Radiology Gatekeeping

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 - David M. Yousem, MD, MBA
David M. Yousem, MD, MBA

When a radiologist went looking for unnecessary imaging, he realized he could earn his salary three times over just by weeding out waste.

Much has been said about the excesses of the American healthcare system. Up until recently, the overutilization of our resources has been beneficial to the radiology community because we have been reimbursed almost exclusively on a fee-for-services basis. Therefore we have turned a blind eye to those questionable “referrals” and reaped their benefits. The more we do, the more we make.

The State of Maryland has instituted a waiver system for its hospitals this year. Essentially, this means that hospital payments for the citizens of Maryland are now capitated in an all-payor system. No matter how much we do, at least on the technical side, we get paid a fixed rate for the entire year, with no opportunity to gain further revenue.

In a curious twist, the professional fees remain outside the waiver system. This leads to an awkward clash of interests. The physician clinical practice still is rewarded for increasing volumes even as the hospital wishes to constrain utilization.

Nonetheless, the impetus is to be more efficient, cut out waste and continue to provide the best possible patient care. However, the waiver process for hospital inpatients led me to spend a week looking for unnecessary studies in neuroradiology. I did not have to look far in my daily practice.

I found them:

  1. CTAs of the head and neck for patients with intracranial subarachnoid hemorrhage: slash the CTA of the neck;
  2. Brain MRI, with and without gadolinium, for follow-up of an oligodendroglioma that has been stable for 4 years and has never ever enhanced: convert to MRI brain without contrast;
  3. MRA of the brain and neck for stroke in a patient who the same day had a negative CTA of the brain for stroke: eliminate the repeat brain study;
  4. MRI of the complete spine, with and without contrast, for a patient who had a negative MRI of the complete spine two days before for medulloblastoma seeding: perform it just with contrast;
  5. CT of the brain and neck for thyroid nodule evaluation: bag the brain study and consider ultrasound instead of CT;
  6. Complete brain and spine MRI with contrast from the ED following a normal complete spine brain and CT for leg weakness in a motor vehicle collision: negotiated to have a neurology consult instead, and the study was cancelled completely.

It’s true that we have not yet instituted “decision support” into our physician order entry system, but some of these scenarios are likely to slip through even that safety net. And since this is inpatient imaging we are not necessarily subject to radiology benefit management.

Radiology leaders fear the potential of “gaming the system” with computer program-based decision support software and the potential for overriding the recommendations. We are using ACR practice parameters to construct our algorithms, but the referrers sometimes want what the referrers want. There needs a human touch.

I proposed to my chairman that, for one year, I play the gatekeeper role for unnecessary studies on a full time basis. I believed that I could save the hospital, in technical fees, twice, three times, or even four times my salary by not performing studies. Sure I’d miss reading the studies but the fat in our hospital’s system needs trimming.  If I cannot cover my salary, I do have an alternative.

Outpatient services are not included in the Maryland waiver. They are still reimbursed on a fee-for-service basis. Therefore, if my “savings plan” does not cover my salary and it looks like there is a salary deficit at the 6 month mark, I can just read some outpatient center studies on the side. I doubt it will be necessary—too much fat.

Food for thought.