Why Less Radiology May Be Better Radiology, Part 2
Why Less Radiology May Be Better Radiology, Part 2
Editor's Note:
Thomas Dehn, MD, FACR, was lauded by Diagnostic Imaging Magazine as one of the top 20 most influential individuals in radiology; he opened up the discussion of cost-effective analysis of imaging technologies and their application while serving as the Chair of the American College of Radiology's Task Force on Managed Care. Dr. Dehn's work helps to inform decision making across the vista of radiology, from healthcare policy makers to community-based radiologists.
Dr. Dehn is Executive Vice President and Chief Medical Officer of National Imaging Associates (NIA), which is a subsidiary of Magellan Health Services, a leading healthcare management organization.
This is the second part of a 2-part interview. Medscape's Pippa Wysong met with Dr. Dehn to get his take on the State of the Imaging Union, especially the eternal push (the quicksilver pace of developments in imaging technology) and pull (determining which patients will benefit most from these advances and how to apply them to peak advantage while limiting the cost burden on the healthcare system).
Medscape: When people look at the costs of diagnostic imaging, do they take into account factors other than just the cost of the test or procedure? Do, or should, cost-effectiveness studies consider reduced costs because of shorter hospital stays, or reduced costs because of shorter times for procedures because they are now less invasive? Aren't there a lot of factors that need to be taken into account?
Dr. Dehn: The new paradigm of imaging management may very well result in an overall increase in volume. That is to say, virtual colonoscopy or CTC may significantly decrease the use of similar optical studies, resulting in a net clinical and economic benefit. The same can be said of coronary CTA vs cardiac catheterization. Rather than manage imaging, we should manage diagnostic approaches to a given set of circumstances.
Medscape: Is there a problem with where technical assessments come from?
Dr. Dehn: With the exception of Medicare and Medicaid programs, insurance carriers pretty much determine on their own which technologies they'll pay for. It is an uncoordinated system right now, unlike, say, Canada, which has a centralized approach in which the type of services covered are determined centrally. Accordingly, there is a fair amount of cost-benefit research done in Canada, which we find useful.
In the United States, health plans make their own technology assessment decisions. Some will buy technical assessment services while others conduct their own technical assessment, but it's not uniform. This approach is also subject to the vagaries of political lobbying within a health plan by excited and interested physicians. And some of this sort of lobbying may be based on consensus, not on science.
Medscape: Is there a fix for all of this?
Dr. Dehn: The Comparative Effectiveness approach seems to be moving under the direction of the National Institutes of Health and the American Association of Health Plans. If that comes to fruition, there will be a well-recognized, outstanding, value-based review of technology available to all independent carriers. Our company and its clients certainly support that approach.
Medscape: Can you touch on what Magellan/NIA does?
Dr. Dehn: Magellan/NIA assists their clients in technical assessment and medical necessity reviews. Essentially, we develop "decision support algorithms" for the use of advanced imaging technology -- CT, MRI, PET, nuclear cardiology.
Medscape: At what point would a group call you in?
Dr. Dehn: Commonly, it might be after they review their data and notice a significant increase in the year-over-year use of diagnostic imaging. Again, as they look at other parts of healthcare spending, there's no evidence that the increased use of diagnostic imaging is offset by a clear reduction in another area. Incidentally, that's why CTC or virtual colonoscopy has a large measure of appeal -- because it will replace a more expensive and dangerous examination.
We review their claims history and evaluate their trends. There are some well-accepted national norms to which we compare regional utilization. These norms are measured in the number of exams per 1000 enrollees per year. So if you see in a similar, comparative population that the use of CT goes from 70 per 1000 per year to 100 per 1000 per year, that's a significant increase and gets a payer's attention. What the companies want to know is, is this appropriate or not?
Medscape: What causes inappropriate use?
Dr. Dehn: In my opinion, the primary cause of inappropriate use of imaging is nonclinical patient demand -- people who don't really need a study such as an MRI for a minor complaint but ask for it anyway. Often doctors are reluctant to turn down these requests.
