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How much does radiology contribute to increasing health care costs? The situation in Greece
How Much Does Radiology Contribute to Increasing Health Care Costs? The Situation in Greece Dimitrios A. Kelekis, MD, and Elias N. Brountzos, MD
he rising cost of health care is becoming a major concern in developed countries worldwide. In 1992 in the United States, heahh care consumed 14% of the total national output; in western European countries, 710% of the gross national product was spent on health care, and these figures are rising. Economists and governments are therefore seeking ways to reduce cost without compromising the quality of care. In most countries, the emphasis is on efficiency, and cost-control plans are being discussed and implemented. Radiology, which is often identified with expensive technologies, and the radiologist, w h o is considered a procedural physician, are logical targets for cost-control activities. In order to judge these activities fairly, it is important to have an estimate of the contribution of radiology to the overall health care costs. In the United States, a recent survey of 115 hospitals revealed that between 1980 and 1990, the number of examinations done annually increased 30-60%. To put this information into perspective, however, a study from Johns Hopkins University reported that the average patient's bill for radiologic services was only 5% of the total hospital bill. In that study, a review showed that the number of radiologic examinations per admitted patient remained constant (about 3.2 per admission) between 1980 and 1993. At tile 1992 meeting of the Radiological SocieW of North America, R. Parker reported that the introduction of new procedures and technologies has resulted in a substantial decrease in the diagnostic and therapeutic costs of various diseases and conditions. Such conflicting reports indicate that further research is necessary. The situation is even less clear in Greece. Here, all citizens are insured in the National Health System (NHS) through several insurance organizations that are under complete or partial state control. The vast majority of hospitals (both state and university) are enrolled in the NHS. A few hospitals (no more than six) and some clinics function as private, for-profit enterprises. On the other hand, there are many private laboratories (e.g., microbiologic, radiologic) and physicians in private practice. NHS doctors are paid a salary, whereas private physicians usually charge a standard amount for every visit or procedure.
T
From the Department of Radiology, Eugenidion Hospital, Athens University, Athens, Greece. Address reprint requests to D. A. Kelekis, MD, Department of Radiology, Eugenidion Hospital, Athens University, Athens, Greece. A cad Radio11996;3:$121 -S124
9 1996, Association of University Radiologists
S121
KELEKIS AND BROUNTZOS
vol. 3, Suppl. 1, April 1996
As a rule, charges for radiologic procedures are based on a government-regulated price list, and no extra fee is charged for the radiologists' services. There are a few exceptions to this rule in large private hospitals. In addition, fee standards for interventional radiologic procedures have not been set. Data from the Social SecuritT Institution (IKA), which is the major heaith insurance provider in Greece, show that during the past 6 years, per-capita expenses for health care have increased four times (Fig. 1). On the other hand, the number of mdiologic procedures has remained more or less constant during the same period (Fig. 2). The goal of our stud}, was to estimate the contribution of radiology to the increasing health care costs in Greece. To do so, we compared the charges for radiologic procedures done in three different hospitals during 1993 and 1994 with the total cost of hospitalization. The hospitals included a large private general hospital
with a fully equipped radiologic department (hospital A), a university hospital with an active radiology department that specialized in ~interventional procedures (hospital B), and a cardiovascular center with an active radiology department (hospital C). The types of equipment available in each hospital are summarized in Figure 3.
RESULTS
The findings are summarized in Tables 1-3, which show the average charge per patient at each hospital broken down according to various imaging techniques. The average number of radiologic examinations per admission ranged from 1.94 to 2.85, and most were plain films of the chest or abdomen (Fig. 4). At hospital A, for the yeai's 1990-1993, the number of examinations per admission remained constant, ranging
96OOOO
~ooo
,.~
\
920000
//
900000 ~-,
880000
o
8600OO
j
8200O0
0+~ 1989
1990
1991
1992
1993
989
1994
FIGURE 1. Per-capitaexpensesfor healthcare in Greece.Data are from the SocialSecurityInstitution(IKA).
