Radiologist As Gatekeeper, Part I

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For at least a dozen years, radiology has played a cat-and-mouse game with the notion of assuming a more active role in determining which patients get imaging. Due to concerns about referring physicians, the mouse, to date, remains elusive. The ascent of value creation in health care, however, has radiology not just thinking about a gatekeeping role, but preparing to assume one. Three speakers shared their thoughts in “The Radiologist As Gatekeeper: Should We Take a More Active Role?” on November 28, 2012, at the annual RSNA meeting in Chicago, Illinois. The session was moderated by Ruth Carlos, MD; Bibb Allen, MD, described the ACR®, Imaging 3.0 initiative to provide practices with the requisite tools to assume that role (see article, page 30, for a brief summary of Imaging 3.0); Alan Kaye, MD, considered the practical aspects of that role; and A. Mark Fendrick, MD, shared insights into what is driving policy. Kaye, who is president of Advanced Radiology Consultants (Trumbull, Connecticut), portrayed the future of the practice as a blank canvas, with many more details unknown than known. “One thing that is consistent along all of the programs that are incentivized by the federal government and by CMS (and recommended in the literature) are calls for safer, more effective, and more efficient care,” he says. Yet to be determined are the roles of capitation and fee-for-service payment, the prevalence of bundling, and how those bundled episodes will be characterized and reimbursed. With gain sharing and closer alignment among different providers likely to be components of the future practice, IT will be a key facilitator, Kaye believes. “The kinds of interactions and interrelationships that are going to be fostered by these new developments can only be done with a lot of IT input,” he notes. Whether those IT mechanisms put in place will be bridges to provider interaction or moats that promote silos and exclusive alignments remains to be seen. Guarding/Inviting Typically, one thinks of a gatekeeper as someone who keeps things out—in the case of radiology, those would be unnecessary exams. “Radiologists are going to be key in that,” Kaye suggests. “We are going to establish guidelines, we are going to use the ACR appropriateness criteria, and we’re going to develop vehicles to implement those.” Letting people in is a less-discussed role of the gatekeeper, and that begins with doing the right exam on the right patient, correctly, the first time. Due to their role in screening exams, the entry point into the system for many patients, radiologists are in the first position. “Then, once we assert ourselves, we can be the referring physicians and move ourselves up the food chain,” Kaye says. “If you buy into the fact that a well-documented and well-validated screening exam leads to early diagnosis, it will improve outcomes—and it saves money, down the road.” Radiologists have three important screening tools: mammography, lung-cancer screening with CT, and coronary-artery calcium scoring. “We need a validated way to stratify risk and screen patients at moderate risk for their chances for disease,” Kaye says. Radiologists deal in information, and as such, are in an IT business, Kaye says. With the success of many new contemplated delivery models dependent on information exchange, radiology has significant health IT domain knowledge that it can share with hospital and accountable-care–organization partners. Another perspective on the radiologist as gatekeeper, Kaye says, is that the specialty can help demonstrate stage 2 meaningful use, which requires patients to access their information electronically. “One thing that is a major component of meaningful use—and a requirement of meaningful use—is the establishment of a patient portal,” he says, noting that many practices are collecting information that they never before collected. If that information goes into the patient portal and becomes portable, it can stay with patients as they move through the system. “Patients really value the ability to visualize that information and have access to it,” Kaye says. “We’ve done that in our practice, and it’s had a lot of significant benefits for us. It lets the patients know who we are; they now know who their radiologists are. We have used it to create a bond with our patients. Patients are accessing their reports, and we’ve had zero complaints from our referring physicians.” Radiologist As Portal Patient sign-ups to the practice’s portal (since it was established, at the start of 2012) have shown steady growth. Kaye says, “Right now, they are accessing their reports at a rate of over 100 per day.” Kaye’s practice also mined its information system and used the patient portal to send patient reminders (rather than letters) in a recent pilot project. About 1,000 female patients, 40 to 75 years old, were divided into three groups, for the purpose of communicating more specifically tailored messages: women who were due for a mammogram; women who had been screened, but hadn’t come back in the allotted time; and women who had had other exams at the practice, but not mammograms. The communication resulted in 235 new mammograms being scheduled—a fact that has significant implications for the radiologist as gatekeeper. “We brought patients into the system,” Kaye says. “We brought patients not only to the referring physicians in our hospitals, but into the kind of care they should be getting.” Because patient compliance with mammography is a key measurement in so many established quality programs, he adds, “We contributed to safer, more effective, and more efficient care.” Being a gatekeeper is not such a bad idea, Kaye notes, particularly as the specialty grapples with concerns about commoditization. “This program changes us from a commodity to a member of the medical team—and an identifiable person to the patient,” he concludes.

Note: “Radiologist As Gatekeeper, Part II,” will appear in the June/July issue of Radiology Business Journal.