Radiology and the Culture of Money
Let’s get the full disclosure part out of the way right up front. I am a capitalist: an Adam Smith, free-market, supply-side, trickle-down-economics entrepreneur who believes that individuals have a right to build wealth for themselves without anyone being able to play Robin Hood with their money, freely redistributing to others what they honestly earned the hard way. It is attractive to many in our society to vilify the power barons on, say, Wall Street. Make no mistake, though. When our financial or corporate institutions fail, most US residents are affected, and many stop buying things. When they stop, people in emerging economies starve. That’s trickle-down economics, and the evidence for it is irrefutable. Greed and obsession with the money culture, however, are entirely different pieces of the capitalist pie. When I see these affecting our health care system, it is worth raising a red flag. A case in point is the fascinating, well-written “Annals of Medicine” column in the June 1, 2009, issue of The New Yorker. In “The Cost Conundrum: What a Texas Town Can Teach Us About Health Care,” Harvard surgeon Atul Gawande, MD, MPH, outlines in some detail what I feel is the essential crisis in our health care system. There is a very strong message here for the medical imaging profession, and it warrants reflection: Our health care system has become dominated by the culture of money. We are close to a tipping point, and in danger of allowing this culture to destroy an honest, ethical means of earning a good living through creation and innovation. The essential problem is that the incentives in our system are built on doing more of everything—more tests, more drugs, more exams, more surgeries and interventions; more, more, more. We spend more (as a percentage of gross domestic product) on health care than any other industrialized nation, and more, per capita, than any country in the world. We have not designed our incentives around quality, outcomes, or performance. We have not aligned incentives in a way that benefits the patient, or requires the current patchwork of specialists to come together to treat the patient in a way that promotes total health and well being. Ours is a system built around turf and the competition over who should be treating what body part, disease state, or malady—and who gets the money. In his column, Gawande discusses the interesting fact that McAllen, Texas, with the lowest US household income, is the second most expensive US health care market, according to statistics from CMS and private payors. His quest is to find out why Medicare is spending twice the national average for each beneficiary in McAllen. Do patients get better care in that town? Are McAllen’s people sicker than those in the rest of the country? Why have McAllen’s costs soared since 1992, when they were essentially in line with national averages? Is the town a malpractice nightmare, requiring an abundance of defensive medicine? After interviewing many local providers, payors, and thought leaders, Gawande discovers that patients in McAllen definitely get more health care than patients in the rest of the country: more diagnostic testing, more hospital treatment, more surgery, and more home care; more of everything. He finds what has become, in the words of one of his physician sources, “a machine” operating in a “culture of money.” A noteworthy fact is that not one of the hospital administrators that Gawande interviews seems to know that McAllen is an outlier. Not one has any clue as to why that is the case. Not one seems to understand this very complex system. Conclusion: Part of our system’s problem is that the key players do not fully understand the problem. As a result, it is not likely that any informed voice will be able to refute what I took to be the central thought that will have the biggest impact on the entire system. Peter Orszag, President Obama’s budget director (and someone very much prepared for the debate on health reform), is quoted as saying that nearly 30% of Medicare costs “could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas.” This will be a great leveling of the playing field, designed to eliminate the regional variations that have plagued the system for years. It is likely that a form of rationing of care will be the result of this leveling to the lowest common denominator (a market like El Paso, Texas, Gawande’s example of a nearby locale where spending is a fraction of McAllen’s). It’s all about appropriateness of care. If we are to ensure the long-term viability of our health care system, then we need to begin by fully understanding the problem. At the core of the problem, driving abundant utilization, is the culture of money. Medical imaging has an opportunity to be the hero of this story. Radiology groups need to develop protocols, processes, and systems that focus on appropriateness. Which tests should be ordered, when, and in what sequence? What are the ideal uses of sophisticated imaging technologies? How should you educate specialists and primary care physicians so that radiologists can regain their lost positions as consulting physicians to those referrers? Work in these areas will separate our profession from the pack, and could go a long way toward deflecting cost-cutting zealots from medical imaging. We should be able to earn more than just good-citizen awards by doing this. The benefits should include investment in imaging as a cost saver, rather than as the cost driver that it is mistakenly seen as at the moment.