J
i
i
1990
1991
1992
FIGURE2. Numberof radiologicproceduresdoneannually,1989--1993.
TABLE 1: Average Inpatient Data at Hospital A During 1993
Technique Diagnostic Computed tomography Magnetic resonance imaging Sonography Angiography Total i
No. of Gross Charges Examinations (Drachma)
Average Charge No. of per Examination Examinations (Drachma) per Admission
29,888 7,559 2,233
410,843,545 1,270,178,515 ?
13,746 (US$55) 35,742 (US$143) ?
1.46 0.36 0.11
10,474 3,336 53,490
138,906,786 111,147,386 934,076,232
13,262 (US$53) 34,216 (US$137) 96,966 (US$388)
0.51 0.16 2.60
i
The total numberof admissionswas 20,456;the total hospitarizationchargeswere8,746,216,2i7drachma. The averagechangefor radioTogyservicesper admissionwas 45,663drachma(US$183);the averagecharge for hospitalizationper admissionwas 427,562drachma(US51,710).
$122
1993
Vol. 3, Suppl. 1, Apd11996
R A D I O L O G Y C O S T S IN G R E E C E
from 2.5 to 2.9, indicating that overutilization of radiology services was not a problem at this institution. The average bill for radiologic services ranged from $50 to $183 (as compared with $407 for Johns Hopkins University), representing 1-20% of the total hospital bill, which ranged from $400 to $4,346 (Fig. 5). Higher hospitalization costs at hospital C were due to cardiac surgery and costs of the intensive care unit. Radi-
ology services, which play a relatively minimal role in total patient care, cost less at hospital C. At hospital B, radiology services accounted for as much as 20~ of the total hospital bill, partly because many patients are admitted specifically for interventional radiology procedures. The charges for various types of examination differed among the three hospitals. This was probably caused by variation in the number of procedures that were paid for privately.
8
iD .~IIJ~GIO
"- 2
DC'I"
13
[] DIAGNOS OCT
DMRI DLIS
10.~ , , f , , HOSP A
DMRI [] US
D M ~
DAHGIO
O X-I~Y
[] INTERV [] TOTAL
2;<
O~
B
---~-
HOSP A
~K)~o C
FIGURE 3. Types of equipment available in radiology department at each hospital. ANGLO = angiography, CT = computed tomography, MRI = magnetic resonance imaging, US = ultrasound, MAMMO = mammography, HOSP = hosp~aL
HOSP B
HOSP C
FIGURE 4. Average number of radiologic examinations per admission. DIAGNOS = conventional radiology, CT = computed tomography, MRI = magnetic resonance imaging, US = ultrasound, ANGLO = angiography, INTERV = interventional, HOSP = hospital.
TABLE 2: Average Inpatient Data at Hospital B During 1994 Techniq~Je
Diagnostic Computed tomography Angiography Interventional and fine-needle aspiration Total
No. of Examinations
Gross Charges (Drachma)
Average Charge No. of per Examination Examinations (Drachma) per Admission
9,452 5,504 2,400 74 86
38,876,000 121,088,000 74,486,120 13,968,020
4,103 (US$16) 22,000 (US$88) 31,035 (US$124) ?
1.54 0.89 0.39 0.03
17,516
248,856,000
57,138 (US$229)
2.85
The total number of admissions was 6,150; total hospitalization charges were 1,230,000,000 drachma. The average radiology service charge per admission was 40,464 drachma (US$162); the average charge for hospitalization per admission was 200,000 drachma (US$800).
TABLE 3: Average Inpatient Data at Hospital C During 1994 Technique
Diagnostic Angiography Sonography Total
No. of Inpatient
Gross Charges
Examinations
(Drachma)
Average Charge No. of per Examination Examinations (Drachma) per Admission
48,885,010 12,285,360 806,380 61,976,750
5,109 41,787 8,671 67,982
9,568 294 93 9,955
(US$20) (US$167) (US$35) (US$272)
1.90 0.06 0.02 1.94
The total number of admissions was 4,992; total hospitalization charges were 5,423,641,100 drachma. The average charge for radiology services per admission was 12,415 drachma (US$50); average charge for hospitalization per admission was 1,086,466 drachma (US$4,346).
