Transcript Too Much of a Good Thing The Inappropriate Use of Medical

Eastern Radiological Society
Southern Pines, North Carolina
April 2013
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Founder and Chief Scientific Officer, ACR Image
Metrix (consultant)
 Imaging contract research organization owned by ACR
▪ Consultant to numerous drug and device companies
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Philips Healthcare Executive Team Advisory Board
and Radiology Medical Advisory Network
(consultant)
Author, The Sorcerer’s Apprentice: How Medical
Imaging is Changing Health Care, Oxford University
Press, 2010 (royalties)
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The perception of overuse
Use and misuse
The impact of uncritical use
Opportunities for change
They say golf is like life,
but don’t believe them.
Golf is more
complicated than that
- Gardner Dickinson
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Modern cross-sectional imaging
has made medicine:
 Safer
 More effective
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Broad economic concerns about
imaging
 Imaging represents about 12% of
health insurers’ outlays
▪ 3-5% in 1995
 2000-2005: Imaging growth 3x
general medical inflation
▪ 5x for high technology imaging
Money doesn’t talk,
it shouts
- Bob Dylan
Cumulative Percent Change
70
Imaging
Tests
Other procedures
All physician services
Major procedures
Evaluation & management
60
50
40
30
20
10
0
Source: MedPAC
2000
2001
2002
2003
2004
2005
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The financial success has led to
an anti-imaging bias
 Imaging has replaced others’
procedures
 Radiologists’ incomes have risen
faster then most others’
 More money for imaging means
less for everyone else
 Too much of imaging is said to be
unnecessary
Whenever a friend
succeeds, a little
something in me dies
- Gore Vidal
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Prevalent attitude that growth
in imaging is necessarily bad
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Reduced technical payments
mandated by 2005 DRA and 2010
PPACA
Attacks on professional payments
Increased imaging actually a
combination of:
 Appropriate growth
 Aberrant incentives
 Uncritical use
Where there is mystery,
it is generally suspected
there must also be evil
- Lord Byron
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Imaging should be growing
 Aging population
▪ Burden of chronic illness
▪ Imaging adept at diagnosis, staging, response to treatment
 Technological improvement has enabled new and
valuable applications
 Less morbidity, shorter convalescence
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Patients desire more care
 Moral hazard of health insurance
 Direct-to-consumer TV and print advertisements
 Boomer interest in wellness and health
 Availability of (mis)information on the Web
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Busy physicians misuse advanced imaging as
a screening/triage tool
 Humor patients and retain their loyalty
 Diminishing time allotted per patient
▪ Mandates for greater productivity
▪ Faster to order a test than spend time:
▪ Talking to patients
▪ Considering the value of the test
 Systemic pressures to perform imaging for
financial gain
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Principle agent moral hazard
 Fancy economic term for self-referral
▪ Physician behavior changes with:
▪ The need to cover their “nut”
▪ The chance to enhance revenue
 Stark in-office ancillary services exception (IOASE)
enabled by canny industry innovations
▪ Single purpose
▪ Minification
▪ Simplification
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Economically motivated
imaging use meets
patient desire for more
and higher tech care
 Physician controls the
volume of referrals
 Patient is protected by third
party insurance from the
cost of care
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Large body of research
confirms higher utilization
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Defensive medical testing – referring physicians
 2009 Massachusetts Medical Society survey: 28% of all
CT referrals to reduce liability
▪ Tendency to overestimate small legal risks if consequences to
patient or physician are severe
▪ Patients referred for imaging even when there is low probability
the test will benefit the patient
▪ Very low or very high probability of disease
▪ Poor test performance
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Defensive medical testing - radiologists
 Radiologists also overestimate malpractice risk
 A “miss” much more likely to generate a suit than an
“overcall”
▪ Adopt high sensitivity/low specificity approach to interpretation
▪ High false positive rate
 Unnecessary follow-on tests and treatment
▪ Recommend follow-on testing for
▪ Low probability concerns
 “Churning” or “auto-referral”
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The less acceptable rationales for imaging focus on
possible benefit, though not always for the patient
BUT
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All imaging bears risks
 For appropriate exams: benfit/risk is high
 for marginal or inappropriate imaging There is low
likelihood of patient benefit
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Most physicians and
patients concerned about
radiation and contrast
media reactions
BUT
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The greatest risk of
uncritical imaging is that
something will be found
Three things can happen
when you pass a football,
and two of them are bad
- Woody Hayes
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The test is negative and the patient truly has
no disease
________________
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What the patient is hoping for
Patient feels less anxious about their
symptoms and may (for a short while) pursue
healthful behaviors
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Cost plus benefit
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The patient has important disease but the
test incorrectly indicates no problem exists
_________________
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The patient and physician may be satisfied
and fail to pursue further diagnostic efforts
even if symptoms worsen
 Late and less effective treatment
Cost, no (negative) benefit
The imaging interpretation is positive but the patient is
actually normal
 Patients receive f/u testing/treatment that does not
improve health, adds cost, and may cause harm
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 Anxiety
 Iatrogenic injury
 Radiation exposure
_______________
Cost, no benefit
Possibility #1
 The patient has a serious condition, which is
treatable, and the outcome of treatment is a
cure or other improvement in health
______________________
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Why we test
Cost and benefit
Possibility #2: Pseudodisease
 Patient has the condition for which she is being tested but
will not be affected by the disease in her lifetime
 Slow growing
 Patient dies of something else
 Disease is resistant to treatment
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Same outcome regardless of imaging finding
__________________
Cost, no benefit
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Possibility #3: Incidentaloma
Finding unrelated to the symptoms leading to testing
 Small fraction with a risk to future health and where
intervention improves outcome
 Much larger fraction receives a workup and/or treatment for
benign conditions
____________________________
Cost, small percent of patients benefit
Uncritical use due to
multiple synergistic
influences derived from
a single root cause.
