In high-tech Japan, most CT scanners are still primitive

Nov 14, 2005

More than 90% of installed CT scanners in Japan are still single-detector machines, and nearly a third of those are nonspiral single-detector scanners, according to a survey by a working group of the Japan Radiological Society (JRS). Worse, perhaps, a severe shortage of board-certified radiologists in the country means that the few available multislice machines probably aren't being used to their full potential.

"The survey revealed that 84% of the medical facilities equipped with a helical CT system do not have a full-time board-certified radiologist, and more than half of those with a multislice helical CT system do not either," wrote Dr. Yasuo Nakajima and colleagues from the JRS working group. "This shortage of specialists jeopardizes the capability of existing high-performance equipment, because high-quality image diagnoses require the skill and the judgment of a specialist."

Because CT technology is advancing rapidly, up-to-date knowledge and skills are required to optimize the clinical results, the group wrote. Board-certified radiologists are responsible for selecting the best imaging modality for the job, choosing the scan parameters and radiation dose, and deciding on the use of contrast media.

The root problem is the "irrationality" of Japan's medical fees, so low that they leave little incentive to install the latest imaging technology, the survey team wrote in the JRS Nippon Acta Radiologica (April 2005, Volume 65:3). (The study on CT installations was published exclusively in the Japanese version, as article #12).

The six months since the report was published have produced little change in the situation, lead author Nakajima told AuntMinnie.com through a translator. However, he noted, the total number of board-certified radiologists in the original report has risen slightly, from 4,429 to 4,604 currently.

Healthcare plagued by funding woes

"In the future, it is strongly hoped that measures will be taken to put in place incentives for high-quality image diagnoses backed by both high-performance equipment and physicians who are skilled in radiology," the survey authors wrote.

For now there is little more than hope to go on. The Japanese government provides fixed fee-for-service payments to doctors at levels that have remained low for decades despite the rapidly rising cost of providing medical care. In recent years the government has blamed the need for belt-tightening on the perennially sluggish economy. However, bureaucracy, intransigent vested interests, and rising costs for treating elderly patients in an aging population have also been cited as contributing factors in the reimbursement crisis.

The Japan Medical Association has warned that hospitals and clinics face financial disaster if the situation does not improve. Prime Minister Junichiro Koizumi was elected in 2001 promising to institute healthcare reforms and reduce wasteful spending, but reform has proved daunting, both practically and politically.

A draft plan for structural reform of the healthcare system developed by the Ministry of Health, Labor and Welfare attaches special importance to curbing the development of so-called lifestyle diseases such as diabetes, hyperlipidemia, and high blood pressure. The goal is to curb the growth of medical costs without overburdening taxpayers. Increasing local control of healthcare plans is another key feature of the draft policy.

To date, the government has been largely unsuccessful in instituting large-scale changes, although some initiatives, such as a scheme to fund long-term care for the elderly by making patients pay a third of the cost, are in place.

Outdated scanner technology

According to the survey results, 57% of the installed CT scanners in Japan are single-slice spiral scanners, 33% are single-slice scanners developed before spiral systems became available, and 10% are multidetector-row CT scanners.

"Full-time specialist attendance is low due to an absolute lack of board-certified radiologists and to an overwhelming diffusion of single-slice CT systems and other inferior equipment," the group wrote.

The authors found 3,403 board-certified radiologists for more than 13,000 scanners. Only 1,716 (16%) of the 7,207 medical facilities equipped with spiral CT systems had full-time specialists to operate them. MRI fared much better, according to a separate report by the group, which found that 1,027 (25%) of 4,103 facilities with MRI systems had full-time specialists.

In all, the survey listed a total of 8,804 facilities with spiral CT scanners, including 1,360 multislice and 7,444 single-detector machines. Attending board-certified radiologists were available for just 26.2% of the facilities overall, including 676 (49.8%) of facilities with multislice machines and 1,635 (22%) with only single-slice scanners, the group wrote. For single- and multidetector spiral scanners together, board-certified radiologists were available for just 26.2%.

In contrast, a 2003 study of board-certified radiologists in the U.S. found that 78% primarily use multidetector CT systems, the team reported. Des Plaines, IL-based IMV Medical Information Division reported in its 2004 CT census study that 51% of all CT scanners had multiple detectors, 42% were single-slice spiral scanners, and 4% were nonspiral single-detector scanners.

"This makes it evident that inferior CT systems occupy a remarkably large proportion of all CT systems in Japan," the survey team concluded. "It is presumed that this trend is due to an inclination to install less-expensive models of equipment, in spite of their limited functions, in favor of responding to demand from clinicians."

Prospects for higher fees

In line with other medical specialties, reimbursement for imaging procedures is very low in Japan, Nakajima and colleagues, along with Kazuko Kobayashi of GE Healthcare in Japan, wrote jointly in an e-mail to AuntMinnie.com. For example, they explained, the current payment for an MRI head scan is approximately $102 (U.S.), in addition to a reading fee of $38, and an additional fee of $5 to $7 if a board-certified radiologist manages the study.

The fee-for-service payments are revised every two years in Japan. In June 2005, the Japan Radiological Society submitted its request for funding revisions to the Ministry of Health, Labor and Welfare, which will issue final funding decisions for the next two-year period in April 2006, Nakajima and colleagues wrote. The June 2005 radiology submissions for the upcoming period included requests for the following:

A separate scanning fee structure depending on system class: high-end or mid/low-tier
Additional fees for the advanced imaging techniques
Differentiation of fees depending on whether the report is written by a radiologist
An increase in the professional component, or physician's fee
New fee levels to promote PACS use
An increase in the mammography scanning fee

The outcome of these requests cannot be predicted at this time, the team wrote.

By Eric Barnes
AuntMinnie.com staff writers
November 15, 2005