Omakase Radiology

September 13, 2013

Referring patients and letting radiologists decide on needed imaging studies could improve quality -- if it's feasible.

I was a fan of sushi before it was cool.

Introduced to the delights of consuming raw fish at an early age, I experienced the dilemma of living with an expensive taste before I had an ability to pay for it. Therefore, in college, medical school, even residency, I placed greater value on quantity than quality for the stuff. (Unless you count not making the consumer ill a hallmark of quality.) As far as I was concerned, all-you-can-eat sushi for $20-30 was pretty much the top shelf.

So, somewhere around the end of my postgrad training, when a former classmate raved about a nearby place offering the best sushi he’d ever had, but with a price tag several times that of my usual haunts, I was skeptical. He insisted I give it a try, though, and I relented – much to my everlasting thankfulness.

As it happened, I got quality for the numerous extra bucks-quality well above my previous frame of reference. Now aware, I actively seek out the better goods, as they are, to me, worth the extra cost.

Key to this experience, and most of my better subsequent outings, is the “omakase” dining option. Japanese for “I’ll leave it to you” (out of trust), the term means you’re asking the chef to use his judgment, skill, and creativity to present you with the best of his repertoire.

By contrast, in diagnostic imaging there’s really no premium set on quality. A crummy scan done on a 0.3T MRI unit, by a tech who really doesn’t know what he’s doing, read by a moonlighting radiology fellow, commands exactly the same rate as an expertly-performed MR from a 3T unit by an ace technologist, read by the department chair of a top-flight academic facility, boasting 20 years’ experience. Not only does insurance pay the same for each-the patient rarely even has an inkling of the cost.

Which has me thinking, from time to time, about what might evolve if we could introduce the element of a premium-level imaging service. Call it Omakase Radiology. A typical clinician referring here doesn’t order a head CT or a carotid duplex. He just refers the patient, along with a script for diagnostic imaging and the relevant clinical history. The radiology team does the rest.

Prior to appointment, the patient communicates with Omakase staff for detailed discussion of the issue at hand-history is taken and arrangements are made for acquisition and review of relevant prior imaging from elsewhere. Synthesizing all of this, the radiologists at Omakase proceed to formulate an imaging plan, such as whether to begin with X-ray, ultrasound, or something else.

On the day of the patient’s appointment, each step of the diagnostic process gets reviewed by the radiologist while the patient is present. If additional imaging (by whichever modality) is relevant and requires no prep, it gets done then and there. If desired by the patient and the referring clinician, results are discussed, face-to-face, between patient and radiologist, possibly with the referrer on conference-call. Virtually gone is the mess of referrers ordering the wrong type of study for the clinical issue and days/weeks of waiting for follow-up appointments after inconclusive reports are generated.

Of course, the financial and logistical realities of our third-party-payer world render this almost entirely unfeasible. Getting authorization for each imaging study, the thorny issue of self-referral, and the imperative of filling every single moment of the day with patients being scanned and radiologists reading those scans (rather than having machines available to receive on-the-spot occupants and doctors available to sit with patients for consultations) are a few of the roadblocks. Many of these would be non-issues if one didn’t need to jump through the hoops of third-party payers.

Really, it wouldn’t be such a departure from other walks of life-one seeks the services of a professional, and one gets quoted an hourly rate in advance. Except in this case, patients could, then, submit their bills to their insurers for whatever partial reimbursement the third parties deemed appropriate (assuming patients, seeing how much better healthcare could be without the interference of insurers, didn’t abandon those middlemen in favor of coupled health savings accounts and high-deductible health plans).

A would-be restaurateur, considering opening an establishment with a sushi bar, might decide that it’s worth the extra cost and effort to offer Omakase-level service – or might not – and opt for varying shades of mediocrity. A major factor in such decision making is whether a sufficient number of customers are likely to attend the place and plunk down the extra coin to keep it afloat.

Similarly, Omakase Radiology might just be possible-if one had a sufficient referral base willing to entrust diagnosticians with the degree of autonomy necessary for this model. Yes, some patients might balk at forking over more than a $10 copay for their imaging workup. Lower-end sushi joints stay in business for such folks. But some of those currently opting for the status quo might only be settling for it because they haven’t yet experienced better.