Diagnostic and Interventional Imaging (2014) 95, 767—770

EDITORIAL

Low cost musculoskeletal MRI: What should we think about it?

Two successive cutbacks on the medical fees for interpretation payments for limb musculoskeletal MRI procedures were negotiated in amendment 8 to the medical agreement signed on October 25th 2012. In terms of the technical payments, new categories of musculoskeletal MRI with payments that are less than those for multidisciplinary 1.5 T MRI are now available. We will go back over the history of these decisions in the last four years during order to better understand whether a logical process is being followed.

The French situation On January 1st 2011, the French MRI equipment bank consisted almost entirely of low density 1.5 Tesla machines (10 MRI machines/million people, far behind most European countries, with 27 MRI machines/million people in Germany, for example) [1]. These small numbers of machines, strictly controlled by installation approvals, and the technical payment in the region of D 200 have however enabled a bank of 1.5 T top of range whole body machines to be introduced, unlike countries such as Germany or the United States, together with renewal of instruments in the private sector every 7 years. This approach however is restricting the increase in the number of instruments and MRI procedures under ONDAM (fixed budget envelope). Therefore, in its ten measure imaging plan, the professional Radiology Council (G4) emphasized the need for ‘appropriate diagnostic and interventional imaging for all patients with a full, wide range of imaging platforms grouped around sufficiently large multi-specialized teams’. As such, G4 obtained agreement from CNAMTS and the DGOS that a low cost MRI would be allocated to high field 1.5 T or greater whole body machine [2].

Musculoskeletal MRI under close scrutiny This diversification needed to be based on the largest volume MRI activity in order to have a significant financial impact, and musculoskeletal MRI thus came under the spotlight.

The volume effect: truncated information The usable activity records are unfortunately partial and only involve the private sector. Limb MRI is the main area of use of MRI in France (approximately 40% of procedures http://dx.doi.org/10.1016/j.diii.2014.08.003 2211-5684/© 2014 Éditions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

768 performed in the private sector, or approximately 682,000 procedures in 2009) [3]. It should be noted that lower limb MRI investigations (particularly knee) are four times more common than upper limb investigations, followed in decreasing order by spinal MRI (24%) and intracranial nervous system (21%) [3—6]. Limb and spine imaging account for 64% of the overall MRI activity in the private sector. The 2012 HAS (French National Health Authority) report on moderate field MRI, which was reiterated in the recent French National Health Insurance Funds Economics Measurement Report for 2015 [7], criticizes the larger number of limb MRI investigations in France compared to other countries. This concept has been taken up widely in the press but is not however based on any comparable private sector activity data in other countries, as the activity data relate either to the public sector alone (for example 25% in Belgium [8]), or mixed public/private sector. According to the same HAS 2012 report, it is not possible to extrapolate the figures and it is not therefore currently possible to confirm that private sector limb MRI activity in France is greater than that in other countries. Mixed, public and private sector activities for limb MRI are not known but undoubtedly account for less than 40%, according to an OECD 2012 report, which refers to a 15% higher rate of MRI procedures in the private compared to the public sector, all indications combined [9].

Viable technological opportunities? The second factor that has advanced musculoskeletal MRI, is the commercial availability of lower cost machines dedicated specifically for this purpose. These machines are not therefore multifunctional and can only be used back to back with whole body, high field MRI with a view to releasing procedures for cerebral and oncological diseases. Chronologically, several types of machine have therefore been assessed.

Editorial Examination of the worldwide MRI machine bank has confirmed a fall in the percentage of low field MRI systems: the market share of 1.5 and 3 T MRI has increased from 27% to almost 85% (1991—2011), and the market share of machines of under 1 T has fallen from 75% to approximately 15%. As a result, SNITEM has defined 1.5 Tesla machines as the reference worldwide market technology.

High field dedicated musculoskeletal MRI After acquisition of the ONI Company, GE Healthcare offered a 1.5 T machine in 2011 dedicated to limb investigations excluding shoulder and hip (Optima MR 430s). This machine incorporated some of the advantages of the low field dedicated MRI such as lower space, bulkiness and weight and was designed specifically to investigate musculoskeletal disorders incorporating very high field gradients (70 mT/m and a ramp time of 300 T/m/s) with greater field homogeneity. In 2012, the SIMS and the SFR were asked by the HAS to produce a report on this instrument, which confirmed both the image quality and their diagnostic appropriateness, although noted that it was not possible to investigate musculoskeletal diseases which required fields of view over 16 cm, which includes many neoplastic and inflammatory diseases. In addition, the lack of multifunctionality and limited fields of view led the working group to estimate that approximately 50% of the activity in the public sector and 30% in private sector could not be investigated using this equipment [14]. Furthermore, the economic viability of these machines was precarious because of the proposed specific technical payment of D 108 (i.e. approximately half of the technical payment for a whole body 1.5 T MRI) set against the high cost of the instrument (D 600,000), high maintenance costs and the staffing costs. These limitations are not specific to France and GE Healthcare has this year stopped marketing the Optima MR 430s throughout the world. It is no longer possible therefore to procure a high field MRI machine dedicated to limb investigations.

