Changing the Conversation

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Cat VaskoAn interesting op-ed in today’s LA Times claims to make “the case for rationing healthcare.” But the author’s real case is to be found near the end:

“How might we ‘bend the curve’ of rising costs without forcing doctors to break with Hippocratic ideals? Percentage points can be trimmed by better coordinating care and providing it more efficiently. But the main driver behind rising costs is indiscriminate adoption of new technology. We must make it much harder for high-cost clinical wizardry to become part of our expectations. We should distinguish between decisive advances . . . and technologies that dazzle but deliver only marginal results.”

And then comes the kicker:

“We can do this by demanding proof that pricey services add value before permitting healthcare providers to tap insurers for payment.”

This is worth noting: Here we have a physician and author advocating in a widely consumer-read platform for what is, essentially, pre-auth. Those of us in the radiology community know that pre-auth is far from a magic bullet; while it has been shown to effectively curb utilization, it also decreases clinical efficiency, which drives costs right back up.

More critically, it takes the power of determination out of the hands of those best qualified—referring physicians and imaging professionals—and gives it to insurers. If the problem with allowing physicians to make these decisions is financial incentives, then what’s better about handing them over to private payors, who, as we’ve seen time and sickening time again, have no moral qualms about denying patients necessary care in order to boost the bottom line?

I have continually felt surprised at the voraciousness with which physicians have thrown the concept of a single-payor health system under the bus. This article reminds me of why radiologists in particular should be advocating for single-payor healthcare: when you remove the profit motive from the payors’ side of the equation, what you have left is a system in which appropriateness, our favorite word in this industry, rules the day. Not economic incentives on either side; appropriateness pure and simple, determined by experts and enforced because it’s the right thing to do, not because we have to.

It’s obvious that the government won’t stop gunning for imaging. Why should it? Imaging shows rapid growth and escalating costs, and there’s evidence that it is being overutilized, even if that overutilization is on the part of self-referring physicians, not radiologists.

But if this industry takes a new tack and tries to partner with CMS on pursuing true appropriateness, it may pay dividends in the long run. After all, what’s the alternative—continue to see utilization attacked until every imaging exam requires a seventeen-point pre-auth process? It’s been six years since the DRA was passed, and at this point I think it’s obvious that the adversarial approach isn’t getting us anywhere. Why not try to change the conversation?