Discussions over how (and even whether) to prove the value of radiology services have been going on for decades now, and pretty much every argument has been made. But one of the problems has been that most of those discussions have not involved practicing radiologists actively participating in talking about what value means. Too often, they have devolved into food fights over the degree to which practicing radiologists in the U.S. are or are not being economically oppressed or squeezed by new policy mandates and by reimbursement changes. As a result, so many of those discussions have remained arid exercises in privilege-driven assertions of the importance of radiologists to healthcare, assertions that really help no one, even radiologists themselves.
But I was very intrigued by a blog posted online today in Diagnostic Imaging by Steven L. Mendelsohn, M.D., entitled “Quality and Value: We’re Doing It Wrong.” After reviewing a few of the suggestions that have been made to reduce the volume of diagnostic imaging procedures, and noting that none of those suggestions speak to the core of what radiologists do and what they can control, Dr. Mendelsohn says this: “Our radiology leadership, pundits, and scholars must stop parroting the same suggestions again and again: talk to patients, use portals for patient results, communicate better with referring doctors, develop rapport with hospital administrators, sit at the table with ACOs and payors, etc. All very nice for that one individual radiologist or that one group, but these individualized divisive tactics are of no benefit to the entire field. None of those ideas prove our field's quality and value one single iota. We must do more than espouse that we radiologists must be ready to accept change. We must study, prove, and most importantly, publish for the salvation of our entire field.”
Dr. Mendelsohn goes on to say, “I could not find a single published study that helps ‘prove’ new 3T MRIs yield any improved patient outcomes compared to the 10-year-old 1.5T units or even the 20-year-old 0.3T open units. There are no studies that ‘prove’ value to the patient by having the entire study performed in 8 minutes rather than 45 minutes. So one can't plead superior quality or value for the millions of dollars of modern equipment, which is completely devalued under the new regime of quality and value measures. The same goes for low-dose CT scanners: no published evidence-based outcome proven study. Even so, it would be divisive, pitting radiologists against each other.”
Instead, he says, “We radiologists (all of us, non-divisively) have yet to prove that obtaining an MRI is a better value than letting the patient go unscanned and symptoms go unanswered. We all need to study a large group of patients that we image and age/symptom/pathology-match with a large group that we don’t image. We clearly will need the help of our (what seems to be unmotivated) orthopedic, neuro, and other colleagues to perform these studies for radiology's exclusive benefit. We need clinical outcomes, subsequent expenses, days lost wages, indemnity payments, and much more follow-up information, none of which is contained in any of our databases.”
In other words, here is a practicing radiologist recognizing that radiology utilization is under the microscope now in a way that it never has been before, and that radiologists must come together with others in healthcare to actually prove the value of the core services they provide. And Dr. Mendelsohn is right, and his insight is supported by the terms value-based reimbursement, accountable care, and risk-based contracting. Because the reality is that, as value-based payment, accountable care, and risk-based contracting move forward, as pushed hard by the public and private payers and purchasers of healthcare, the utilization and ordering of diagnostic imaging services are going to come under severe pressure over time. And the longer that radiologists resist explaining the value of what they do, to payers and purchasers, the tougher things will get for them.
Of course, I totally understand the point that some of the responsibility for this will fall to the ordering physicians, not the radiologists themselves, who after all are servicing the ordering physicians. Yet the broader point stands. Dr. Mendelsohn has it right: radiologists are going to need to demonstrate, and indeed, prove, the value of diagnostic imaging services, to improved clinical outcomes, and they’ll have to do it relatively, meaning, as he says, they’ll have to show why one particular diagnostic imaging procedure has greater value than another.
Of course, in many cases, there is no evidence yet in the literature to support hard-and-fast pronouncements. But even so, radiologists can put forward consensus-driven data and information. This is where it would be great for organizations like the American College of Radiology to get involved, as this is a policy-level discussion, and certainly, individual radiologists in practice will not have the capability to produce data and information, even consensus-based data and information, in this area.
I do think that the development of tools around peer review for efficacy and outcomes quality that is beginning in earnest now in radiology groups will be one element in this going forward. Another will be the requirement under Medicare for ordering physicians to consult evidence-based guidelines before ordering diagnostic imaging procedures, a requirement that begins in 2017 under Medicare.
And here is where clinical and other informaticists come in. They will necessarily be helping radiologists, ordering physicians, and everyone else, to create the data and information to support utilization and utilization management in this area. Indeed, CMIOs, imaging informaticists (an emerging but very important group), and other medical informaticists, along with non-clinician informaticists, could become real heroes to radiologists, and to ordering physicians, in all this.
Fundamentally, though, Dr. Mendelsohn is onto something here. How long before the majority of radiologists see the light? Hint: it’s a policy luminescence, not one that can be seen in a PACS viewing station.