Radiologists Should Act on Appropriateness Decisions

November 29, 2012

Are we willing and ready to be active in making appropriateness decisions? We need to act now if we want it done properly.

I recently received a letter from one of the insurers in my state. It explained that I was not in compliance with their policy regarding indications for headache imaging, nor was the study in compliance with ACR standards.

It’s not the first letter I’ve gotten in the last year from them. And my initial impression is to toss it in the trash as silly. I didn’t order the study and certainly can’t stop the next order from being written today or tomorrow. I also don’t plan on calling the patient or referring provider and informing them of this.

Then I thought about it and wondered if the insurer also had a sent a letter to the patient or provider. So I looked up the patient and as it turned out they were referred by a close friend and colleague. I called and asked if he was receiving these letters too. He hadn’t seen one, he informed me. I’m going to presume the patient didn’t get one either.

I had to know what the insurer was up to, so I put in a call to our contact there. Those are just to raise your awareness, they said, in the hopes of changing behavior in the long run. Did they know I didn’t get to approve or disapprove studies? I asked. They were under the impression that I should.

That was eye opening. I don’t usually feel empowered to be part of this process, with regards to approving or disapproving of study appropriateness. A few recent things came to mind:

• Medicare just published results of a review that shows imaging is not the cause of increases in health cost

• The ACR supported the findings of the Government Accountability Office indicating self-referral was a significant cause of over-imaging and excess cost.

• Almost a quarter or physicians indicated they order more diagnostic tests than are needed due to concerns over malpractice.

Yet, the focus for health imaging policy is on the MPPR and on fraudulent billing practices. Anybody else feel like somebody is sticking their head in the sand?

I have come to feel that we have been too passive in being part of the process of performing studies. We know the most about what is needed, and could dramatically reduce the number of unneeded studies if empowered and allowed to do so.

We’ve had reasons not to be active. It exposes us to malpractice risks. We are financially incentivized not to, because cutting down on studies would cost us. Taking that responsibility also would require a lot of time from us, and that also would be costly.

But it would also mean more appropriate care, and that is what most of us got into this for. Are we willing and ready to be part of that process? I feel like the insurer is asking me that with the letter, and to the extent it makes me think, it is serving its purpose. In isolation in the present climate, it is screaming into the wind and hoping someone will hear. It is also ridiculously simplistic in its thinking. But as part of a broader policy it is fundamentally a good idea.

Is the legal system willing to insulate us from the malpractice risk involved in making appropriateness decisions? Is the insurance system, chiefly CMS, willing to clamp down on inappropriate self-referral? Are patients willing to take direction from standards and societies and not demand additional testing?

It seems pretty overwhelming and maybe insurmountable. And as it stands it is not reasonable to expect us to solely act on our own. But we need to be part of the process and ready to be included, not resistant, for the greater good and also so we aren’t run over.

Like all things, fixing a big problem starts with small steps, and until you take them, it won’t get fixed. So we need to act now, if we want things to be done properly. That is:

A: Advocate for self-referral enforcement and malpractice reforms to your local representatives and national organizations;

C: Communicate whenever possible with referring physicians, facility managers and explain that you are happy to help with choosing appropriate studies; and educate yourself about appropriateness; and

T: Take the tough steps to defer or reduce imaging where appropriate. Ask to review orders in advance and request adequate reasons for studies to be done. It’s not easy but we do need to act.