Gatekeeper, Part II: Understanding Clinical Nuance

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A. Mark Fendrick, MD, is a self-described generalist. His research (as a professor of internal medicine and director of the University of Michigan’s Center for Value-based Insurance Design) has probed the cost of the common cold, explored the value of new imaging techniques, and quantified the value of Katie Couric’s colonoscopy in preventing colon cancer in the United States as worth more than $1 billion in National Institutes of Health funding. “I was introduced to the US Congress as the shallowest guy in academic medicine, which you—as subspecialists—would take as an insult, but I took as a compliment,” he quips in his segment of “The Radiologist As Gatekeeper: Should We Take a More Active Role?” The session was presented on November 28, 2012, at the annual RSNA meeting in Chicago, Illinois. Fendrick shared the podium with Bibb Allen, MD; Alan Kaye, MD; and moderator Ruth Carlo, MD. While Fendrick was impressed with the panelists’ head-on approach to health-care reform, he characterized the behavior of other specialty organizations as ostrichlike. He recalls, “The first thing I said, in a talk given to the American College of Cardiology, was, ‘Before you get angry at me, the approach we are trying to outline will actually increase your income. It may change what you are doing, but it is not the threat it is being made out to be to the practice of any type of medicine—because (as all of us know) there is more than enough money in the system.’” Furthermore, Fendrick points out, no one, when talking about bending the cost curve, is talking about cutting health-care costs in any way. “If you look at projected trends relative to the doomsday scenarios, hundreds of billions of dollars, in new money, are projected to be spent, all across the board,” he emphasizes, adding that the more radiologists focus on the issue of value over volume, the better off they will be. Volume to Value Radiology’s path from volume to value should be based on three tenets, Fendrick says: the creation of evidence, the creation of tools, and (most important) the creation of incentives, the subject of much of his research activity. “I hope we spend a fair amount of time talking about how we move from a fee-for-service payment model to one that is based on the health we create,” he says. “We need to realize, moving forward, that outcome equals income. I don’t know why this has never been the case, but how you perform—the good that we are supposed to create, which is health—will, ultimately and finally,” determine how health-care providers are judged (and paid). Fendrick urges radiology to consider its value proposition seriously, in the context of the health that it creates—even though the dialogue in Washington and in state governments is exclusively about cost. For instance, Fendrick recognizes that the emphasis, in imaging circles, is on the ineffective and inappropriate use of imaging. “Why isn’t there equal attention (which is the focus of my research) to the underutilization of the effective imaging technologies that we have? You have to understand that as there is overuse on one side, there is clear underuse on the other side.” The answer, Fendrick believes, is to merge supply-side incentives with demand-side incentives. On the demand side, the creation of consumer-directed, high-deductible health plans and defined-contribution models means that patients are almost universally being required to contribute more to the cost of their health care. “What we are finding is that as patients are required to pay more (out of pocket) for all services, they not only stop buying the stuff that we don’t want them to buy, but they also stop buying the things that we beg them to buy,” Fendrick emphasizes. Rationalizing Incentives In order to rationalize incentives on both sides of the health-care relationship, physicians must find a way to communicate clinical nuance to policymakers. “What we all know—but what payors and policymakers don’t understand—is that medical services differ in the value that they create,” he says. “I have strongly suggested (for more than a decade) that we should be paid more for the things that produce the most amount of health, and we should be paid less for things that don’t. Patients should have easier access to those services with the highest level of evidence of impact or benefit. Patients should have to pay more for things with no indication.” On the supply side, real battles will break out among physicians over determining which health services should be highly valued, Fendrick predicts. On the demand side (and in his role as a practicing physician), Fendrick has seen, firsthand, patients whose chief complaint is that they need an MRI exam. “They don’t even tell me which joint is bothering them—or whether it’s their head or their knee,” he says. Misplaced incentives, media health-care coverage, and other factors have led to complete distraction from the fact that there is clinical nuance in the things that physicians do. Some progress in the convergence of supply- and demand-side incentives can be seen in physician pay-for-performance incentives and value-based insurance design, which “makes the good stuff easier for patients to get and the bad stuff harder,” Fendrick says. “Although there seems to be a lot of focus on the overuse issue, you need to focus much, much more on the underuse of imaging, the transformative nature of imaging, and how it has made the practice of medicine so much easier . . . across all specialties.” One of the most popular elements in the Patient Protection and Affordable Care Act (PPACA) is the page in the 2,700-page law that mandates the provision of high-value preventive services (as determined by the United States Preventive Services Task Force and other organizations)—including mammograms and colorectal-cancer screenings—at no cost to patients. “Where you and virtual colonoscopy fit into those guidelines depends on your research,” Fendrick says. Paying Farmers Not to Plant Fendrick, a frequent visitor to Washington, DC, shares the story of how the idea of clinical nuance made its way into the PPACA during a discussion about pricing stent placement with some US senators. He told them that in the setting of an acute myocardial infarction, a coronary stent is the most valuable thing that we have in medicine. It saves lives a remarkably high percentage of time. He adds, “Many of you know that at your institutions, this specific service is markedly underutilized, for a lot of reasons: not getting to patients in time, having no cardiologist available, or the catheterization laboratory being unavailable. I suggested paying cardiologists a lot more, in that setting, for stent placement.” When Fendrick moved on to describe to the senators the 30% of stents placed unnecessarily, a senator stood and asked if he was going to suggest that cardiologists be paid not to put in stents, in those situations. Before Fendrick could respond in the affirmative, Sen Chuck Grassley (R–IA) said, “If we can pay farmers not to plant corn, we can pay cardiologists not to put in stents.” Fendrick says, “It was that moment of reason that actually got the concept of clinically nuanced payment and benefit design into the PPACA.” In conclusion, Fendrick invited attendees to give him a list of underutilized services in radiology to bring forward to national policy specialists. “I would like you to take this idea of clinical nuance (that services differ), combined with the idea that incentives must change for all of you, from volume to outcomes, as you think about where you sit in this whole process,” he suggests.