Dr. Pollei is a neuroradiologist and medical director of Center for Diagnostic Imaging in Federal Way & Lakewood, WA
Radiology services continued to be hammered in the past few months, both by the Centers for Medicare & Medicaid Services (CMS) and in the federal health reform bill. All signs point to further pounding in subsequent bills and regulation.
Even while those of us running imaging centers are trying to figure out how we are to achieve a 75% patient utilization rate for Medicare patients, we are being told that the White House still believes the rate should be set at 90%. Since there is no documentation to support this level of utilization, the result of this change is a net overall rate cut to all imaging providers, good and bad.
These reimbursement cuts are directly related to the belief by many of our public officials that there are still too many “inappropriate” imaging tests being ordered. This is despite the data that is finally trickling in which indicates a severe downturn after the Deficit Reduction Act of 2005 went into effect. Inappropriate imaging would be better attacked by selectively targeting overuse and self-referral than globally decreasing rates.
As radiologists, we can stand in the middle of the field and let everyone continue to use us as a target or we can find available cover. Adoption of clinical decision support continues to offer us the opportunity of a solution (and therefore “cover”) to the concerns about inappropriate utilization without forcing us to use the “just say no approach,” as the radiology benefit management (RBM) companies are doing across the country.
Clinical decision support vs. RBMs
The Imaging e-Ordering Coalition continues to push for rapid adoption of clinical decision support in the marketplace while continuing to block the adoption of an RBM prior-authorization approach by Medicare. Specifically the e-Ordering Coalition seeks to advance the use of electronic clinical decision support technologies (such as tools like RadPort from Nuance, Burlington, MA) that provide physicians with guidance regarding the ordering of patient-appropriate imaging services. It also provides radiologists with the opportunity to electronically document the clinical appropriateness of the services we provide. For all medical personnel involved, we are being offered a non-intrusive way to continuously improve the services collectively delivered to our patients. This cannot be done with an RBM approach since there is not the same opportunity for referring clinician learning or feedback as to which test is most appropriate for each specific patient.
The success of this effort has been impressive in Washington but tepid in the marketplace, where the larger health insurers have integrated a for-profit RBM subsidiary into their company and therefore are rebuffing suggestions of a tool which could put the RBMs out of business. Also hampering marketplace adoption has been the slow pace of the statewide clinical decision support project in Minnesota and the delay by CMS in establishing the decision support demos included in the 2008 Medicare law, which were to be up and running by January 1, 2010. The 2008 mandated CMS demonstration project is intended to evaluate the effectiveness of point-of-order electronic decision support technologies in promoting the appropriate utilization of advanced diagnostic imaging services. The Minnesota project, which is a collaboration of payers and providers under the umbrella of the Institute for Clinical Systems Information is expected to launch shortly.
The coalition and healthcare reform legislation
The Coalition also worked over the past year to impact the development of health care reform legislation. We were successful in lobbying to keep out of the final legislation that was enacted in March a requirement for the use of Radiology Benefit Managers (RBMs) under Medicare that had been tacitly supported by the General Accounting Office and included in an early Administration proposal.
Efforts around the HITECH Act
The other major area of Coalition focus has been on the creation and implementation of the Health IT for Economic and Clinical Health (HITECH) Act that was included in the American Recovery and Reinvestment Act. Early on, we worked for definitions of computerized provider order entry and clinical decision support that would not be limited to prescription drugs, thereby including imaging ordering within the extent of the law. Subsequently, we defined the general goals that the Coalition wanted to see in the development of meaningful use and certification requirements, met with National Coordinator for HIT David Blumenthal, MD, provided testimony to the Health IT Policy Committee and submitted formal comments as part of the first round of rulemaking. These hefty HIT efforts would not have been possible without the Coalition’s Provider Roundtable, headed by Nancy Koenig of Merge (Milwaukee, WI) with active participation of several radiology CIOs/CAOs and American College of Radiology (ACR) staff.
The work of the e-Ordering Coalition is not designed as a direct return on investment; it is a strategy for survival. The ACR, GE Healthcare (Chalfont St. Giles, UK) and several other imaging industry leaders are actively involved with these efforts. However, the best lobbyists can’t do what we as radiologists can: promote the electronic documentation of the appropriateness of the services we are providing by educating our referral clinicians about the opportunities of electronic clinical decision support. It is on our shoulders to continue the push for new transparent technology with feedback to the referring clinician as opposed to the deliberately obscure “just say no” RBM approach.