I, too, have been frustrated by our local hospital system ERs overuse of imaging and the current ER practice of having CT scan stand in for physical exam. But this is not a "per doctor" issue. This is a SYSTEM issue. In our system, anyone > 65 who has a fall or other accident comes in as a "trauma". They are evaluated per the trauma team. This includes and encompasses every elderly person who falls. 82 y/o and fall at home: trauma pathway. 92 year old who falls while getting into the bathroom (monthly): trauma pathway. The imaging occurs per the protocol, before any physician has done an evaluation. the docs want the scans to do the evaluation. The trauma pathway calls for total body CT scan: CT of: brain; cervical, thoracic, and lumbar spine and the chest/abdomen/pelvis. The ENTIRE BODY. Nobody cares about the exact mechanism for each fall. I even had a patient who didn't "fall" but simply "slumped to the floor" when he felt weak. This is the system and the protocol.
Somewhere within the hospital structure, this needs to be questioned. At the time this protocol was enacted, we started experiencing 2-3 week delays for imaging reads/reports. Generating multiple patient calls of "what did my scan show??" And weeks waiting to get CT/MRI in the first place. So, we'll have 30, 40, 60 year olds waiting weeks to have sometimes serious symptoms evaluated while the extreme elderly are glowing.
I do not want to short-change elderly patients. If I thought this was a clinically responsible way to evaluate the vast majority (or even a significant minority) of these patients, I'd understand. But it really is not. It just takes some pressure off a busy trauma team. Which I also understand. But we can't continue to kick the can down the road and not make some hard choices in everyone's best interest.
Again - it is a SYSTEM ISSUE. Playing games on a per physician basis is not helpful. We've been "gamed" enough as it is - and none of those have been helpful. As a medical community, as a citizen/patient community, we need to decide how to best spend our resources. This is big picture, not doctor-by-doctor problem.
Very interesting concept. I am not sure doctors and patients would go for it though but I do like it in theory. It's like when I broke my radio head and was going back for my 6-week follow-up I said why do I need an x-ray and my doctor said well. We always take an x-ray. But I agree. I guess you don't need it. Most people would have just gotten the X-ray. My armed healed. I didn't need the X-ray
Medical students and residents in training need to be expose to this kind of analysis. We must find a way -- this one or another -- to make physicians responsible for use and overuse of expensive diagnostic testing. Because I had a history of a traumatic hemorrhagic stroke, when I showed up in an excellent hospital's ER four times over six months with various confusing neurological symptoms, I received a head CT and head MRI each and every time with clear reports of "no interval change". None of my presenting symptoms were really stroke-like! There was no downside for anyone involved in the ordering of these testing. I was discharged within 48 hours in each hospitalization.
For ED it starts at 911! Who needs to get an ambulance ride? I like the concept! Starting my career without CT and ending it by consulting on every "multitrauma" patient with any degenerative or mild traumatic spinal CT finding was a stark contrast. Removing all the neurosurgery consultation costs alone would probably be significant $avings!
Hmm… does this mean radiologists will stop pushing yearly mammography for low risk patients…? What about CT lung cancer screening ( questionable evidence to support)? In my world, radiology directly benefits financially from the amount of studies done.
While I am not sure that the solution is practical, there is ample evidence in behavioral science that small negative incentives for patients (and probably doctors) can affect utilization decisions. I agree completely that overutilization is both wasteful and harmful. In addition, there are aligned perverse incentives among practitioners, patients, and institutions to promote overutilization. Incidentalomas particularly gripe me. I would be supportive of patients having informed decision-making prior to advanced imaging to allow opting out of any interpretation beyond the area of clinical concern. So there would not be any interpretation of the lungs when a CT of the abdomen was ordered for example. This would have saved me an unnecessary MRI with contrast. Probably just as impractical as the suggestion put forward by the author.
Unfortunately, this has been tried. It’s the capitation model. Misalignment of incentives between patients and physician in terms of dollars has never worked well. It might be interesting to see if incentives changes in states with malpractice caps but I doubt there is much difference in ordering. It is almost impossible to leave an emergency room without getting a CAT scan. To change physician behavior you must have measurement tools in place with subsequent wide dissemination of the data. Simply measuring and reporting the number of scans done per ER doctor per month will reduce the number of scans. In addition reviewing protocols to make sure they don’t include routine and unnecessary testing as mentioned is helpful. Finally feedback in terms of outcomes completes the loop -If it’s determined that CT in trauma has value within limits.