A second cause is physician demand. A busy physician may order an MRI because it takes less time to resolve the visit rather than spending 45 minutes explaining the nuances of chronic headache to a patient. So the technology affords physicians a vehicle to increase their throughput in their offices. Essentially, it's an electronic way to replace a fair amount of cognitive services, which are poorly reimbursed.
Medscape: Is any of the overuse of diagnostic imaging driven by radiologists to improve business?
Dr. Dehn: The American College of Radiology is extremely concerned about self-referral abuse by nonradiologists, but they recognize that there is also potential for abuse by radiologists. Radiologists are in a unique position to recommend additional examinations at the conclusion of each report. While the vast majority of "additional study" recommendations are based on clinical need and honest concern, one has to consider the fact that some of those recommendations might be economically related.
If you review similar populations served by different radiology providers, you'll see some in which as much as 35% or 40% of the advanced imaging examinations that they do (CT, MR, etc.) result in another recommendation. Among others it's as low as 5%, 6%, to 7%. Some of it is related to the fact that some radiologists are uncertain about what they see and want additional examinations. That's perfectly acceptable. But when you see it in a large percentage, you begin to wonder whether a particular interpreting radiologist has some sort of problem. Either they're having trouble with their ability to interpret, they're having trouble with their ability to take a positive position on something, or it may be economically driven.
Medscape: Is fear of litigation a driver?
Dr. Dehn: Some of it is driven by being in a litigious society. But when you look at the amount of diagnostic imaging that's done, the percentage is estimated to be around 10%. Fear of litigation contributes to base utilization but doesn't account for the trend.
Medscape: Is the picture of all of this the same across the States?
Dr. Dehn: Interestingly, when we look at the northern tier of States -- North Dakota, upper Minnesota, Michigan -- we see utilization rates that are similar to the utilization in Canada, which is lower than that of most States.
Medscape: Really?
Dr. Dehn: So what's the driving factor? We get back to patient demand, the self-medicators. In general, when you combine the "worried well" with massive infrastructure, patients will avail themselves of that capacity. However, when you look at Oregon, Montana, North Dakota, Minnesota, that northern tier of States demonstrates a lower utilization. Yet there's no shortage of infrastructure. The question is, is there something different about the patients? Are they healthier? I doubt it. In fact, the worried well are killing us!
Medscape: They're the ones going for whole-body CT scans, "just-in-case something is wrong," right?
Dr. Dehn: Exactly. But what makes a "worried well" person? We have data on the use of diagnostic imaging in Manhattan for the 6 months before and the 6 months after 9/11. Other than Ground Zero, there was really no compromise of the infrastructure. There were plenty of MRI centers that stayed open but utilization dropped by 30% or 35%. We haven't seen a rebound. You begin to wonder whether, when people have other things to worry about, maybe they don't worry about getting questionably necessary MRIs or CTs.
Medscape: How safe is all this imaging?
Dr. Dehn: When we talk about inappropriate diagnostic imaging, there are 3 areas we're concerned about: The first is the direct effect of radiation; the second is the direct effect of contrast material; and the third is unavoidable false-positives, which drives a lot of inappropriate healthcare delivery.
Medscape: If you had a wish list of key things you'd like to see happen in the future, what would they be?
Dr. Dehn: Number one, from a population standpoint, is to get a handle on the extreme variation in healthcare utilization in general -- not just diagnostic imaging -- related to the stresses of society. We need to understand that better and get a handle on managing that.
In terms of the individual management of diagnostic imaging from a user standpoint, we need consensus on when to use contrast material and when not to use it. There are plenty of articles in the literature about when to use or not use a CT exam. But the use of contrast material doubles, sometimes triples, the radiation exposure and increases the cost. There are no good guidelines.
Also on my wish list is the appropriate use of follow-up examinations. There is no good consensus on what the interval between follow-up exams should be and under what circumstances. The literature is devoid of information about follow-up.
Finally, can we get diagnostic images that are of acceptable quality to interpreting physicians with less radiation exposure? This is something incumbent upon the radiologist as well as equipment manufacturers. Manufacturers claim that the length of life of an x-ray tube for the same number of studies in Europe is about 30% longer than the life of an x-ray tube in the United States. In the States we put more energy into it, more radiation.
