Getting uncomfortable..in a good way


I turned 50 last month. In thinking about how best to celebrate this milestone I've decided that it's going to be about forcing myself to go beyond my comfort zone. Getting on a bike in NYC for the first time? Sure! Advocating for new ways that radiologists can deliver value and for payment policy that aligns incentives? Absolutely. With input from all our stakeholders: patients and colleagues and with the goal of the highest value care front and center. Let's do this.

 I think all of us in radiology have been feeling out of our comfort zone lately. Healthcare is in a state of flux. We're just starting to feel the impact of the ACA with millions of new healthcare beneficiaries and a shift from volume to value that has often seemed to cast us as part of the problem. Rapid growth in utilization of advanced imaging as the new Millennium dawned, growing awareness that there might be a price to pay for the exquisite resolution offered by newer CT scanners and widespread questioning of the benefits of screening mammography have all chipped away at the notion that radiologists have value to deliver in healthcare. Our protestations have often felt like they fell on deaf ears. Nobody seemed to be interested that much of the growth in imaging was happening in the offices of self-referrers churning out studies on their own machines at 4 times the rate they'd refer to us. Our Image Gently and Image Wisely programs that were at the forefront of improving radiation safety awareness seemed to get far less coverage than alarmist reports of CT scans causing cancer. Real, solid science demonstrating that mammography saves lives was buried under report after misleading report that confuse our patients.  All this plus a sustained attack on reimbursement for what we do has left us feeling decidedly less than comfortable.

 

But I am proud to say that as a specialty we have decided that rather than dig in and whine about our predicament we have chosen to embrace the possibilities of change and the events of this past week have shown us a path forward where we are very much part of the solution in the delivery of the highest value imaging care for our patients: a big Imaging 3.0 (http://www.acr.org/Advocacy/Economics-Health-Policy/Imaging-3) success.

 

If you're not a physician who has been subject to the slings and arrows of the flawed payment formula called the "SGR" you might have missed the complex negotiations that aimed to finally fix this flawed system. I won't belabor the details but a well-intentioned attempt in the late 1990s to make sure that Medicare spending did not outstrip spending on other programs has since 2002 led to a series of potential cuts in physician reimbursement. Each time a double digit cut would loom it would be averted at the last minute and existing payments restored. Each temporary fix or patch would last only a short time and then the whole sorry saga would start again. Each fix came with a price. The difference between what would have been paid under the proposed cut and the restored payments was chalked up as a "debt" that would have to be paid back before any permanent fix could be enacted. This year, some internal Government accounting magic reduced the debt by more than half to a relatively manageable (in overall healthcare spending terms at least) $138 billion. This galvanized physician groups and lawmakers alike to fix the payment formula and use the fix to embed new incentives for value rather than volume into the system.

 

At the ACR we saw this as an opportunity to drive appropriate imaging for Medicare beneficiaries through the use of our evidence based, educational point of care decision support toolkit. This leverages 20 years of Appropriateness Criteria development by ACR physician volunteers in collaboration with other physician groups. It has been shown to reduce advanced imaging utilization with increased appropriateness and importantly to reduce costs. Ever since ACR members flooded Capitol Hill at last year's ACR leadership meeting and demonstrated the tool to their representatives we have been telling the story of how we as radiologists can deliver value in the new world of healthcare. 

 

Our dysfunctional Congress rarely delivers these days and the SGR reform, which had seemed so promising, looked in recent weeks to be dying on the vine. Senator Max Baucus, a key champion, left for his new post as Ambassador to China. House Republicans looked to tie reform to yet another attempt to roll back Obamacare and Senate Democrats wanted to tap unused war funding to pay for it. It became clear that all we could hope for was another temporary patch. Another "bandaid" was opposed by important groups such as the AMA and I respect their desire to see this problem fixed for good. But at the ACR we decided that the momentum around the use of CDS was not something we could afford to waste, not for the future of our profession and not for our patients. The SGR patches are typically enacted as "clean" bills i.e they do not include any other provisions. Our tireless campaign to tell the story of appropriate imaging's value paid off however and the language in the abandoned full reform bill that mandated the use of CDS for advance imaging made it into the patch.

 

Is this out of our comfort zone as radiologists? For sure. We will probably do fewer studies overall although in some cases, lung cancer screening with CT for example, we may do more. But it will be the right imaging. We must make ourselves readily available to our colleagues to help them navigate those scenarios where the AC inevitably do not always have an answer. But we will, by doing this, immeasurably increase our profile and relevance. We must develop and advocate for future payment policy that recognizes and incentivizes the value added activities that only radiologists can deliver. This advocacy will ensure not only the future of our specialty but also the improved health of our most important constituency: our patients.

 

So here's to getting out of our comfort zone!