What Can Radiologists Really Do About Unnecessary Imaging?

Unnecessary imaging and appropriateness criteria. These two phrases have dominated radiology discussions for the past several years. It’s a complicated topic that has an even more complex, and elusive, answer.

And, according to industry leaders, one of the most critical components to the discussion is the role radiologists play in limiting the number of unnecessary and duplicative imaging studies performed.

“Radiologists get painted as these selfish people who are self-interested and who are going to fight against change,” said Jeremy Bikman, chief executive officer for peer60, a big data survey company that provides analysis based on conversations with on-the-ground professionals. “But, they didn’t create their reimbursement structure. It comes from the Centers for Medicare & Medicaid Services, and radiologists are just doing the best they can.”

That performance includes responding to and meeting referring physicians’ needs and desires, which, frequently, he said, can be wasteful. A recent peer60 report puts the nationwide cost of unnecessary imaging between $7.47 billion and $11.95 billion annually.

It’s a widely-acknowledged problem. According to a 2014 Robert Wood Johnson Foundation and American Board of Internal Medicine (ABIM) Foundation study, 72% of physicians report knowingly ordering at least one unnecessary test a week, including advanced diagnostic imaging studies. Some said they do so to reassure themselves or to make sure they’ve covered all the bases. However, more than 50% said they order unnecessary tests to avoid potential malpractice suits.

Hospital leaders surveyed for the peer60 report agreed – 90% reported this type of defensive medicine is a primary contributor to unnecessary imaging in their institutions. But, few, Bikman said, know how to address the problem, especially those in smaller facilities.

“Many have competing priorities, and they don’t have a lot of money by comparison. They’re still trying to get through Meaningful Use Stage 1 and 2, the ICD10 conversation is barreling down, and they have to worry about patient engagement and data security politics,” he said. “It’s tough to build a strategy for controlling imaging when you’re in the foxhole in the middle of a war, and there’s gunfire all over the place.”

Radiology’s Role
This is where radiologist involvement is so critical, said Richard Duszak, MD, chief medical officer for the American College of Radiology (ACR) Neiman Health Policy Institute. Instead of only following referring physicians’ orders, it’s time for radiologists to reach out to other providers and help them see the bigger picture around advanced imaging services.[[{"type":"media","view_mode":"media_crop","fid":"31015","attributes":{"alt":"waste","class":"media-image media-image-right","id":"media_crop_8722481643210","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3274","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 106px; width: 161px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

The most important step, he said, is being available to talk with providers about patient cases and to answer their questions. Not only does it present the opportunity for more open conversations that could influence providers’ ordering decisions, but it also places radiologists in the role of being the imaging champion for their health care systems. They will be better positioned to advise colleagues on the best ways to use imaging technology wisely.

“We need to realize that this is really an ‘us’ issue and not a ‘them’ issue,” said Duszak, who is also vice chair for health policy and practice in Emory University School of Medicine’s radiology and imaging sciences department. “We are the specialists, and the days of the knee-jerk reaction of doing the improper study ordered by the family doctor and, then, recommending the right study are over.”

Currently, the ACR’s Imaging 3.0 initiative is the most widespread resource available to radiologists, supporting and guiding them into the greater leadership functions that will help control unnecessary imaging in their institutions, he said. However, there are also other like-intended tools already in use.

For example, especially for patients with private insurance, many hospitals and referring physicians still primarily rely on the pre-authorization or pre-certification processes of radiology benefit management (RBM) companies to determine whether a diagnostic imaging service is appropriate. But, they aren’t fool-proof.

“RBMs have certainly curtailed inappropriate imaging, but if phone calls to RBMs happen several days after the interaction between referring physician and patient, the conversations are less impactful,” he said. “So, there’s the added question of whether they’re making it more difficult to get imaging that is actually necessary.”

In addition, new federal legislation – the Protecting Access to Medicare Act (PAMA) – is set to push clinical decision support software (CDS) ahead of RBMs as of 2017. Under this law, radiologists will only receive reimbursement for their services if the referring physician provides evidence on a claim that he or she consulted a CDS tool before ordering an advanced imaging study.

Several CDS options are already available, including ACR Select and tools from various vendors, such as McKesson and Medicalis. But their existence doesn’t mean they’re known to hospital leadership, Bikman said. According to the peer60 study, no hospital executives involved in the survey mentioned using a commercial CDS tool to guide imaging practices.

“We know vendors have great products, but they have to change their message. They have a lot of work to do to get that message to the C-suite executives who make decisions,” he said. “Not one of the hospitals included in our study named an off-the-shelf product that they’re using to limit unnecessary imaging. Until they get into the C-suite mind, vendors will be swimming upstream.”

Consequently, radiologists are in a prime position, he said, to educate their colleagues and hospital leadership on vendor products that can positively impact how institutions use advanced imaging overall.

The Coming Reimbursement Change
When it comes to the success of any new payment model – either the accountable care organization (ACO) or other bundled-payment model – controlling unnecessary imaging will be a linchpin, Bikman said.

“The primary care provider is really more important than ever, and there’s no way to pull off an ACO or medical home structure without giving them the technology, context, and content to move them in the right direction,” he said. “It can’t be done without establishing more coordination around the patient.”

By creating clear communication channels, radiologists can give these providers the tools to choose the correct tests and avoid ordering ones that would either be incorrect, duplicative, or useless. Doing so is critical, Bikman said, especially while smaller private practices and healthcare facilities struggle to meet the technology requirements under the HITECH Act.

Duszak agreed controlling unnecessary imaging will be a keystone in any new payment model. He also added the move away from fee-for-service presents radiologists with the chance – and power – to change how the industry is viewed in health care nationwide. But, radiologists must be willing to let go of how they’ve practiced over the past decade and embrace a more team-based environment.

“Providers who rely on legislation or computers to take care of everything will never be decision makers in their facilities or ACOs. They relegate themselves to being pawns in a system,” he said. “For the visionary radiologists who embrace concepts, such as Imaging 3.0, they will be the key stakeholders who will determine how to bring resources, manpower, and logistics together.”

And, this is a movement that’s gained momentum over the past year, he said. More radiologists are stepping forward, talking with their hospital leaders, and sharing their knowledge and guidance on how to use radiology’s significant technology investments to positively influence the institution’s financial status.

“Don’t be afraid to say, ‘I have an idea. Let me help you,’” Duszak said. “Start the conversation about shared risk and reward models and talk about ways radiology can help control imaging utilization to have a favorable impact on your bottom line.”