Physicians and the E Word
Physicians are understandably suspicious of efficiency efforts in medicine, but nowhere in the Hippocratic oath are they absolved from addressing the appropriate delivery of care As we gallop toward the culmination of possibly the most entertaining—and important—presidential election in collective memory, the issue of health care emerges and recedes on the national stage. Like the disappearing ducks in a carnival shooting gallery, it mostly recedes. This underscores the difficulty of the challenge ahead: lowering health care costs while extending coverage. Health care providers struggle to define quality, as payors strive to hold down costs. Caught in the middle are the physicians charged with practicing medicine. If medicine were strictly a science, the quality problem would be easier to solve, and if people were androids, manufactured to conform to specifications, the problem would be easier yet to solve and, therefore, regulate. The human animal, however, comes with such a wide range of physical, circumstantial, and genetic variables that the art of medicine is now, and is likely to remain, a decisive resource in the physician’s toolkit. Nonetheless, there also is room in this equation for efficiency. In this environment of high deficits, looming Medicare Trust Fund insufficiencies, and soaring health care costs, it is reasonable to ask: Why is efficiency such a dirty word among physicians? For the answer, I turn to a pilot project commissioned by the country’s largest health care payor, CMS, which aims to develop and vet a number of imaging-efficiency measures that would accomplish improvements in efficiency and, ostensibly, improve the quality of care. Four measures were put forth earlier this year by the Washington, DC-based research and consulting firm L & M Policy Research for comments from the radiology community:
  • MRI of the lumbar spine for lower-back pain (the number of patients with lower back pain receiving MRI with antecedent conservative therapy);
  • mammography follow-up rates (essentially, call-back rates);
  • use of contrast material for CT of the abdomen (the percentage of patients receiving abdominal CT without the use of contrast for the diagnosis of calculi in the kidney, ureter, and/or urinary tract; renal colic; hydronephrosis; and unspecified abdominal pain), with the percentage expected to be high; and
  • use of contrast material for CT of the thorax (the percentage of total studies performed with the use of contrast), with the percentage expected to be high.
Consider the mammography call-back–rate measure. In putting forth the measure, L & M Policy Research and subcontractor NIA/Magellan Healthcare suggested that abnormally high rates (exceeding 10%) for call-backs indicate the absence of an on-site interpreter and may signal the inability of the reader to determine adequately when additional imaging is necessary. Without going into detail on all of the measures, I would have expected the mammography follow-up–rates measure to be the least controversial, with the fewest negative responses. I was dead wrong. The most vociferous negative feedback was reserved for this measure. While the literature suggests that a 10% call-back rate may be reasonable from an experienced mammography subspecialist, feedback pointed out that it would be not only unreasonable, but potentially dangerous, to hold the entire specialty to this standard. Why? Call it the real-world factor. In the real world, there are not enough mammography subspecialists to handle the current number of mammograms, and that number is likely to increase over the next 20 years. Medicolegal issues demand both caution and courage from those who interpret these examinations. Is it prudent to ask radiologists to limit callbacks to less than 10% if 11% or 14% is more comfortable? While many breast-imaging centers offer patients the service of reading their mammograms while the patient is on-site, this is not the norm. The fastest and most efficient way of reading mammograms is batch reading, and that is how most mammograms are read. This example clearly illustrates why physicians in general, and radiologists specifically, dislike the word efficiency. Insurers are governed by actuarial principles, cost efficiencies, and operating policies. Physicians operate in a messy world of exceptions, anomalies, and sick people. Attempts by insurers to impose measures that are not in step with the standard of care are likely to be ignored or to cause unintended consequences. Cost efficiencies dressed up as quality improvements are likely to draw sneers. Nonetheless, where in the Hippocratic oath are physicians absolved from delivering the appropriate amount of care? Within our current health care delivery model, fraught with misaligned incentives and a public accustomed to getting the care it demands, there are not a lot of options to reduce the cost of imaging. Shall we fix quarterly reimbursement caps for providers and let them pay for all care provided beyond that cap? No? I heard a German physician on a National Public Radio broadcast complaining bitterly about this policy of his country’s national health insurance. I don’t blame him. Here’s a solution: Stop self-referral, period. Leave imaging to the imaging professionals. Imaging technology is sufficiently deployed to ensure patient access in all but the most remote areas, so the patient-convenience argument made by technology-owning, self-referring physicians is null and void. Promote the adoption of online ordering systems with appropriateness criteria embedded at the point of ordering—and reimburse radiologists, not radiology benefit management companies, for the costs of utilization management (see article, page 28). As for radiologists and their aversion to the word efficiency: Ladies and gentlemen, you would be wise to get over it. Radiologists are understandably suspicious of efficiency efforts in medicine, but there are dirtier words in the English language: waste and want.