AuntMinnie.com spoke with Seltzer, who is the chair of radiology at Brigham and Women's Hospital in Boston, about the issue.
AuntMinnie: This opinion appeared in JAMA rather than a radiology-specific journal. What caused you to write it?
Dr. Steven Seltzer from Brigham and Women's Hospital.
Seltzer: So much of the overall conversation about new healthcare delivery and payment systems has been focused on primary care physicians as gatekeepers, or on healthcare delivery systems, rather than on how specialists will be affected by these trends in the marketplace. Dr. Lee and I thought it would be a good opportunity to share some of the radiology community's current thinking to remind the larger medical world not to forget about us -- we're part of the care continuum, too.
Massachusetts is a few years ahead of the country, in that the state adopted universal health insurance in 2006. We've been successful at covering 98% of adults and 99% of children since then, but now we're dealing with how this model affects the economics of healthcare.
The state has put some constraints on the growth rate of healthcare spending via linking it to the gross state product -- much like the sustainable growth rate links U.S. spending to gross domestic product -- and our own healthcare system has volunteered to be an accountable care organization for Medicare and has entered into risk-sharing contracts with private payors. Seeing this state government response, as well as that of Partners HealthCare [the healthcare network that operates Brigham and Women's], catalyzed our thinking about how radiology can best prepare for the transition to a shared risk and/or capitated payment model.
In your article, you write that technology advances in radiology have boosted its use -- and caused the specialty to be a cost driver. You ask whether radiologists should be advocates of broader use of potentially lifesaving imaging technology, or gatekeepers who control access and costs. How would you answer this question?
What's the right thing for a radiology department to do: be gatekeepers or encourage our economic self-interest? At Brigham and Women's, we realized that we can't resolve this conflict. The only proper thing to do is the right thing, which is to image when necessary. If imaging isn't indicated or if it's wasteful, we need to head it off at the pass.
We've put a clinical decision-support framework and consulting services into place at Brigham and Women's, so that primary care physicians can get a consultation either peer to peer, or via telephone or pager. It means that where there is uncertainty about whether an imaging test is indicated, or when the practitioner is less specialized, the referring doctor can include diagnostic radiology in the decision-making process.
We also have radiologists physically present in clinics so they can read scans and interact with referring doctors or patients. For example, they can read the PET scan before the patient sees the oncologist, which makes that office visit more effective. So we're not gatekeepers, but collaborators.
How do primary care physicians respond to radiology's efforts to provide support? Is there resistance?
Our primary care doctors are enthusiastic about working with specialists; they want to have cardiology, radiology, and pathology on their speed dial. They tell us that when they're working with a patient with, say, newly diagnosed lung cancer, they want easy access to consult.
An added benefit, at least for us here in Boston, has been that as we offer clinical decision support for radiology test ordering in real-time, we don't have to deal with preauthorization, which can really throw sand into the gears of any referring physician's practice. We've talked to insurers here and let them know that we're doing that work for them. Their response is, "Great, as long as your utilization rates don't go up." And they haven't. In fact, the use of unnecessary high-tech imaging has decreased in ambulatory, inpatient, and emergency settings because of our clinical decision support and consulting programs.
You use the term "bellwether" to describe radiology. What do you mean by that?
There's been so much focus on care delivery via primary care and less attention paid to hospital-based specialties. Dr. Lee and I wondered whether radiology could be a test case of sorts. It's hospital-based and its physicians are generally employed, particularly in academic medical centers, so we need to be responsive to economic and care delivery changes.
In many ways, radiology is delivered much like pathology services, emergency medicine, or anesthesia, in that it has been paid through fee-for-service frameworks, and increased utilization means more money. So we think that developing an economic and care delivery model for radiology in the era of accountable care organizations and risk contracts would provide a framework for other specialties that need to adapt to a new environment.
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