Leaders in Imaging: A conversation with Dr. Bruce Hillman

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AuntMinnie.com is pleased to present the next installment of Leaders in Imaging, a series of interviews with individuals who are shaping the radiology landscape. We spoke with Bruce Hillman, MD, professor of radiology at the University of Virginia, about his new book, written with Jeff Goldsmith, PhD, and published by Oxford University Press: the Sorcerer's Apprentice: How Medical Imaging is Changing Health Care. Hillman is also editor in chief of the Journal of the American College of Radiology and chief scientific officer of the American College of Radiology Image Metrix.

AuntMinnie: Why did you feel it necessary to write the book?

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Bruce Hillman, MD, professor of radiology at the University of Virginia.

Hillman: We wrote the book for the lay public and for radiologists, but also for policymakers. Jeff and I both felt that, especially among policymakers, too little is known about imaging, particularly high-tech imaging. Too little is known about who actually interprets the exams and why it is important for trained experts to do that interpretation, and there's a rising anti-imaging bias based on increased imaging expenditures from 2000 to 2006.

While some of those cost increases are justifiable -- the U.S. population is aging and there's more chronic disease that our technology is good at diagnosing and tracking -- there is a deep suspicion that too many imaging exams are unnecessary. Medical imaging is the kind of thing that has enormous potential for good, but also potential to get out of hand, like what happens in the sorcerer's apprentice segment of the Disney movie "Fantasia."

What are the major themes of the book?

We introduced one of the primary themes right away: that radiologists are the most important doctor patients rarely meet. We want to make the public aware of what radiologists do and why a radiologist's training makes him an expert on imaging exam interpretation.

Other themes in the book are the risks of medical imaging, especially the problem of overdiagnosis; how physicians actually get paid; and how this affects the overall cost of imaging.

We also wrote about the organization of radiology and how it is moving toward corporatization and globalization, two trends that are most likely not reversible. We touch on the "moral hazard" that physicians face when there's an economic incentive to use medical imaging, and also how imaging is at the cusp of innovation in the molecular and physiological arenas.

The book mentions that medical imaging "could spin out of control," as does Mickey Mouse's experiment with magic. What are the signs that this is beginning to happen?

In "Fantasia," Mickey's boss, the sorcerer, has left him with the job of cleaning the castle. Mickey passes the job to the mops and pails, falls asleep, and things quickly go wild. Jeff and I see that as a potential scenario in medical imaging, and perhaps even what's already beginning to happen. No one knows the exact fraction, but some estimates are that one-third of all imaging is unnecessary and doesn't contribute to positive patient outcomes. The real culprit in imaging overuse is how doctors use it. The idea of elegant diagnosis has vanished, and people more and more use a shotgun approach.

Do you think that with all the negative headlines about medical imaging in the past few years, the specialty has developed a public relations problem in the eyes of the public?

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The Sorcerer's Apprentice. Image courtesy of Bruce Hillman, MD.

Definitely. The anti-imaging bias started out being about healthcare cost, but now it's also about radiation doses, too. But this public relations problem doesn't seem to lead to appropriate measures to contain unnecessary imaging: rather, it tends to make the powers that be implement heavy handed -- and we believe ineffectual -- policies.

At one point in the book you write that radiologists "enable" self-referral. What do you mean by that?

Radiologists enable self-referral by reading nonradiologists' exams. Most nonradiologists don't want to interpret their own studies, in part because the professional fee is low compared to the technical fee, and in part because they don't want to expose themselves to legal risk through malpractice suits. Radiologists will bid against each other for contracts to read these exams to bolster revenues, telling themselves, "if we don't do it someone across town will, and we'll lose referrals." But refusing to do these reads would drive nonradiologists out of business. The self-referral battle is fought hand to hand in the streets, practice to practice, and each practice has to decide how it will respond.

In the chapter of the book on control of imaging, you describe what you call a "nuclear winter" payment policy for imaging services. Can you describe that in more detail?

What we mean by this is that there's the potential for a cycle -- first described, I believe, by Jim Borgstede -- that hurts radiologists in the end. The powers that be -- [the U.S. Centers for Medicare and Medicaid Services (CMS)] and private payors -- watch the imaging rate rise and it frightens them how fast it climbs, so they implement policies such as the [Deficit Reduction Act (DRA) of 2005] to reduce the rate. The DRA goes into effect, and yes, the prices go down.

But the thing is, the doctors who can self-refer boost their volumes to deal with the payment decrease, a phenomenon called physician offset. So pretty soon, imaging rates start to climb again, and insurers say, well, our cost-cutting measures worked last time, let's do that again.

But after a few cycles of this, it's not profitable to be in imaging anymore, and the doctors that have other revenue streams get out of it, while the radiologists -- who don't have the ability necessarily to increase their imaging volume -- end up with all the imaging at reimbursement rates that aren't sustainable.

What would you like the book to accomplish?

We've distributed it to quite a few people in the executive branch, and we hope it will help shape the debate over healthcare policy. We'd like to spark a conversation about how to allow for imaging innovations, which are crucial for our specialty's continued development and for better patient care, but also to make imaging affordable. Healthcare costs can't keep going up and up and up: not only policymakers but also lay people understand this and are concerned about it.

By Kate Madden Yee
AuntMinnie.com staff writer
January 19, 2011

Related Reading

Leaders in Imaging: A conversation with Keith Dreyer, DO, PhD, November 17, 2010

Leaders in Imaging: A conversation with William Hendee, PhD, October 13, 2010

Leaders in Imaging: David Dowe, MD, September 15, 2010

Leaders in Imaging: Cynthia Sherry, MD, July 8, 2010

Leaders in Imaging: Dr. Leonard Berlin, May 25, 2010

Copyright © 2011 AuntMinnie.com

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