Editor's Note:
Thomas Dehn, MD, FACR, was lauded by Diagnostic Imaging Magazine as one of the top 20 most influential individuals in radiology; he opened up the discussion of cost-effective analysis of imaging technologies and their application while serving as the Chair of the American College of Radiology's Task Force on Managed Care. Dr. Dehn's work helps to inform decision making across the vista of radiology, from healthcare policy makers to community-based radiologists.
Dr. Dehn is Executive Vice President and Chief Medical Officer of National Imaging Associates (NIA), which is a subsidiary of Magellan Health Services, a leading healthcare management organization.
This is the second part of a 2-part interview. Medscape's Pippa Wysong met with Dr. Dehn to get his take on the State of the Imaging Union, especially the eternal push (the quicksilver pace of developments in imaging technology) and pull (determining which patients will benefit most from these advances and how to apply them to peak advantage while limiting the cost burden on the healthcare system).
Medscape: When people look at the costs of diagnostic imaging, do they take into account factors other than just the cost of the test or procedure? Do, or should, cost-effectiveness studies consider reduced costs because of shorter hospital stays, or reduced costs because of shorter times for procedures because they are now less invasive? Aren't there a lot of factors that need to be taken into account?
Dr. Dehn: The new paradigm of imaging management may very well result in an overall increase in volume. That is to say, virtual colonoscopy or CTC may significantly decrease the use of similar optical studies, resulting in a net clinical and economic benefit. The same can be said of coronary CTA vs cardiac catheterization. Rather than manage imaging, we should manage diagnostic approaches to a given set of circumstances.
Medscape: Is there a problem with where technical assessments come from?
Dr. Dehn: With the exception of Medicare and Medicaid programs, insurance carriers pretty much determine on their own which technologies they'll pay for. It is an uncoordinated system right now, unlike, say, Canada, which has a centralized approach in which the type of services covered are determined centrally. Accordingly, there is a fair amount of cost-benefit research done in Canada, which we find useful.
In the United States, health plans make their own technology assessment decisions. Some will buy technical assessment services while others conduct their own technical assessment, but it's not uniform. This approach is also subject to the vagaries of political lobbying within a health plan by excited and interested physicians. And some of this sort of lobbying may be based on consensus, not on science.
Medscape: Is there a fix for all of this?
Dr. Dehn: The Comparative Effectiveness approach seems to be moving under the direction of the National Institutes of Health and the American Association of Health Plans. If that comes to fruition, there will be a well-recognized, outstanding, value-based review of technology available to all independent carriers. Our company and its clients certainly support that approach.
Medscape: Can you touch on what Magellan/NIA does?
Dr. Dehn: Magellan/NIA assists their clients in technical assessment and medical necessity reviews. Essentially, we develop "decision support algorithms" for the use of advanced imaging technology -- CT, MRI, PET, nuclear cardiology.
Medscape: At what point would a group call you in?
Dr. Dehn: Commonly, it might be after they review their data and notice a significant increase in the year-over-year use of diagnostic imaging. Again, as they look at other parts of healthcare spending, there's no evidence that the increased use of diagnostic imaging is offset by a clear reduction in another area. Incidentally, that's why CTC or virtual colonoscopy has a large measure of appeal -- because it will replace a more expensive and dangerous examination.
We review their claims history and evaluate their trends. There are some well-accepted national norms to which we compare regional utilization. These norms are measured in the number of exams per 1000 enrollees per year. So if you see in a similar, comparative population that the use of CT goes from 70 per 1000 per year to 100 per 1000 per year, that's a significant increase and gets a payer's attention. What the companies want to know is, is this appropriate or not?
Medscape: What causes inappropriate use?
Dr. Dehn: In my opinion, the primary cause of inappropriate use of imaging is nonclinical patient demand -- people who don't really need a study such as an MRI for a minor complaint but ask for it anyway. Often doctors are reluctant to turn down these requests.
