From imaging rationing to rational imaging

As imaging utilization slows, finding a way to incentivize performance rather than volume becomes ever more imperative for the field of radiology, according to a panel discussion published in the January issue of the American Journal of Roentgenology (AJR).

Part of AJR’s “Masters of Radiology” series, the discussion began with Howard P. Forman, of Yale University School of Medicine in New Haven, Conn., asking a question about decreasing utilization, but the conversation that followed was focused on one word: value.

“I think radiologists have to be stewards of not only trying to increase volume but also increasing volume where it brings value, decreasing volume where it doesn’t, and using our operational and business skills to help look at the healthcare costs in academic medical centers and across communities,” said Norman J. Beauchamp, Jr., of the University of Washington in Seattle.

John K. Crowe, of Scottsdale Medical Imaging in Arizona made a similar point, adding that data must be used to inform clinicians and improve their use of imaging. “Even as radiology becomes less of an income center and tries to become more clinically productive, we must simultaneously master information and increasingly provide leadership to the entire healthcare enterprise,” he said.

Ella A. Kazerooni, of the University of Michigan Hospital in Ann Arbor, lamented that there is often not positive feedback or incentive when a radiologist recommends that a test is not needed. Similarly, the fee-for-service model creates an environment where imaging is seen as a cost, not a benefit, said Alexander Norbash, of Boston University Medical Center.

“We’re living in an era of imaging rationing rather than rational imaging,” quipped Norbash.

He added that technology designed to improve practice has contributed to the problem, as PACS allow for remote image review and disconnected relationships that were traditionally made between radiologists and clinicians.

Another new technology, however, was held up as a way to increase imaging’s value. Marcia C. Javitt, of the Uniformed Services University of the Health Sciences in Bethesda, Md., said computerized order entry systems could help achieve better value in radiology while reducing unnecessary imaging.

As for realigning incentives for radiologists, Forman noted that even though efforts to increase value through nonrevenue-generating work may penalize some providers while fee-for-service remains entrenched, in the future, after payment models such as accountable care organizations have proliferated, value generation may be more financially stable. Kazerooni agreed, and said those making the transition early may benefit in the long run. “The more that we stick to the volume-based method where we find value, we will be prevented from doing the things we need to do to position ourselves well for accountable care organizations and being reimbursed in the future,” she said.

David B. Larson, of Cincinnati Children’s Hospital Medical Center concluded the discussion by arguing that payers will respond if radiologists develop ways to better objectively measure quality and align incentives. “Whether we lead them or they lead us to that destination is up to us. I think it is much better for everyone, including patients and even payers, if we lead the payers rather than vice versa. That choice is ours to make—for now.”