Low field dedicated musculoskeletal MRI These MRI machines are only dedicated for use on limbs because of their narrow magnet dimensions. They are relatively cheap as they can be located in small areas, do not require a Faraday cage and are less costly to maintain than high field MRI [10]. They are not multifunctional as they cannot be used to investigate the shoulder, hip or pelvis and are also not appropriate for tumors [11]. In addition, they only have a low patient throughput because of the longer time needed for the investigations (imaging time). The HAS has examined this type of machine and the performance of low fields on several occasions in 1999, 2008 and 2012 [10,12]. In September 2010, CNAMTS submitted its initial report to the HAS to define the power of magnetic field guaranteeing sufficient or adequate diagnostic performance in musculoskeletal limb MRI. Members of the HAS Working Group summarized the set of technical considerations and stated that ‘only a high field whole body MRI machine can adapt to the technical requirements for all of the indications required for limb investigation’ [13]. The technological option of low field MRI (dedicated to muscuooskeletal use but also closed or open whole body MRI) has therefore been abandoned as a result of these different reports.

Specialized musculoskeletal high field MRI The lack of multifunctionality of the musculoskeletal dedicated 1.5 T MRI and the difficulties installing them were preempted by CNAMTS and SNITEM, which created an exclusive French 1.5 T MRI ‘specialized musculoskeletal’ category with an intermediary technical payment of D 125. This was a multifunctional 1.5 T whole body MRI which was ‘approved for musculoskeletal investigations’ as only limb, including limb girdle investigations, and spine were allocated tariff values. Unlike the Optima MR 430s, neither the SFR nor SIMS were approached for their opinion about these machines. Some manufacturers offer ‘specific’ instruments such as the Magnetom Essenza Osteo Class (Siemens), Brivo MS Edition (General Electric), the Multiva (Philips Healthcare) or vantage osteoarticular Elan (Toshiba), but in reality all 1.5 T MRI machines may be used, subject to economic viability. In fact, only the entry range whole body 1.5 T MRI can meet these specifications, with limited power gradients and a small set of coils. We are therefore witnessing an extension of the initial concept of MRI designed specifically for musculoskeletal investigations to MRI designed economically for those which are the most common (limb and spine accounting for 64% of

Editorial private activities). The profile of these ‘specialized’ musculoskeletal MRI machines is such that they may be more easily introduced for patient use, as demonstrated by the article written in this issue, by the RSI regional fund (social security scheme for liberal professionals) of the Provence-AlpesCôte d’Azur region [15]. However, the physical installation restrictions are the same as for high field multifunctional MRI machines, and they are extremely expensive. Their one redeeming feature is that the approvals are easier to obtain. CNAMTS has estimated that 51% of investigations carried out for musculoskeletal disorders in Île-de-France could be performed on dedicated specialized MRI machines. Each ARS (French Regional Health Agency) has been asked to assess their needs for dedicated or specialized MRI machines for its region in 2015. Facilities with musculoskeletal MRI activities representing over 60% of their investigations have been listed for each French department. When spinal MRI investigations were included, 15 facilities were identified in Île-de-France (figures from the ARS survey carried out at the start of 2011, to which 113 facilities responded). The SROS—PRS (2011—2016) target for the Île-de-France region is to have 211 MRI machines, all categories combined (55 of which are additional machines) [14]. Specialized musculoskeletal MRI installations therefore potentially represent a maximum of 27% of new machines.

Specialized musculoskeletal MRI: the wonder solution? Worldwide, over the years whole body 1.5 T MRI has become the standard multifunctional machine. As a result of the technical tariff allocated in France to this type of instrument, a bank of recent top of range machines has been installed. On the background of budget restrictions, it is only possible to increase the overall MRI machine bank by introducing less expensive equipment, which attracts lower technical tariffs. There is no scientific rationale to confine musculoskeletal investigations to entry range machines, which are not able to carry out all of the musculoskeletal investigations, which require high spatial or temporal resolutions. Recent economies by the French National Health Insurance Funds for 2015 which have reduced limb and spine MRI procedures by 15% [7], without any medical evidence need to be consistent with appropriateness of care, which is described in the guide for the correct use of imaging investigations (GBU) produced by the Société Franc ¸aise de Radiologie and the Société Franc ¸aise de Médecine Nucléaire. On the other hand, are these not inconsistent with the desire to install specialized musculoskeletal MRI machines, which will by definition increase the number of these procedures? Would it not be better to create several classes of multifunctional whole body 1.5 T MRI classes and leave the facilities themselves to look after diversification of their technical platforms and the distribution of organs and their investigations? Another approach would be to tailor the technical tariffs to the length of the investigation.