A second cause is physician demand. A busy physician may order an MRI because it takes less time to resolve the visit rather than spending 45 minutes explaining the nuances of chronic headache to a patient. So the technology affords physicians a vehicle to increase their throughput in their offices. Essentially, it's an electronic way to replace a fair amount of cognitive services, which are poorly reimbursed.
Medscape: Is any of the overuse of diagnostic imaging driven by radiologists to improve business?
Dr. Dehn: The American College of Radiology is extremely concerned about self-referral abuse by nonradiologists, but they recognize that there is also potential for abuse by radiologists. Radiologists are in a unique position to recommend additional examinations at the conclusion of each report. While the vast majority of "additional study" recommendations are based on clinical need and honest concern, one has to consider the fact that some of those recommendations might be economically related.
If you review similar populations served by different radiology providers, you'll see some in which as much as 35% or 40% of the advanced imaging examinations that they do (CT, MR, etc.) result in another recommendation. Among others it's as low as 5%, 6%, to 7%. Some of it is related to the fact that some radiologists are uncertain about what they see and want additional examinations. That's perfectly acceptable. But when you see it in a large percentage, you begin to wonder whether a particular interpreting radiologist has some sort of problem. Either they're having trouble with their ability to interpret, they're having trouble with their ability to take a positive position on something, or it may be economically driven.
Medscape: Is fear of litigation a driver?
Dr. Dehn: Some of it is driven by being in a litigious society. But when you look at the amount of diagnostic imaging that's done, the percentage is estimated to be around 10%. Fear of litigation contributes to base utilization but doesn't account for the trend.
Medscape: Is the picture of all of this the same across the States?
Dr. Dehn: Interestingly, when we look at the northern tier of States -- North Dakota, upper Minnesota, Michigan -- we see utilization rates that are similar to the utilization in Canada, which is lower than that of most States.
Medscape: Really?
Dr. Dehn: So what's the driving factor? We get back to patient demand, the self-medicators. In general, when you combine the "worried well" with massive infrastructure, patients will avail themselves of that capacity. However, when you look at Oregon, Montana, North Dakota, Minnesota, that northern tier of States demonstrates a lower utilization. Yet there's no shortage of infrastructure. The question is, is there something different about the patients? Are they healthier? I doubt it. In fact, the worried well are killing us!
Medscape: They're the ones going for whole-body CT scans, "just-in-case something is wrong," right?
Dr. Dehn: Exactly. But what makes a "worried well" person? We have data on the use of diagnostic imaging in Manhattan for the 6 months before and the 6 months after 9/11. Other than Ground Zero, there was really no compromise of the infrastructure. There were plenty of MRI centers that stayed open but utilization dropped by 30% or 35%. We haven't seen a rebound. You begin to wonder whether, when people have other things to worry about, maybe they don't worry about getting questionably necessary MRIs or CTs.
Medscape: How safe is all this imaging?
Dr. Dehn: When we talk about inappropriate diagnostic imaging, there are 3 areas we're concerned about: The first is the direct effect of radiation; the second is the direct effect of contrast material; and the third is unavoidable false-positives, which drives a lot of inappropriate healthcare delivery.
Medscape: If you had a wish list of key things you'd like to see happen in the future, what would they be?
Dr. Dehn: Number one, from a population standpoint, is to get a handle on the extreme variation in healthcare utilization in general -- not just diagnostic imaging -- related to the stresses of society. We need to understand that better and get a handle on managing that.
In terms of the individual management of diagnostic imaging from a user standpoint, we need consensus on when to use contrast material and when not to use it. There are plenty of articles in the literature about when to use or not use a CT exam. But the use of contrast material doubles, sometimes triples, the radiation exposure and increases the cost. There are no good guidelines.
Also on my wish list is the appropriate use of follow-up examinations. There is no good consensus on what the interval between follow-up exams should be and under what circumstances. The literature is devoid of information about follow-up.
Finally, can we get diagnostic images that are of acceptable quality to interpreting physicians with less radiation exposure? This is something incumbent upon the radiologist as well as equipment manufacturers. Manufacturers claim that the length of life of an x-ray tube for the same number of studies in Europe is about 30% longer than the life of an x-ray tube in the United States. In the States we put more energy into it, more radiation.
