Are You the Gatekeeper?

April 26, 2013

ACOs mean the healthcare team will have to manage care under a budget. Who, then, will be the gatekeeper? Will radiologists step up the challenge?

The other day, I'm winding down a shift, and along comes a chest/abdomen/pelvis trauma CT on a young lady who had a little too much to drink and took a tumble.

I say it was a C/A/P scan, but really it was more of a CCC/AAA/PPP, as they scanned her three times: first without contrast, next with, and then again during the delayed phase. That's right. They even rescanned her chest in delay. If the clinicians or tech had any specific reason for the extra ionization, they didn't share it. I wish I could say this particular ER is the only such routine offender I have encountered.

For teleradiologists like myself, and even those doing locums work, there isn't much we can do about such things. We can see red and grind our teeth. We can complain to anybody who will listen (including the on-staff docs, radiological and otherwise) about how wrong this is, whether because of the needless extra radiation or just because we'd prefer not to have an extra few hundred images to view.

When our e-mails, phone calls, or even in-person communications on the subject get no traction, it's a solid reminder that, as outsiders providing coverage, our input carries little weight. We're to just read the scan and not meddle with internal hospital affairs.

However, it wasn't that long ago that I was one of the on-staff, there-in-person radiologists who supposedly had more pull. Guess what - we didn't. Try to flex some muscle and modify (or God forbid, refuse) a study if the order was inappropriate, and you risked a firestorm from other departments and/or admin. Maybe even your own department, if you made waves with the wrong people.

No matter if you're doing it for all the right reasons - the reward for trying to be a good radiological physician was often a big bundle of hassle. The path of least resistance it was, then: just read the scans, no matter how inappropriate, and shut up.

So now, I'm put in mind of a recent discussion on another physicians' forum I frequent. A pathologist described a situation in his hospital where they're facing the thorny issue of who's to be the "gatekeeper" of pathological services, lest they hemorrhage resources on expensive testing that ultimately does not get reimbursed.

The issue is coming closer to home with ACOs, assuming that the healthcare law doesn't prove to be a self-dismantling train wreck. There will be a finite sum per patient/diagnosis, and if your healthcare team (including the parts over which you have no control, like the patient's behavior) doesn't manage things under budget, the team eats the cost. This is the government saying that it (and insurers) won't, directly at least, be the gatekeeper - for pathology, radiology, subspecialty consults, you name it.

We could continue as things are. That is, let the clinical services police their own ordering habits (which either means that they are the gatekeepers or that there are no gatekeepers, depending on how cynical you are). This is fine if we're willing to continue with excessive and/or inappropriate imaging, runaway costs, etc. Just be prepared for when the non-radiological members of your ACO "team" want your department to suffer the financial losses incurred by their ordering habits.

Assuming that this status quo proves unpalatable, someone other than the clinical services is going to receive the power and responsibility of being the gatekeeper. Will we step up to the challenge? Or will we let others ride herd on us some more?