The quixotic pursuit of unattainable
clinical certainty
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All physicians educated
and most trained in
academic medical centers
 High probability of disease
 High severity of illness index
 High intensity of care
The only time my
prayers are never
answered is when I’m
playing golf
- Billy Graham
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Academic faculty distracted by multiple missions
 Clinical service
 Education and training
 Scholarly work
 Service and administration
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Success in academics requires adaptive strategies
 How to handle time-consuming clinical work while managing
the responsibilities that advance a career?
OR
 How to be two places at once?!
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“Supervise” students and
house staff
 Conduct morning rounds
 Make assignments
 Entrust house staff to make
management decisions at
off-hours
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Housestaff:
 Have variable but usually lesser expertise
 Also are torn among diverse responsibilities
▪ Clinical care
▪ Read and study
▪ Research and administration
 Are under pressure to open beds
▪ Crowded ERs
▪ Maximize institutional profit from DRGs and capitation
 Learn early-on that calling the attending is a weakness
▪ Discouraged by fellow trainees
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Housestaff adopt a shotgun approach to
imaging exams that fails to consider
 Performance characteristics of the test
 Likelihood of disease
 Consequences to patients
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Objectives are to minimize:
 Attending exertions
 “Wasted” time that could be used for more
concrete responsibilities
 The possibility of humiliation
An example made of
one individual is a
lesson taught to all
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Even in high frequency,
high acuity
environments, these
practices are wasteful
and potentially harmful
BUT
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Physicians take high
intensity practice style
learned in academic
health centers to lower
intensity settings in
which the problems are
magnified
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Learned practice style persists and is even
encouraged by other physicians in the practice
▪ Saves time in patient encounters and improves throughput
▪ Perceived as a safeguard against malpractice liability
▪ May generate revenue for self-referral practices or for
horizontally integrated health system
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Even when there is either near certainty or near
impossibility of a condition:
▪ Referring physicians tend to request an exam
▪ Radiologists err on the side of overcalls
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Imaging begets more imaging
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Correct lawyers’ incentives
 Current incentives encourage frivolous suits and
disenfranchise some with legitimate claims
 Alternatives
▪ Malpractice suit fee schedule
▪ Loser pays
▪ Cap amount earned by contingency fees
___________________
Opposed by a powerful lobby
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Terminate the in-office ancillary services exception
allowing high-tech imaging in offices
 Never intended to sanction high-tech imaging
 The money is too big to be ignored
 Wasteful of public and personal resources
 Harmful to patients’ health
_____________________
Opposed by large and powerful coalition
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For future referring MDs
 Teach “elegant diagnosis”
 Encourage critical reading of the
medical literature
 Gear teaching toward:
▪ Appropriate use of imaging
▪ Consultation with radiologists
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Did the patient already have the test?
 Why repeat?
 Can the previous test/result be obtained?
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Will the test change patient care?
What are the probability and negative
consequences of a FP test or pseudodisease?
What is the short term danger of not performing
the exam?
Is the reason for testing patient expectations?
▪ What else could be done?
- Laine, Ann Int Med, Jan. 2012
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Radiology benefits management firms (RBMs) hired
by insurers to reduce uncritical imaging
 Preauthorization required or the patient is charged
▪ “Black box” clinical guidelines
▪ Sentinel effect
▪ Barrier effect
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Clinical decision support systems
 Based on guidelines
 Require major cultural change
 Must mandate a “hard stop” to be effective
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Be a role model to trainees and newly minted radiologists
Reinvigorate consultation with referring MDs
 Avoid the appearance of self-interest
▪ Support policies that benefit patients even if less revenue
▪ Take the lead in reducing imaging exams that are unlikely to benefit patients
▪ Contest marginal and unnecessary requests
▪ Discourage imaging to reduce small uncertainties
▪ Minimize indecisiveness over findings of low importance
 Advocate valuable and underutilized imaging
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Establish direct communications with patients
 Pre-exam consultation
 Direct reporting
 Post-exam consultation
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Uncritical imaging is related to a combination of
educational, cultural, and economic factors that
promote marginal and unnecessary use
Decreasing the effects of external influences like
financial incentives and fear of litigation are
important but will not be sufficient to stem
uncritical imaging
Physicians must adopt a different practice style
emphasizing consultation with radiologists and
critical thought before requesting imaging exams
Golf is a game
invented by the same
people who think
music comes out of a
bagpipe.
- unattributed