Clinical Management
Amid cost and quality concerns, hospitals explore ways to ensure that radiation use is always appropriate and safe.
When Partners HealthCare System entered into contracts with three large insurers that had imaging utilization targets, radiologists had a choice. Referring physicians would either have to call an 800 number to get preauthorization for high-cost scans, or create a decision support feature for their existing computerized order entry system, says James H. Thrall, M.D., radiologist-in-chief and chairman of Massachusetts General Hospital's radiology department.
Physicians chose the latter option. In late 2004, Massachusetts General implemented a decision support program for outpatient MRIs, CT scans and nuclear radiology. Referring doctors plug in the test they want done, along with the clinical indications for it. The system then rates the appropriateness of the scan on a 9-point scale, with 1 indicating the least clinical value and 9 the most.
The system also offers suggestions for alternative scans, lists the phone numbers of radiology subspecialists to call for help, and provides hot links to summary clinical documents for doctors who want more information before ordering.
"We are able to give the ordering physician what I call just-in-time information about appropriateness," Thrall says.
Before the system went online, annual growth was 12 percent for both CT and MRI. Afterward, growth fell to 1 percent and 7 percent, respectively, despite increasing patient volumes.
Public and private payers' concerns about the growth of imaging means more hospitals are under pressure to control utilization. From 2000 through 2006, Medicare Part B spending for imaging services paid for under the physician fee schedule more than doubled—to about $14 billion, according to a June 2008 Government Accountability Office report. Spending on CT scans, MRIs and nuclear medicine rose almost twice as fast—17 percent a year, on average—as expenditures on ultrasound, X-rays and other standard imaging.
During that period, a larger share of Part B spending for imaging shifted to physician offices from institutional settings, the GAO noted. Physician office settings accounted for 64 percent of expenditures for imaging services in 2006, compared with 58 percent in 2000. In contrast, the share of Part B spending for the services in hospital settings declined from 35 to 25 percent. Although this shift has raised payers' concern about the appropriateness of in-office scans, their attempts to control spending are touching hospitals as well.
This cost pressure is occurring amid heightened attention to the safety of imaging. Worries about the connection between medical radiation exposure and cancer are reinforcing payers' push to monitor the appropriateness of scans.
On the cost side, opposing forces are colliding in outpatient imaging, says M. Shane Foreman, principal and founder of the Chicago consulting firm 3d Health Inc. "The demographics of the U.S. suggest that the demand for outpatient imaging will absolutely continue to increase as the population ages. But at the same time, the payers—government and private—are really trying to wrestle those costs to the ground."
Insurers, as a first step, want to weed out what they see as unneeded scans. "It's an interesting time for hospitals and health systems to step forward and potentially solve some of this on behalf of the payers," Foreman says. "Hospitals and health systems, in partnering with radiologists, can set up appropriateness criteria and other mechanisms to make certain that when a scan is ordered, it's actually needed."
If hospitals and doctors don't take on the task, payers might turn to radiology benefits managers, Foreman says. Patients call the RBM to get approval for a scan, RBM representatives walk them through appropriateness criteria and, if the scan is deemed needed, suggest where patients should go for the tests. RBMs claim they do not steer patients to particular facilities, but others assert the companies send patients to the lowest-cost setting, often a free-standing center.
Benefits managers have been successful at trimming imaging growth, Foreman notes. However, physicians say they set up too many obstacles between patients and doctors. That's one reason Mass General opted to develop its decision support system, which is now licensed to Nuance Communications Inc.
Requiring a patient to call an 800 number to get approval for a scan interrupts physician workflow and puts a wedge between patient and doctor, Thrall says. "It in some ways devalues the relationship between the doctor and the patient because the patient sees the doctor is not the decision-maker, and the person who is making the decision for their care is someone who will never see them and never have any responsibility or accountability for the outcome of the care."
Under the Massachusetts General system, now being expanded to inpatient radiology, referring doctors' orders are not rejected. "We've learned over the years that there are not enough scenarios that can be imagined to cover every possibility," Thrall explains. "We value the wisdom, the intuition and the special knowledge that a doctor has about his or her patient." Plus, he says, one group of doctors should not dictate what another group of doctors can and can't do.
