179 120

0 0 5 10 40 35

5 15 20 98 140 105

DPSI = digital phosphor storage imaging.

TABLE 3: Digital Imaging in Conventional Radiology in Private Practice Use of Digital Imaging No, not equipped Have intensifier Have DPSI Have both

No. of Radiologists in Practice

1

<4

>_4

71.8 16.5 10.7 1.0

58.2 20.9 16.3 3.3

36.7 30.0 15.4 15.0

Overall 56.1 22.0 15.4 6.1

Numbers are percentagesof radiologists in private practice. DPSI = digital phosphor storage imaging.

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voL 3, Suppl. 1, April 1996

Estimation of Public System Data

come under scrutiny, along with biology, nursing, and private clinics. In August 1991, the Federation Nationale des Medecins Radiologues (FNMR) accepted a general agreement concerning a change in the radiology nomenclature and a modification of so-called "heavy equipment" tariffs. These two measures represented a 6-9% reduction in professional income. In return for these concessions, the FNMR obtained an economic incentive (60 francs per examination) for digital imaging in conventional radiology as a step on the way to filmless radiology. To put this incentive into perspective--a chest examination costs 120 francs, a mammographic study costs 440 francs, and a double-contrast barium enema costs 1,000 francs. We had some idea of the effect Of the incentive with image intensifiers. Because the incentive was put in place, France has become and remains the foremost European market for remote-control RFUs.

During the time we collected data; the public system offered no economic incentive to change. Picture archiving and communication systems (PACS) and organizational changes are now affecting radiologists in the public system as well.

DISCUSSION Four main factors need to be considered in order to understand the influences affecting investment decisions: (1) the financing principles of the French heahh system, (2) improvement in image quality, (3) the ease of image archiving and transmission, and (4) economic incentive.

Financing of the French Health System During ttie 1970s and 1980s, the financial structure of the French~ health system was unstable. At first, both Social Secu'rity resources and heahh costs were growing fast and the system was kept in balance. During this period, the number of consultations did not grow as quickly as radiology or sonography, and the government did not reevaluate the national nomenclature (key letters) for these two activities (Figs. 1 and 2). The system reached its limits, however, when unemPloyment increased (to 12% of the active population). At that point, it was decided that health care reforms were necessary to contain expenses. Radiology was one of the first areas to

Improvement in Image Quality The gain in image quality, even with the most recent generation of systems, is limited. The most important advantages of digital imaging are the ability to adjust the image quality after it is obtained and the ability to compensate for exposure errors, but modern phototimers have already decreased the number of underexposed or overexposed films. The real usefulness of digital imaging has already been demonstrated in pediatrics and in intensive care units.

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ECONOMIC INCENTIVES FOR DIGITAL IMAGING

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Ease of ImagelArchiving and Transmission

Although PAcs have b e e n in use since the 1980s, their use is still experimental and limited to hospitalbased departments. Film remains the major tool of image transmission, especially in private practice. Teleradiology is: not yet a reality in France, perhaps because there is no incentive to invest in it. Economic Incentive

The g o v e r n m e n t measures w e r e intended to reduce earnings in radiology private practice, and radiologists tried to find a w a y to compensate for these constraints. To offset the purchase cost of n e w digital equipment, a

practice needs to perform 15--25 examinations per day, 250 days a year for 5 years. As the average radiology practice sees about 50 patients a day, o n e examination out of two has to b e digital. CONCLUSIONS

The French health care system is a single-payer system with a national n o m e n c l a t u r e for reimbursement and tight constraints on fees for service. Even in this environment, w e observed that an economic incentive can modify radiologists' investment behavior. This experience in a state-driven heahh system shows that economics m a y surpass medical considerations.

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