The clinical and financial impact of non-invasive vascular testing in the USA

Health care costs in the USA have increased dramatically during the past 10 years, and it is widely believed that they have reached crisis dimensions. Vascular laboratories are a segment of the USA health care industry that has experienced particularly rapid growth in the last decade. In 1992, USA Medicare payments (for patients > or = 65 years) totalled US$304,492,588 for 3,673,695 non-invasive vascular studies. This figure represents only one segment of USA health care costs and, if all segments were considered, the 1992 total for vascular laboratory services would probably approach one billion USA dollars. The expansion of vascular laboratory utilization is attributed to a number of factors: (i) increased recognition of the clinical value of non-invasive vascular studies; (ii) replacement of invasive (angiographic) procedures; (iii) expanded surveillance application; (iv) the verification of carotid endarterectomy for treatment of carotid stenosis; (v) widespread, unlimited access; (vi) over-utilization; (vii) greed. Widespread awareness of the crisis in USA health care funding has imposed cost-containment pressure where virtually none existed previously. The vascular laboratory is no exception to this trend, and the following measures have been suggested for controlling vascular laboratory costs: (i) demonstration of the clinical and cost effectiveness of non-invasive vascular studies; (ii) utilization review; (iii) pre-approval of requests for vascular studies; (iv) linkage of vascular study reimbursement with clinical diagnosis; (v) limitations on self-referral; (vi) reduced reimbursement; (vii) capitation; (viii) diagnosis-related reimbursement; (ix) accreditation. This article summarizes the factors that have led to increased utilization of vascular laboratory services, and discusses methods proposed for containing vascular laboratory expenditure.