However, if a referring doctor shows a pattern of ordering scans of low clinical value, the radiology department intervenes with education. On a monthly basis, the department provides information on utilization and average appropriateness scores to referring physician practices. "When the information was first provided, there was a certain skepticism and even defensiveness," Thrall says. "Now the practice leaders are asking for the information. They all know there is variation between their colleagues. There are high utilizers for substantially the same patient population, and ultimately the health system has to squeeze out unnecessary resource utilization."
The decision support system is based on American College of Radiology Appropriateness Criteria, supplemented with criteria developed locally by multidisciplinary teams of specialists.
It is a learning tool for doctors and patients, Thrall says. When a patient presses for a scan of little clinical value, the physician can call up clinical information using the hot links, print out the materials and share them with patients.
At Johns Hopkins, regular multispecialty meetings and, in some cases, one-on-one interactions help educate physicians. "You don't want to be questioning [referring physicians'] judgment on every single thing," says Elliot Fishman, M.D., professor of radiology and oncology and director of diagnostic imaging. "But it's important, whatever hospital you're at, that you inform them what you can do, what you can't do, when a study is indicated, when it's not indicated, and what the best studies might be in select indications." The days of radiologists saying "you wanted a study, we'll do it," are over, Fishman says.
The importance of evaluating scan appropriateness was reinforced by two December 2009 articles in the Archives of Internal Medicine. One found significant variation in CT doses and the other predicted that about 29,000 future cancers could be related to radiation exposure from CT scans performed in 2007, the year studied by the authors. CT scans utilize much higher doses than regular X-rays and are the largest source of medical radiation exposure, says Thrall, chairman of the American College of Radiology's Board of Chancellors.
Use of CT has increased more than three-fold since 1993, to 70 million annually, notes one of the Archives articles. The rise is attributed to many factors, including the high quality of the images, patient demand and defensive medicine.
Some in the radiology community question the assumptions on which the Archives studies are based and believe the cancer predictions are overstated. What radiologists do agree on, Fishman says, is the need to make certain that every test is the best clinical choice and is done at the lowest dose possible.
"If a person didn't really need the study in the first place, in some sense, that's the most hurtful radiation exposure of all," Thrall says. The push to scrutinize the use of scans began with payers, but is now driven by providers' desire to practice the best medicine, he says.
The trend in imaging is to make quality and safety "a greater central focus," Fishman says. "All of us always strive for the best quality, the best safety. Now people are asking how do you know?" The answers, he says, are quality measurement and use of the best protocols.
Protocols should focus not only on dose, but also on conducting the right scan the right way, Fishman says. "One of the highest doses to patients is when the study is done poorly in the first place and you have to do it a second time."
Efforts to limit radiation dose have been helped greatly by constant improvements in imaging equipment. Newer CT machines are quicker and use much lower doses of radiation.
As part of its Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging, the Food and Drug Administration plans to establish requirements for makers of CT and fluoroscopic devices to incorporate additional safeguards into design, labeling and user training. The initiative, announced in February, also recommends that the health care community continue to develop scan appropriateness criteria and guidelines for radiation dose levels.
Meanwhile, researchers are exploring the use of adaptive statistical iterative reconstruction, a way of using computer software to reduce "noise" in CT images, Fishman says. The goal is to allow radiologists to do CT scans with lower radiation doses without hurting image quality.
Financially, imaging trends could hurt radiology practices, at least when it comes to the increased attention to imaging appropriateness. People ask Thrall if his practice is suffering from the reduced growth in scans resulting from Massachusetts General's decision support system. "The short answer is, sure, everyone wants to grow, but it doesn't strike me as a long-term viable strategy to build a practice doing things that don't really add value to the patient. [Radiologists] feel that it's actually a waste of their time."
Geri Aston is a freelance writer in Chicago.
Clinical Management is a regular series that examines specific disease or treatment areas. Clinical Management aims to uncover trends in technology, staffing, financing and other issues of concern to senior hospital executives. Our next installment will look at neurology.
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