Will Decision Support Deflect Preauthorization?

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Decision support might be able to remove the target taped to radiology’s back, according to a tandem presentation that was made by two of the specialty’s respected leaders on May 3, 2010, at the annual meeting of the American Roentgen Ray Society in San Diego, California. Pat A. Basu, MD, MBA, explained how that target came to be there in the first place; he presented “Overutilization: Background, Trends, and Causes.”

Basu, an attending radiologist at Stanford University Medical Center and at the VA Palo Alto Health Care System in California, is Stanford University’s course director of health finance, policy, and economics. Now serving as a White House fellow and special assistant to the president, he is the first radiologist to be appointed to that position. By understanding the reasons for radiology’s current struggles, he says, both individual radiologists and health-care organizations can begin to find ways to identify and correct inappropriate utilization of imaging.

James H. Thrall, MD, provided a real-world example of how decision support could help decrease radiology’s vulnerability to external control (or outright attack) and declining reimbursement, presenting “Opportunities for Reducing Over-utilization.” Thrall is radiologist-in-chief at Massachusetts General Hospital (MGH) in Boston and Juan M. Taveras professor of radiology at Harvard Medical School.

Even if the overutilization of imaging is a problem created largely outside radiology by self-referring nonradiologists, patients’ underinformed demands, and referrers’ errors and malpractice worries, it has become radiology’s problem because radiologists bear the brunt of measures meant to curb utilization, Thrall notes. In clarifying the need for radiology practices to move beyond simply accepting overutilization as part of keeping referring physicians happy (or as part of maintaining current revenue levels), he says, “It’s not a sound business principle to try to build a practice or a business based on things people don’t need—on providing services that are unnecessary.”

Growth Versus Overutilization

It is important, Basu says, to avoid confusing growth with overutilization in imaging, as this mistake has done much to damage the reputation of radiology in the eyes of lawmakers, regulatory agencies, insurers, and the public. Growth in procedural volumes can often represent completely appropriate increases in the utilization of imaging services in response to technological advances and to improving medical evidence of the best applications for imaging modalities and procedures.

Many of the major growth spurts that imaging volumes underwent in previous years were wrongly characterized by policymakers as the simple addition of yet another costly, high-tech, and possibly unnecessary study to the diagnostic protocol for a given disorder, with the economic effects of that addition then multiplied, across the nation, by the number of patients initially suspected of having that condition.

Basu point out that this oversimplified and erroneous model has harmed radiology both by exaggerating the cost of imaging and by overlooking its value (in clinical and monetary terms). In many—or even most—cases, the imaging-utilization statistics could have been showing growth in the use of a procedure or modality for sound reasons. Often, one type of imaging is substituted for another as its superiority becomes more obvious to referring physicians.

In such instances, figures demonstrating growth in that modality must be weighed against any declines seen in the utilization of other modalities, if any realistic conclusions are to be drawn. This is relatively obvious for analyses of the utilization of one modality versus another (but not often brought to broad attention, even so). This type of comparison has been far more difficult to make when one procedure largely replaces another within the same modality, partly due to lack of data and partly because this kind of work hasn’t often been undertaken.

Radiologists in the field might see a strong trend toward one less-expensive but diagnostically equivalent study replacing a more costly one within a modality, for example, but this kind of positive change is unlikely to be tabulated anywhere—and still less likely to reach a level where it could gain the attention of policymakers.

The value of imaging in replacing diagnostic procedures outside radiology is even more pronounced, but just as often overlooked. How often,