Increasing use of advanced medical imaging is often cited as a key driver of cost growth in medical spending. In 2011, the Medicare Imaging Demonstration from the Centers for Medicare & Medicaid Services began testing whether exposing ordering clinicians to appropriateness guidelines for advanced imaging would reduce ordering inappropriate images. The evaluation examined trends in advanced diagnostic imaging utilization starting January 1, 2009 — more than two years before the beginning of the demonstration — to November 30, 2013 — two months after the close of the demonstration. Small changes in ordering patterns were noted, but decision support systems were unable to assign appropriateness ratings to many orders, thus limiting the potential effectiveness of decision support. Many opportunities to refine decision support systems have been identified.

Table of Contents

  • Section I

    Report Overview

    • Chapter One

      Background and Description of the Demonstration and Its Evaluation

  • Section II

    Convener-Level Results Associated with Advanced Image Ordering with Decision Support Systems for Practices Associated with the Medicare Imaging Demonstration

    • Chapter Two

      Analysis of DSS Data

    • Chapter Three

      Analysis of the Impact of the MID Demonstration on the Appropriateness of Advanced Imaging Orders

    • Chapter Four

      Relationships Between the Appropriateness of Advanced Imaging Procedure Orders and Imaging Results

  • Section III

    Convener-Level Analyses of Advanced Image Utilization Before and After the Medicare Imaging Demonstration Was Introduced in Practices Associated with the Demonstration Compared with Comparable Control Practices

    • Chapter Five

      Trends in Imaging Utilization in the Medicare Imaging Demonstration

  • Section IV

    Physician and Patient Experience with Appropriateness Criteria for Advanced Imaging

    • Chapter Six

      Physician Satisfaction with Exposure to Advanced Imaging Appropriateness Criteria in the Demonstration

    • Chapter Seven

      Medicare Patient Satisfaction in the Demonstration with Receiving an Advanced Imaging Procedure after Physicians Were Exposed to Appropriateness Criteria

  • Section V

    Six Statute Questions That Can Inform Future Recommendations About Decision Support

    • Chapter Eight

      Recommendations About the Acceptability of MID's DSS for Identifying Appropriate Versus Inappropriate Advanced Imaging Orders

    • Chapter Nine

      Recommendations About Volume of Utilization in Response to Physician Exposure to Advanced Imaging Appropriateness Criteria at the Time of Orders

    • Chapter Ten

      Recommendations About the Advisability of Expanding the Use of Appropriateness Criteria for Ordering Advancing Imaging to a Broader Population of Medicare Beneficiaries

    • Chapter Eleven

      Recommendations About the Advisability of Allowing High-Performing Physicians to Be Exempt from Requirements to Consult Appropriateness Criteria

    • Chapter Twelve

      Recommendations About the Value of Live Feedback on the Appropriateness of Advanced Imaging Orders from a Decision Support System Compared with Feedback Reports to Individual Physicians or Physician Practices

    • Chapter Thirteen

      Recommendations About Strategies for Motivating Physicians to Comply with Ordering Advanced Imaging Appropriately According to Appropriateness Criteria

  • Section VI


    • Chapter Fourteen


  • Technical Appendix A

    DSS and Claims Methods

  • Technical Appendix B

    Evaluation of the MID: Focus Group Methodology

The research described in this report was sponsored by the Centers for Medicare & Medicaid Services (CMS) and conducted in RAND Health, a division of the RAND Corporation.

This report is part of the RAND Corporation Research report series. RAND reports present research findings and objective analysis that address the challenges facing the public and private sectors. All RAND reports undergo rigorous peer review to ensure high standards for research quality and objectivity.

This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited; linking directly to this product page is encouraged. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial purposes. For information on reprint and reuse permissions, please visit

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.