Check­ing the facts

Ra­di­ol­o­gists’ ef­forts aim to de­fend use of imag­ing

Modern Healthcare - - COVER STORY - Jaimy Lee

Ra­di­ol­o­gists are push­ing back against crit­ics of med­i­cal imag­ing overuse with a broad ef­fort that seeks to de­fend the role of ra­di­ol­ogy and imag­ing within new pay­ment and care-de­liv­ery models.

Un­nec­es­sary med­i­cal imag­ing is of­ten cited as a driver of health­care costs in the U.S., with a no­table growth pe­riod oc­cur­ring from 2000 to 2005 when CT and MRI uti­liza­tion for Medi­care ben­e­fi­cia­ries each grew at an an­nual rate of about 14%. Imag­ing use has since de­clined.

In ad­di­tion to the of­ten-cited growth pe­riod and re­im­burse­ment cuts, an­other cause for con­cern took place last year when re­searchers at the Medi­care Pay­ment Ad­vi­sory Com­mis­sion listed re­peat test­ing as a source of cost and waste re­duc­tion. A study also pub­lished in 2012 in JAMA In­ter­nal Medicine found that Medi­care ben­e­fi­cia­ries fre­quently re­ceive re­peat di­ag­nos­tic tests. Imag­ing also is on the lists of tests and pro­ce­dures that shouldn’t be done as part of the physi­cian spe­cialty group-backed Choos­ing Wisely cam­paign, which just ex­panded.

“It makes sense to tar­get imag­ing and ra­di­ol­ogy be­cause some are dis­cre­tionary ser­vices,” said Ger­ard An­der­son, di­rec­tor of the Cen­ter for Hospi­tal Fi­nance and Man­age­ment at Johns Hop­kins Bloomberg

School of Pub­lic Health. “It’s part of the large pic­ture of look­ing at ev­ery­thing that clin­i­cians do and mak­ing sure there is not overuse.”

Ra­di­ol­o­gists have be­come in­creas­ingly con­cerned about the sta­tus of their roles within bun­dled or cap­i­tated pay­ment models as well as whether new pay­ment poli­cies may limit pa­tient ac­cess to test­ing.

Th­ese fac­tors led the Amer­i­can Col­lege of Ra­di­ol­ogy to last year es­tab­lish the Har­vey L. Neiman Health Pol­icy In­sti­tute, which plans to fund and con­duct re­search on imag­ing uti­liza­tion.

“There’s a wide­spread be­lief—and I think it’s cur­rently in­ac­cu­rate and based on dated ma­te­rial—that med­i­cal imag­ing is lead­ing the way in our very ex­pen­sive health­care sys­tem and its ris­ing costs,” said Dr. Richard Duszak Jr., the or­ga­ni­za­tion’s CEO and se­nior re­search fel­low.

The Neiman Health Pol­icy In­sti­tute last week pro­posed a clas­si­fi­ca­tion sys­tem that would sep­a­rate re­peat med­i­cal imag­ing into four cat­e­gories: sup­ple­men­tary, du­pli­cate, fol­low-up, and un­re­lated. “Stud­ies and pol­icy reme­dies that seek to ex­am­ine re­peat test­ing for po­ten­tial ef­fi­cien­cies may pro­duce un­in­tended con­se­quences for over­all qual­ity of care if re­searchers and pol­i­cy­mak­ers do not care­fully con­sider the clin­i­cal con­text of a par­tic­u­lar text—a prob­lem that is only con­founded by on­go­ing use of am­bigu­ous ter­mi­nol­ogy,” ac­cord­ing to the in­sti­tute’s report.

In ad­di­tion, the in­sti­tute plans to pay up to $60,000 each for projects that tar­get the value of imag­ing, the role of ra­di­ol­o­gists in alternative health­care models, the re­la­tion­ship be­tween imag­ing and qual­ity, and the im­pact of new pay­ment models on pa­tient ac­cess, prac­tice own­er­ship and uti­liza­tion.

“Our in­tended pri­mary tar­get for this, be­cause we’re really get­ting to the core of a de­vel­op­ing body of re­search in re­peat test­ing, is to help im­prove the level of thought­ful con­ver­sa­tion among health ser­vices re­searchers and the pol­i­cy­mak­ers that then will be mak­ing pay­ment or cov­er­age or other de­ter­mi­na­tions based upon that re­search,” Duszak said. “Our goal is not to say that ra­di­ol­ogy should be paid more, or imag­ing should be done more.”

A com­monly cited statis­tic is that 30% of med­i­cal imag­ing is un­nec­es­sary. How­ever, there is a lack of data back­ing up the es­ti­mate.

A study of staff ra­di­ol­o­gists at Mas­sachusetts Gen­eral Hospi­tal in Bos­ton found that more ex­pe­ri­enced ra­di­ol­o­gists were less likely to call for re­peat imag­ing. Older physi­cians had a “more finely tuned sense” of when it was ap­pro­pri­ate to call for re­peat imag­ing, said Dr. Jef­frey Weil­burg, as­so­ciate med­i­cal di­rec­tor of Mass Gen­eral’s physi­cian or­ga­ni­za­tion.

Dr. Steven Amis, chair of ra­di­ol­ogy at the Al­bert Ein­stein Col­lege of Medicine and the Mon­te­fiore Med­i­cal Cen­ter in New York, said other stud­ies show ge­o­graphic dif­fer­ences, with more fre­quent imag­ing or­dered by physi­cians based in cer­tain re­gions of the U.S. and for pa­tients with cer­tain clin­i­cal con­di­tions.

“De­ci­sion sup­port may not force the doc­tor not to or­der an in­ap­pro­pri­ate test,” Amis said. “But at least it may raise the ques­tion.”

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