$123
KELEKIS AND BROUNTZOS
Vol. 3, Suppl. 1, April 1996
4000A
12000 - /
"~
35ooH
=
axx)H
~"
8000"
1000H
N
6000"
~
4000 /
"~ ~ooH
=
e~
HOSP A
r~
/-~
10000"
HO6P B
HOSP C
2000-/,~
FIGURE 5. Comparison of average cost for radiologic (RADIOL) services and total cost of hospitalization. HOSP = hospital.
0 .'r B~,~:_, ~ 1
H~P A
R~"~~
I-I~P B
B,~ - ~ - , i
H~P C
~,
,, ,,y,;
J HOP
FIGURE 7. Comparison of total cost of hospitalization in the United States and Greece. HOSP = hospital, J HOP = Johns Hopkins.
rJ
200
CONCLUSIONS
1
DIAGNOS
CT
MRI
ANGLO
US
T FIGURE 6. Comparison of cost of radiologic examinations in Greece (state hospitals and private hospitals) and in the United States. GR = Greece, PR = private, ST = state, DIAGNOS = conventional radiology, CT = computed tomography, MRI = magnetic resonance imaging, ANGLO = afigiography, US = ultrasound.
A final comparison between costs in the United States and Greece shows that both radiologic examinations (Fig. 6) and total hospitalization (Fig. 7) cost o n e fourth to one fifth less in Greece than in the United States.
$124
The claim that radiology is a prime contributor to increased heahh costs cannot be supported by this study, because radiology costs were found to account for an average of only 10% of the total health care cost. In addition, absolute charges per examination are considerably less than in other countries, even though the cost of equipment purchase and maintenance is-the same. Reduction in health care costs therefore can come only with reorganization and updating the whole system in order to catch up with the increasing demands of m o d e r n care of patients.
he rising cost of health care is becoming a major concern in developed countries worldwide. In 1992 in the United States, heahh care consumed 14% of the total national output; in western European countries, 710% of the gross national product was spent on health care, and these figures are rising. Economists and governments are therefore seeking ways to reduce cost without compromising the quality of care. In most countries, the emphasis is on efficiency, and cost-control plans are being discussed and implemented. Radiology, which is often identified with expensive technologies, and the radiologist, w h o is considered a procedural physician, are logical targets for cost-control activities. In order to judge these activities fairly, it is important to have an estimate of the contribution of radiology to the overall health care costs. In the United States, a recent survey of 115 hospitals revealed that between 1980 and 1990, the number of examinations done annually increased 30-60%. To put this information into perspective, however, a study from Johns Hopkins University reported that the average patient's bill for radiologic services was only 5% of the total hospital bill. In that study, a review showed that the number of radiologic examinations per admitted patient remained constant (about 3.2 per admission) between 1980 and 1993. At tile 1992 meeting of the Radiological SocieW of North America, R. Parker reported that the introduction of new procedures and technologies has resulted in a substantial decrease in the diagnostic and therapeutic costs of various diseases and conditions. Such conflicting reports indicate that further research is necessary. The situation is even less clear in Greece. Here, all citizens are insured in the National Health System (NHS) through several insurance organizations that are under complete or partial state control. The vast majority of hospitals (both state and university) are enrolled in the NHS. A few hospitals (no more than six) and some clinics function as private, for-profit enterprises. On the other hand, there are many private laboratories (e.g., microbiologic, radiologic) and physicians in private practice. NHS doctors are paid a salary, whereas private physicians usually charge a standard amount for every visit or procedure.
