Simple arithmetic dictates that a $500 MRI scan cannot include all of the following: state-of-the-art equipment and a technologist engaged for thirty minutes, contrast media 30% of the time, and physician supervision and interpretation.

Payers are aware that MRI centers must reduce costs to match available payments, including restriction of services where the standard of care is flexible. Federal (Medicare) and other payers' reimbursement, made on behalf of their insured (patients), for fixed technical costs effectively forces supervising radiologists to remove the least important components of the MRI procedure.

The responsible practice of medicine includes remaining economically viable to sustain the availability of MRI services in the community. Local decisions must be made by MRI centers or individual radiologists to refuse to provide what they believe to be sub-standard care, to refuse certain contracts, or to go out of business. Nevertheless, for common MRI services, we can closely estimate the standard of care for millions of patients, as this is largely determined by federal and state policies and reflected in the community reimbursement level.

It is not at all clear whether the standard of care can be adjusted patient-by-patient, or payer-by-payer. Cost shifting, though questionable, is a historical factor which supports the current level of care for many patients. Therefore, assuming a single community standard of care, when the average global reimbursement falls below $500, responsible radiologists must consider the following:

1. Reducing the number of pulse sequences from current levels to save time.

2. Reducing image resolution (quality) by using thicker slices, gaps, coarser pixels, or fewer excitations.

3. Not providing expensive and inefficient on-site physician coverage, instead relying on standard protocols backed-up by selective patient call-backs.

4. Not providing physician coverage of contrast media injections.

5. Not using contrast media in initial "screening" MRI exams.

These conclusions seem inescapable and must be considered an inherent part of the insured-payer-provider-patient continuum in defining what is the standard of care for the individual patient, payer, or community.

Dr. Stark is Professor and Chairman, Department of Radiology, University of Nebraska Medical Center, Omaha, NE; he is also a member of the editorial advisory board of this journal. Dr. Kanal is Associate Professor and Director of Clinical and Educational MR, Department of Radiology, University of Pittsburgh. Dr. Bradley is Professor of Radiology, University of California at Irvine, Orange, CA, and Director of MRI, Long Beach Memorial Medical Center, Long Beach, CA.