The practice of medicine has long been understood as an elegant blend of art and science, of "style" and evidence. As technologies and patients become increasingly sophisticated, the demand for diagnostic precision has contributed to the growth of defensive medicine. A CT or MR study may be ordered at presentation of a new onset headache—not based on physical exam findings but to mitigate the unfounded risk that a patient might have a mass lesion or other life-threatening pathology.
This is compounded by the perceived threat of litigation that lurks in the background. Inappropriate utilization of high-cost imaging assays also is driven by the misaligned incentives of a fee-for-service reimbursement system, which drives as much as $16 billion in unnecessary tests.1 High-end imaging tests are some of the most overused diagnostic tools because they are easy to perform and deliver attractive reimbursement rates for providers. In a special report published in Radiology, the role of defensive medicine in imaging overutilization was estimated to be 5 percent to 25 percent of total imaging costs.2
American College of Radiology appropriate use criteria for imaging—combined with clinical decision support systems—can give physicians the tools they need to guide ordering of imaging exams. By instituting endorsed standards of care, clinical decision support systems also can protect physicians from lawsuits.
Because CMS administers reimbursement for Medicare/Medicaid patients, their guidelines set a standard that is usually followed by commercial medical plans. If Congress had maintained the radiology-related timelines dictated by the Protecting Access to Medicare Act (PAMA), radiologists would have been required to present a clinical decision support system for all ambulatory radiology orders and report compliance for each claim. In order to drive ordering providers to make use of these advisory tools, the data would be analyzed to determine strata of compliance for implementation and mandate pre-authorization processes for poor performers.
The executive team at Baystate Health (one of the largest IDNs in New England) is evaluating clinical decision support systems and expects to select a supplier by the end of 2016. We plan to roll out the system in stages, starting with our native EMR platform. Our near-term vision is to deploy radiology clinical decision support at Baycare Health Partners—a physician-hospital organization serving five Baystate Health hospitals and more than 200 medical practices in Western Massachusetts.
Our goal is to provide the right test or treatment to the right patient at the right time. Decision support systems are vital tools because they use nationally recognized, evidence-based guidelines that help physicians make treatment decisions while helping to protect them from arbitrary malpractice charges.
For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide information and analysis about national, regional and local markets, as well as hospitals and their affiliated physicians. This research has helped policymakers, the media, healthcare analysts and others improve their understanding of our healthcare system and forms the foundation for many of the ongoing efforts to improve patient health and healthcare delivery systems across America.
Utilization data shows vast disparities in Medicare expenses per patient. Studies of the data have shown that many of these disparities are due to inappropriate testing for financial gain. Average costs per Medicare patient can vary by 20 to 50 percent from one city to another and from one county to another. Also the highest costs are not related to the cost of living in the area, as was documented years ago by Atul Gawande in his groundbreaking article in The New Yorker. He spoke to the cost environment in McAllen, Texas, where Medicare payments were twice the national average despite being an impoverished area with affordable living expenses. Once these excessive costs were exposed, healthcare facilities in McAllen implemented standards for care and costs went down—without impacting the quality of care.
I can give a personal example related to excessive treatment. A family member suffered a minor stroke in which the symptoms resolved quickly. She was quite fortunate to come through the event without neurologic residua. During her hospital stay, she received a thorough evaluation that included multiple visits by the consulting neurologist, an MRI/MRA of the brain, a transthoracic Doppler echocardiogram, 48-hour telemetry monitoring and a carotid Doppler study. The results of these studies were reassuring and her treatment regimen was designed accordingly. At discharge, she was given a follow-up appointment with a cardiologist for unspecified reasons. By the end of this appointment, the cardiologist ordered a transesophageal echocardiogram, a cardiac stress nuclear imaging study and another five days of heart rhythm monitoring. Hearing this, I couldn't help but instigate myself in my loved one's healthcare, breaking one of my personal cardinal rules. But this plan sounded excessive, wasteful and potentially harmful and I did not think these additional tests were warranted. Before making my decision, however, I reviewed the literature and discussed the case with two colleagues: a stroke neurologist and an interventional cardiologist. We determined my initial impressions were appropriate and these tests were declined. Fortunately, my family member had the luxury of a "concierge" experience.
The implementation of facile and effective clinical decision support protocols is long overdue. We need to "right size" the use of imaging studies to reduce risk—both clinical (e.g., radiation dose) and cost (unnecessary and/or duplicative studies). The challenge is to interpolate standardized guidelines into physician workflows that can effectively reduce unnecessary procedures without impeding the delivery of care or imposing undue costs and hindrances to patients and providers.
Our aging population and rising national debt demonstrates that our country cannot afford to support excessive healthcare spending. Widespread deployment of clinical decision support systems offer physicians the ability to make informed choices for their patients that include appropriate testing, while simultaneously protecting them from unwarranted malpractice claims. It also reduces unnecessary testing ordered for financial gains.
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1. Levin DC, Rao VM, "Turf wars in radiology: the overutilization of imaging resulting from self-referral," J Am Coll Radiol 2004;1(3):169–172.
2. Hendee, et. al., "Addressing Overutilization in Medical Imaging," Radiology, Oct 2010, Vol. 257:240–245, 10.1148/radiol 10100063
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