T
From the Department of Radiology, Eugenidion Hospital, Athens University, Athens, Greece. Address reprint requests to D. A. Kelekis, MD, Department of Radiology, Eugenidion Hospital, Athens University, Athens, Greece. A cad Radio11996;3:$121 -S124
9 1996, Association of University Radiologists
S121
KELEKIS AND BROUNTZOS
vol. 3, Suppl. 1, April 1996
As a rule, charges for radiologic procedures are based on a government-regulated price list, and no extra fee is charged for the radiologists' services. There are a few exceptions to this rule in large private hospitals. In addition, fee standards for interventional radiologic procedures have not been set. Data from the Social SecuritT Institution (IKA), which is the major heaith insurance provider in Greece, show that during the past 6 years, per-capita expenses for health care have increased four times (Fig. 1). On the other hand, the number of mdiologic procedures has remained more or less constant during the same period (Fig. 2). The goal of our stud}, was to estimate the contribution of radiology to the increasing health care costs in Greece. To do so, we compared the charges for radiologic procedures done in three different hospitals during 1993 and 1994 with the total cost of hospitalization. The hospitals included a large private general hospital
with a fully equipped radiologic department (hospital A), a university hospital with an active radiology department that specialized in ~interventional procedures (hospital B), and a cardiovascular center with an active radiology department (hospital C). The types of equipment available in each hospital are summarized in Figure 3.
RESULTS
The findings are summarized in Tables 1-3, which show the average charge per patient at each hospital broken down according to various imaging techniques. The average number of radiologic examinations per admission ranged from 1.94 to 2.85, and most were plain films of the chest or abdomen (Fig. 4). At hospital A, for the yeai's 1990-1993, the number of examinations per admission remained constant, ranging
96OOOO
~ooo
,.~
\
920000
//
900000 ~-,
880000
o
8600OO
j
8200O0
0+~ 1989
1990
1991
1992
1993
989
1994
FIGURE 1. Per-capitaexpensesfor healthcare in Greece.Data are from the SocialSecurityInstitution(IKA).
J
i
i
1990
1991
1992
FIGURE2. Numberof radiologicproceduresdoneannually,1989--1993.
TABLE 1: Average Inpatient Data at Hospital A During 1993
Technique Diagnostic Computed tomography Magnetic resonance imaging Sonography Angiography Total i
No. of Gross Charges Examinations (Drachma)
Average Charge No. of per Examination Examinations (Drachma) per Admission
29,888 7,559 2,233
410,843,545 1,270,178,515 ?
13,746 (US$55) 35,742 (US$143) ?
1.46 0.36 0.11
10,474 3,336 53,490
138,906,786 111,147,386 934,076,232
13,262 (US$53) 34,216 (US$137) 96,966 (US$388)
0.51 0.16 2.60
i
The total numberof admissionswas 20,456;the total hospitarizationchargeswere8,746,216,2i7drachma. The averagechangefor radioTogyservicesper admissionwas 45,663drachma(US$183);the averagecharge for hospitalizationper admissionwas 427,562drachma(US51,710).
$122
1993
Vol. 3, Suppl. 1, Apd11996
R A D I O L O G Y C O S T S IN G R E E C E
from 2.5 to 2.9, indicating that overutilization of radiology services was not a problem at this institution. The average bill for radiologic services ranged from $50 to $183 (as compared with $407 for Johns Hopkins University), representing 1-20% of the total hospital bill, which ranged from $400 to $4,346 (Fig. 5). Higher hospitalization costs at hospital C were due to cardiac surgery and costs of the intensive care unit. Radi-
ology services, which play a relatively minimal role in total patient care, cost less at hospital C. At hospital B, radiology services accounted for as much as 20~ of the total hospital bill, partly because many patients are admitted specifically for interventional radiology procedures. The charges for various types of examination differed among the three hospitals. This was probably caused by variation in the number of procedures that were paid for privately.