Disclosure of interest The authors have not supplied their declaration of conflict of interest.

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References [1] Cemka-Eval. Les insuffisances en matière d’équipements d’imagerie médicale en France : étude sur les délais d’attente pour un rendez-vous IRM 2011. Étude pour Imagerie santé avenir. Bourg la Reine: Cemka-Eval; 2011. [2] Direction de l’hospitalisation et de l’organisation des soins. Circulaire no DHOS/SDO/O4/2002/250 du 24 Avril 2002 relative aux recommendations pour le développement de l’imagerie en coupe par scanner et IRM. Bulletin Officiel 2002 [2002—19]. [3] Caisse nationale de l’assurance maladie des travailleurs salariés. Évolution des actes techniques en secteur libéral en 2009. Points de repère 2010;31:1—14. [4] Caisse nationale de l’assurance maladie des travailleurs salariés. Les associations d’actes CCAM en 2008. Points de repère 2010;29:1—8. [5] Caisse nationale de l’assurance maladie des travailleurs salariés. Un an de codage CCAM en secteur libéral. Premiers résultats sur une année complète : 2006. Points de repère 2008;14:1—12. [6] Caisse nationale de l’assurance maladie des travailleurs salariés. Démographie et honoraires des médecins libéraux en 2006. Points de repère 2008;23:1—12. [7] Améliorer la qualité du système de santé et maîtriser les dépenses : propositions de l’Assurance maladie pour 2015. Rapport au ministre chargé de la sécurité sociale et au Parlement sur l’évolution des charges et des produits de l’Assurance maladie au titre de 2015 (loi du 13 août 2004); 2014 [99 p.]. [8] Imagerie par resonance magnétique : analyse des coûts KCE reports 106B. http://www.kce.fgov.be/sites/default/files/ page documents/d20091027315.pdf [9] ‘‘Technologies médicales’’ in OECD. Panorama de la santé 2011 : les indicateurs de l’OCDE. Editions OCDE; 2012 [270 p.] http://www.oecd-ilibrary.org/social-issues-migration-health/ panorama-de-la-sante-2011/technologies-medicales health glance-2011-30-fr [10] Haute Autorité de santé. Évaluation des IRM dédiées et à champ modéré < 1 T. Saint-Denis La Plaine: HAS; 2008 http://www.hassante.fr/portail/upload/docs/application/ pdf/2009-03/rapport irm vf.pdf [11] Drapé JL. IRM de la polyarthrite rhumatoïde : une double urgence. J Radiol 2008;89:543—5. [12] Agence nationale d’accréditation et d’évaluation en santé. Évaluation clinique et état du marché des appareils d’IRM à bas champ magnétique (< 0.5 tesla). Paris: ANAES; 1999 http://www.hassante.fr/portail/upload/docs/application/ pdf/irmlong.pdf [13] Haute Autorité de santé. Exploration ostéoarticulaire des membres par IRM : interêt diagnostique des équipements à champ modéré et des équipements dédiés. Saint-Denis La Plaine: HAS; 2012 http://www.has-sante.fr/portail/upload/ docs/application/pdf/2012-04/exploration osteo-articulaire des membres par irm - interet diagnostique des equipements a champs modere et des equipements dedies - rapport devaluation 2012-04-25 13-10-14 533.pdf [14] Tallon JB. Note de synthèse des reunions avec les Délégations Territoriales de ARS Île-de-France; 2012 http://www. ars.iledefrance.sante.fr/fileadmin/ILE-DE-FRANCE/ARS/2 Offre-Soins MS/SROS Volet-Hospitalier/Groupe-de travail/ GT13/Note de synthese reunions DT imagerie 2011.doc [15] Ha-Vinh P, Régnard P, Rochas M, Moncada M. MRI dedicated to bones and joints: what are their market shares in terms of number of patients in the community? Diagn Intervent Imaging 2014.

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Editorial

Glossary ONDAM: National French Health Insurance Expenditure Target CNAMTS: French National Health Insurance Funds for Employees DGOS: Directorate General for the Care Offering HAS: French National Health Authority ASN: French National Nuclear Safety Authority SFR: French Radiology Society SNITEM: National Union of Medical Technology Industries SROS—PRS: Regional Care Organization Plans—Regional Health Project ARS: Regional Health Agencies

J.-L. Drapé a,∗ , A. Cotten b , A. Blum c a

Paris Descartes University, Cochin Hospital, Paris, France

b Department of Radiology and Musculoskeletal Imaging, CCIAL, Lille Regional University Hospital, Lille, France c Guilloz Imaging Department, Nancy University Hospital, Nancy, France ∗ Corresponding author. Service de radiologie B, université Paris Descartes Sorbonne Paris Centre, hôpitale Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France. E-mail address: [email protected] (J.-L. Drapé)

Low cost musculoskeletal MRI: what should we think about it?

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