This study was performed to determine the rate of utilizing MRI services in people covered by supplemental insurance in Iran. According to the results, in total, the average number of referrals of the insured covered by insurance to receive diagnostic and therapeutic MRI services in the whole country was equal to 0.07. The rate of utilizing MRI services in the whole country was obtained as 6%.
The use of medical imaging services is growing in countries around the world despite its high costs. The average referral frequency of each person to receive diagnostic and therapeutic services depends on multiple factors such as the increased rate of patients’ demand, the increased number of MRI units, increasing advances in diagnostic technologies, the increased number of radiologists and other health care providers, access to MRI services, and the physicians' behavior in creating induced demand (9, 12, 22, 23). As demonstrated by the results of a study conducted in one of the cities of Isfahan province, the most requested diagnostic services have included laboratory and radiology and the average frequency of referrals to medical diagnostic centers per person has been 1.32 per year. The mean referral for diagnostic services was obtained as 0.7 and 1.22 in other studies. The results of these studies indicate that each person uses diagnostic and treatment services almost once a year. The findings also suggest that the demand for diagnostic services increases with the increased age of parents, increased number of children, employed parents working in government offices and living in different geographical areas, the increased income of the whole household, higher education levels of parents, and the use of insurance coverage, especially in the case of full coverage of costs (21, 24, 25).
The average per capita MRI unit index in the OECD countries has been equal to 15.9 units per million populations in 2017. The per capita MRI frequency has been at the highest level in Germany, the United States, Japan, and France (more than 100 MRI tests per 1000 population). The number of MRI uses in 2017 has doubled in most of these countries compared to the previous decade. The highest and lowest number of MRI units per million populations has been reported in Japan (46.9) and Mexico (2.1) in 2015, respectively. On average, 13.3 MRI units per million populations have been available in these countries. This ratio has been reported to be 11.6 units for Germany and 6.1 units for the United Kingdom. The utilization of these services has increased in countries with an increased number of diagnostic and therapeutic devices (26–28).
With the introduction of new diagnostic and treatment technologies during the past years, the import of these devices into Iran has dramatically grown (29). The total number of MRI units in Iran's hospitals has been equal to 181 devices in 2017 based on statistical reports obtained from the hospital statistics and information system of the Ministry of Health. Also, 2036408 people have been referred to hospitals to receive the relevant services. The number of clients per 1000 population has been reported to be 25.19. Moreover, the MRI index per population (per million population) in the hospitals of all organizations and hospitals of the Ministry of Health has been 3.85 and 1.19, respectively. In 2016, MRI units had the highest frequency among imaging devices in Iran after CT scans (17, 30). In general, there are no general guidelines or international criteria for the ideal number of MRI units per million people. However, a very low number of these devices may lead to reduced access, especially geographically. An excessive increase in the number of devices can also lead to the overuse of costly diagnostic methods while using these methods has no benefit for the patients (28).
According to the results of a study performed in 46 universities of medical sciences of Iran in 2016, most of the diagnostic capital equipment and devices are concentrated in the northern and central regions of the country, especially in Tehran, while the eastern and southern regions of Iran have much lower access to such equipment. The results of this national study suggested that there is a fairer distribution of the MRI devices than other devices and the dispersion index of this device in Iran is lower than other imaging devices (17). It should be borne in mind that improper distribution of health system resources is known as one of the contexts of developing inequality in the health status of society (31) and equitable access of communities to healthcare services will lead to the improvement of the health level and the growth atmosphere in the country. Besides, the level of access to health care providers is also considered as one of the most important factors in benefiting from health services (32). The results of Pourreza study focused on evaluating justice in providing, allocating, and distributing resources in Iran’s health system suggested differences in the allocation of resources geographically and economically, which have led to limited access in the deprived and low-income areas of the country (33). Sepehrdoost has also found a deep inter-provincial gap in the country in the ranking of the provinces of Iran based on benefiting from healthcare facilities and equipment (34). Due to numerous gaps in the utilization of health indicators both between countries and between different regions of a country, and even within the provinces (35), the balanced development of health care facilities in different geographical locations seems to be necessary.
The introduction of diagnostic and therapeutic technologies may lead to the development of induced demand by service providers and inappropriate and wasteful consumption of these services. Research by Ivan K et al. has demonstrated that the radiologist's advice is associated with the repetition of imaging exams and this rate has been reported to be much higher in outpatients (36). About 20 to 50% of imaging techniques that use advanced and up-to-date technologies are unnecessary according to available studies (37, 38). The provision of unnecessary services such as MRIs, CT scans, etc. can be associated with side effects for patients besides imposing additional costs on the health system. On the other hand, imposing costs on insurance companies will ultimately lead to the patients’ dissatisfaction due to the lack of resources. In their study, Jones et al. showed that performing routine screenings such as physical examinations, and radiography to diagnose malignancies only accounts for 0.1 of the cost compared to MRIs, while the cost of finding one more malignancy with performing an MRI exam accounts for $ 625,000 (39). Therefore, we have to pay attention to the culture of optimal use of diagnostic and treatment services and the expansion of overseeing service providers both in the public and private sectors. In general, one can suggest that evaluating the referral times of people to receive diagnostic and therapeutic services associated with identifying predisposing factors and determining socio-economic factors affecting the availability and receiving of such services are important in order to provide optimal health services, allocating resources, and facilitating the access and utilization, and ultimately increasing the people's satisfaction.