8
iD .~IIJ~GIO
"- 2
DC'I"
13
[] DIAGNOS OCT
DMRI DLIS
10.~ , , f , , HOSP A
DMRI [] US
D M ~
DAHGIO
O X-I~Y
[] INTERV [] TOTAL
2;<
O~
B
---~-
HOSP A
~K)~o C
FIGURE 3. Types of equipment available in radiology department at each hospital. ANGLO = angiography, CT = computed tomography, MRI = magnetic resonance imaging, US = ultrasound, MAMMO = mammography, HOSP = hosp~aL
HOSP B
HOSP C
FIGURE 4. Average number of radiologic examinations per admission. DIAGNOS = conventional radiology, CT = computed tomography, MRI = magnetic resonance imaging, US = ultrasound, ANGLO = angiography, INTERV = interventional, HOSP = hospital.
TABLE 2: Average Inpatient Data at Hospital B During 1994 Techniq~Je
Diagnostic Computed tomography Angiography Interventional and fine-needle aspiration Total
No. of Examinations
Gross Charges (Drachma)
Average Charge No. of per Examination Examinations (Drachma) per Admission
9,452 5,504 2,400 74 86
38,876,000 121,088,000 74,486,120 13,968,020
4,103 (US$16) 22,000 (US$88) 31,035 (US$124) ?
1.54 0.89 0.39 0.03
17,516
248,856,000
57,138 (US$229)
2.85
The total number of admissions was 6,150; total hospitalization charges were 1,230,000,000 drachma. The average radiology service charge per admission was 40,464 drachma (US$162); the average charge for hospitalization per admission was 200,000 drachma (US$800).
TABLE 3: Average Inpatient Data at Hospital C During 1994 Technique
Diagnostic Angiography Sonography Total
No. of Inpatient
Gross Charges
Examinations
(Drachma)
Average Charge No. of per Examination Examinations (Drachma) per Admission
48,885,010 12,285,360 806,380 61,976,750
5,109 41,787 8,671 67,982
9,568 294 93 9,955
(US$20) (US$167) (US$35) (US$272)
1.90 0.06 0.02 1.94
The total number of admissions was 4,992; total hospitalization charges were 5,423,641,100 drachma. The average charge for radiology services per admission was 12,415 drachma (US$50); average charge for hospitalization per admission was 1,086,466 drachma (US$4,346).
$123
KELEKIS AND BROUNTZOS
Vol. 3, Suppl. 1, April 1996
4000A
12000 - /
"~
35ooH
=
axx)H
~"
8000"
1000H
N
6000"
~
4000 /
"~ ~ooH
=
e~
HOSP A
r~
/-~
10000"
HO6P B
HOSP C
2000-/,~
FIGURE 5. Comparison of average cost for radiologic (RADIOL) services and total cost of hospitalization. HOSP = hospital.
0 .'r B~,~:_, ~ 1
H~P A
R~"~~
I-I~P B
B,~ - ~ - , i
H~P C
~,
,, ,,y,;
J HOP
FIGURE 7. Comparison of total cost of hospitalization in the United States and Greece. HOSP = hospital, J HOP = Johns Hopkins.
rJ
200
CONCLUSIONS
1
DIAGNOS
CT
MRI
ANGLO
US
T FIGURE 6. Comparison of cost of radiologic examinations in Greece (state hospitals and private hospitals) and in the United States. GR = Greece, PR = private, ST = state, DIAGNOS = conventional radiology, CT = computed tomography, MRI = magnetic resonance imaging, ANGLO = afigiography, US = ultrasound.
A final comparison between costs in the United States and Greece shows that both radiologic examinations (Fig. 6) and total hospitalization (Fig. 7) cost o n e fourth to one fifth less in Greece than in the United States.
$124
The claim that radiology is a prime contributor to increased heahh costs cannot be supported by this study, because radiology costs were found to account for an average of only 10% of the total health care cost. In addition, absolute charges per examination are considerably less than in other countries, even though the cost of equipment purchase and maintenance is-the same. Reduction in health care costs therefore can come only with reorganization and updating the whole system in order to catch up with the increasing demands of m o d e r n care of patients.