Why Didn’t My Doctor Order an MRI

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Short Answer: MRI’s are expensive and often unnecessary in the grand scheme, especially for chronic conditions.

Long Answer:

Medical Treatment Providers (I am deviating from the term “healthcare providers” because the “healthcare” system is really just a bunch of professionals that treat conditions. True healthcare is largely dependent on the individual making healthy choices on a daily basis so they do not need medical treatment...sorry, rant over) do their best to provide good quality care to their patients.  Part of this is providing the best value care, that is the best outcome for the least cost.  MRI is often something that is not as often prescribed as patients might like.  There are a few things that come into play here.

• It may be unnecessary.
• Part of going through medical school, especially for sports medicine or orthopedic physicians involves a lot of education on clinical diagnosis of pathology.  A clinical examination performed by a skilled practitioner in many cases can be just as good or even better than an MRI at diagnosing a condition.  While an MRI might be nice to look at, if a physician (or other medical provider) has a pretty clear idea what the issue is and does not feel that surgery is necessary (at least at the time), they will likely delay the MRI in favor of a procedure or intervention that will help the healing process rather than just look at what is wrong when they are already pretty confident in their diagnosis.

• It may do more harm than good.
• The unfortunate nature of living is that our bodies do not look quite as good at age 50 as they did at age 20.  Over the course of time there will likely be some breakdown of tissue that is visible on an image. These visible “pathologies” may or may not be the cause of pain. One of the easiest examples to use is chronic back pain.  Almost everyone will suffer from back pain at some point in their life.  If you have chronic back pain it can be from a multitude of factors, and while we have no silver bullet, it seems that starting with a conservative approach is best. Other interventions like injections and surgery often come only after a failed bout of physical therapy or potentially chiropractic care.  
• While an MRI is a piece of the puzzle, it is not necessary in the rehab world for treatment to be successful. A good clinical examination will focus on identifying irritating movements, stiff joints, areas of decreased flexibility and potential strength deficits. If there is a chronic injury present, the body has done what it can to heal that injury and it may be other factors that are leading to pain more so than the “injury” itself.  Unless there are significant radicular symptoms (in the case of the neck or back) or significant instability or tearing (in the case of the shoulder, potentially the knee, or other joints of the extremities), it is likely that a good bout of physical therapy has about as much chance of success as surgery, sometimes more.
• In many cases, it is easy to get caught up in the anatomy of what is wrong with an injury and assume that because you have a “flaw” in your anatomy or “significant degeneration” of your spine, or “the worst bone-on-bone your surgeon has seen” and think that the only way to fix that is surgery to repair the anatomy. While that is not completely wrong, it does not take the whole picture into account.  Our nervous system can play a huge part in the amount of pain that we feel and oftentimes things as simple as exercise can help to down regulate the nervous system or create the strength in the muscles, or mobility in the joints that is necessary to decrease pain. While that is not always the case, and surgery can be a great solution in many cases, it is always wise to start with a good bout of rehabilitation where the clinical exam will be the ultimate driving factor in creating a custom plan to help someone get back to doing what they want to do.  If someone begins to hang their hat on their “damaged anatomy” it can take away from the fact that the abnormal imaging on their MRI does not necessarily mean that they will be unable to function at a completely normal level without undergoing surgery which is never a sure bet to restore normal pain free function.

• MRIs are expensive and insurance companies don’t want to pay.
• As we discussed above, MRIs are not always necessary for value based medical treatment to continue.  Insurance companies know this and may not reimburse for an MRI unless a bout of physical therapy is first performed. Depending on where someone gets an MRI it can run the insurance company upwards of $4000 in some cases.  Considering cash rates for MRIs are normally between $300 - $500 at an imaging center, the rates that larger hospital systems charge is unjustifiable in my opinion. Knowing that an MRI has little to no bearing on the long term outcomes of a patient for nearly all chronic conditions, insurance companies are not super excited to fork out over $4000 when a bout of physical therapy that has measurable clinical improvements will likely cost somewhere between $1000-$2000, and if the clinic is really trying to milk insurance for all it is worth, maybe the entire bout of care will cost $4000. So if the option is pay for something that produces clinical results, or pay for something that may add to the fear of a patient because there is “something wrong with them” that may be present on 75% of the pain free population, I may not want to pay for that either, and neither should the consumer as unnecessary procedures will drive premiums higher.

• But what if I really want an MRI?
• My advice, go to an imaging center and pay cash. Cash rates for an MRI are far lower than the insurance rate, and if you have yet to meet your deductible this is by far the better option.
• https://radiologyassist.com/MRI.html is a place to find MRI imaging centers near you that have an affordable price. I am located in Philadelphia and the out of pocket cost for an MRI for a unilateral knee was listed at $311.03, including the reading.  For those using insurance, the total cost (not necessarily out of pocket cost which will vary based on insurance) is ~ $1,000 - $4000 price range listed for those using insurance.
• If you really want an MRI and have a high deductible health plan, or have not yet met your deductible it may be wise to pursue a cash option.

Summary:

• MRIs are really expensive (when paid for by the insurance company, especially to a major hospital system) and while they are a great piece of the clinical picture to have, the value that they bring to the table does not justify their use early in the medical treatment process, especially for chronic conditions.  Early on, the best bet for musculoskeletal pain is going to be getting into the care of a good physical therapist that will give you the tools to decrease and manage your pain and get you back to doing what you want to do.  If your physician recommends an MRI, make sure that you understand your insurance policy and consider going somewhere other than a major hospital system or wherever your physician recommends to help save hundreds, or even thousands of dollars.