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Some medical testing centers in western Pennsylvania may be in trouble because of new rules coming from private insurers and Medicare that could force them out of business by making it more expensive to operate.

Highmark Inc., a Blue Cross Blue Shield health care provider, has informed operators of independently owned MRI centers that they must adhere to new requirements this year to receive reimbursement for diagnostic scans.

Highmark will pay for the MRI scans only at facilities that employ a board-certified radiologist on site and offer four other image-testing procedures, such as mammography and CT scans. The centers also must be open at least 40 hours a week, including at least one evening a week and two Saturdays a month.

The new policy already is in effect in western Pennsylvania and will be implemented this summer in the central part of the state.

The changes are being implemented to ensure that only experienced providers will perform the tests, according to Highmark officials who said there have been problems with poor-quality scans. The changes also are designed to trim escalating costs from an increasing number of unnecessary tests.

This week, the Medicare Cost Payment Advisory Commission will ask Congress to consider ways to cut costs of MRIs and other diagnostic scans.

There are nearly 160 MRI machines in western Pennsylvania, more than in all of Canada, according to Vic Panza, a senior vice president at National Imaging Associates. The radiology management firm estimates that there are between 400 and 450 MRI machines statewide.

The average cost of an MRI scanner is $2 million, according to the Pennsylvania Health Care Cost Containment Council, which estimates that it takes another $800,000 a year to maintain the equipment.

In 2003, 120,000 MRI scans were performed in Pennsylvania at costs ranging from $700 to $900, according to the council.

The use of MRI -- short for Magnetic Resonance Imaging -- as a diagnostic tool has increased 20 percent a year since 2000. Highmark pays $500 million annually for the tests, according to the company.

"Imaging costs are rising faster than any other component in health care," said Highmark spokesman Michael Weinstein.

Unlike X-rays, which emit radiation, MRIs use magnetic force to obtain an internal picture of soft tissue. Increasingly, the tests are being used to diagnose a number of ailments such as bone, muscle, tendon and ligament injuries, in addition to detecting breast cancer, assessing damage done by heart attacks and strokes, and diagnosing other internal ailments that conventional X-rays would not detect.

But they also are being overused, Panza said.

Richard McGarvey, a spokesman for the state Health Department, said there is no licensing requirement to own or operate an MRI center.

Weinstein said Highmark does not know how many independent providers offer MRI testing. Although he could not provide specific numbers, Weinstein said a majority of the state's MRI operators already meet Highmark's new guidelines, while the others are in the process of complying.

Panza estimates between 40 percent and 50 percent of all imaging is performed in the private sector rather than in hospitals.

Many MRIs are owned by physicians who can order the tests for their patients, and some say that leads to the possibility of abuse.

The Pennsylvania Health Care Cost Containment Council reported that 20 percent of MRI tests done in the state are so-called self-referrals, ordered by physicians who own MRI scanners. Those physicians, according to the council, order two to eight times more of the tests than do other doctors.

"You can't ignore the fact that a significant portion of the increase is due to self-referral abuse," Panza said. "You order the test and render it. That's a combination that can be abused."

Panza said Highmark and other insurers also have to deal with unnecessary costs for duplicate testing, and sometimes multiple billings for the same test.

"There also are horrific problems with quality of diagnostic imaging in this country," he said.

Other insurers in the region are following Highmark's lead to reduce the amounts they pay for MRIs.

Dr. Michael Mesouras, medical director of Aetna in western Pennsylvania, said his company, which has 900,000 clients in the state, will reimburse only those centers that are accredited by the American College of Radiology.

"We believe the people who should have MRI scans should have the scans, but if performing the scan is not going to change the course of care, why do it?" Mesouras said.

A spokesman for HealthAmerica and HealthAssurance, which has 730,000 members, said her company now requires prior approval for imaging tests.

"Some of the increase is understandable, because there is better technology and more available services," she said. "Other, less-laudable issues leading to increases are defensive medicine and the patient's need for reassurance. Additionally, with a larger number of competing technologies, the option of choosing the wrong test for a particular purpose can lead to either redundancy or waste."

The UPMC Health Plan also will require providers to obtain certification before they can receive reimbursement, said Sandra McAnallen, vice president of clinical services.

"In our 2005 business plan, we are exploring the use of privileging for MRIs, CT scans and cardiac nuclear studies," she said. "The criteria goes beyond exploring a rate with a provider. We are using guidelines approved by the American College of Radiology."

Insurers in other states also are taking action.

In Massachusetts, one health insurer requires consultations between the MRI operator and the insurer before approving tests for non-emergencies. Blue Shield of California requires independent providers to have a radiologist on site when testing is done.

Colorado, Nevada, New Hampshire, Connecticut, Maine, Indiana, Ohio, Kentucky and Virginia are imposing requirements designed to control imaging costs.

Meanwhile, physicians who own MRI machines charge that the new rules are a "smokescreen" so Highmark and other insurers can exert control over testing. They also maintain the rules are designed to protect hospitals, which have seen their revenue decline because of competition from independent operators.

Charles Moran, a spokesman for the Pennsylvania Medical Society, questioned the viability of the changes.

Moran said there already is a shortage of radiologists in Pennsylvania and wondered where independent operators will find radiologists to staff their sites.

MRI scans and other image testing were once the exclusive domain of hospitals, said Dr. David Beyer, an anesthesiologist, pain management expert and partner in the freestanding, physician-owned Laurel Surgical Associates in Hempfield Township.

"The problem with insurance companies is that many times they already have financial arrangements with the hospitals. In some ways, this all comes down to competition. The insurers are trying to dictate care to providers," Beyer said.

Dr. Ian Rawson, president of the Hospital Council of Western Pennsylvania, doesn't believe the new rules will limit access to care for patients who legitimately need an MRI.

However, they may curb patient demand.

"What Highmark is simply trying to do is shift payment from demand for services to a need for services," Rawson said.

Dr. Greg Lauro, an orthopedic surgeon and partner in Laurel Surgical Associates in Hempfield Township, said much of the use of MRIs is patient-driven.

"The patient comes to the physician, and they have it in their mind they need an MRI. You spend 40 minutes trying to explain to them they don't need an MRI, but they won't hear a word the physician said," Lauro added.

"There also is the litigious factor. If you have a patient you think may be a problem -- perhaps he is disgruntled for whatever reason -- a physician will simply go ahead and order the MRI."

Panza said patients have a mindset that if they have a medical problem, they want a test -- regardless of the need.

"There's a mentality in this country that folks don't think they're getting good health care unless they get some sort of test," he said.

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