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July 16, 2008

Yes Virginia, the GAO points a finger at diagnostic imaging providers

"Round up the usual suspects!

Once again, diagnostic imaging providers are singled out by the federales. This time the GAO says controls on diagnostic imaging utilization are needed -- including (yikes!) prior authorization requirements -- because diagnostic imaging costs have doubled between 2000 and 2006.  Sounds serious. Well, guess what?  While some advanced imaging costs have increased at a faster rate, the cost of employment-based health insurance has also doubled in the same time frame.  (In addition, this rampant growth story is half of an unintended consequences story -- service settings have changed: less hospital, more physician office.  Also, imaging, while expensive, is cheaper -- and easier on the patient -- than exploratory surgery . . . . )

My inbox has been graced with a couple of press releases on this topic from, yes, the usual suspects -- MITA and AMIC -- decrying the government's heavy-handedness. MITA referred to an interesting report on diagnostic imaging released last week by Avalere Health, which MITA had commissioned.  (Coincidentally, I met Avalere's founder, Dan Mendelson, last weekend -- but that's another story entirely.) 

The Avalere imaging report (an interesting read, by the way) points to the utility of a number of strategies worthy of wider consideration, rather than focusing like GAO on layering prior authorization requirements on top of retrospective utilization review.  These are,   

primarily [, ] three sets of approaches – updated and more comprehensive appropriateness guidelines; enhanced accreditation and certification programs; and expanded education and training – [which are] programs [that] can influence provider behavior, imaging quality, and patient care.

The first of these really caught my interest.  To the extent such a system can be implemented without adding significantly to the ordering clinician's administrative burden, I'm all in favor.  In fact, that's the sort of thing that should be propagated across the entire medical-industrial complex, not just imaging: expert EHR systems incorporating evidence-based medicine (EBM) into computerized physician order entry (CPOE). 

-- David Harlow


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Of course, instead of limited diagnositc imaging, the GAO could instead ask how to perform the studies cheaper...

The other day while jogging my wife twisted her ankle. 2 days later it 'locked' in a flexed position.

X-rays were normal so her orthopedist obtained an MRI. Both the radiologist and the orthopedist read the MRI as 'normal' (you can guess what they charged my health plan for this wisdom).

My wife, curios to see what an MRI of her ankle looked like, while in the orthopedists office and having never seen an MRI in her life prior, looked at it for a minute and asked "what's that"? Of course it was the osteochondral fragment that was later removed surgically.

I have never understood why a physician needs to read most diagnostic imaging studies. Kaiser has studied this and has come to similar conclusions

We don't have physicians read most pap-smears. Why do we treat MRIs as any different?

You tell me why a trained art student, say a kid from Parson's school of design who has "they eye", could not be trained to read an MRI?

My guess their eyes would be better than many radiologists.

So instead of limiting the number of studies performed, why not focus on how to do them cheaper with a similar quality outcome? We could order even more for the same price we pay.

And if an ordering physician needs the services of a radiologist over say a trained diagnostic reading 'mid-level' (like a PAs or NPs used in clinical care), that physician can then request a radiology consultation.

There is more than one way to skin this cat without letting patient access suffer.

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