When you’re dealing with doctors, what you incentivize you achieve, what gets measured gets done, and what you permit you promote. I have enough gray hair to promise you this is true. Paying doctors who are more consistently following the written guidelines with ongoing data- as opposed to a per click arrangement will change behavior.
And finally, any time a radiologist suggests ordering a different study in their report- that is reported as well. If you complete a loop you get an award. The doc orders at CT the CT reader says get an MRI. The MRI reader says get an ultrasound. The ultrasound reader suggests ordering a CT. When this occur occurs a public award is given!
What has been glaringly left out of this solution is the push from large hospital systems to do more tests so they can make more money. This is not addressed at all. How does that figure in? My doctor ordered a bone density scan - I had 3 texts and 2 phone calls within 3 days from the hospital system to set up the appointment. They were quite anxious to have me do this test.
Who would control the RAD dollars? The government, the hospital system? How would they be allocated? Would you have to prove you need a certain amount? Would different specialties get different amounts (orthopedics vs. cardiologists)?
Really, allocating RAD dollars is just another way of controlling the physician's practice; it's a surreptitious way of doing it, but still controlling. What will be missed because a physician is waiting for the "right" patient to spend them on? Or what happens if the physician isn't willing to spend money to buy more RAD dollars?
The biggest complaint I have heard from physicians is that they are not trusted to do the right thing by insurance companies, hospital systems, etc. How would this help?
The problem is more complex than just doctors ordering too many tests.
While I applaud the out-of-the-box thinking, this is not the right direction.
I like the attempt to handle the problem by means of micro-incentives that encourage better choices. But the root cause of this problem is excessive reliance on 3rd party payment arrangements that insulate patients from costs. A market-based system would create appropriate incentives automatically.
Sorry, government run health system do not create desirable incentives automatically or, usually, ever. They incentivize opportunism. The point is obvious but proponents of public pograms refuse to acknowledge it.
I agree patients need to be brought into the mix. After all, in your proposal what would prevent patients from gaming the system by visiting their clinician early in the month, when the "Rad Dollar" balance has been replenished. Also, pity the poor patient who gets sick on the 31st of the month and every scan ordered is going to cost the doctor some real money. Different standards of care based on the day of the month. Hmmmm........
Thank you for this article. so thought-provoking. agree with comment from George. Let’s bring the patients in to the mix also and they should get a certain amount of lab/rad/diagnostic testing dollars. Insurance companies are already capping PT visits, home healthcare visits, skilled nursing stay days. Let’s take it farther. I love this out of the box thinking. Let’s be open to fixing a system That doesn’t quite work as well as it should.
I, too, have been frustrated by our local hospital system ERs overuse of imaging and the current ER practice of having CT scan stand in for physical exam. But this is not a "per doctor" issue. This is a SYSTEM issue. In our system, anyone > 65 who has a fall or other accident comes in as a "trauma". They are evaluated per the trauma team. This includes and encompasses every elderly person who falls. 82 y/o and fall at home: trauma pathway. 92 year old who falls while getting into the bathroom (monthly): trauma pathway. The imaging occurs per the protocol, before any physician has done an evaluation. the docs want the scans to do the evaluation. The trauma pathway calls for total body CT scan: CT of: brain; cervical, thoracic, and lumbar spine and the chest/abdomen/pelvis. The ENTIRE BODY. Nobody cares about the exact mechanism for each fall. I even had a patient who didn't "fall" but simply "slumped to the floor" when he felt weak. This is the system and the protocol.
Somewhere within the hospital structure, this needs to be questioned. At the time this protocol was enacted, we started experiencing 2-3 week delays for imaging reads/reports. Generating multiple patient calls of "what did my scan show??" And weeks waiting to get CT/MRI in the first place. So, we'll have 30, 40, 60 year olds waiting weeks to have sometimes serious symptoms evaluated while the extreme elderly are glowing.
I do not want to short-change elderly patients. If I thought this was a clinically responsible way to evaluate the vast majority (or even a significant minority) of these patients, I'd understand. But it really is not. It just takes some pressure off a busy trauma team. Which I also understand. But we can't continue to kick the can down the road and not make some hard choices in everyone's best interest.
Again - it is a SYSTEM ISSUE. Playing games on a per physician basis is not helpful. We've been "gamed" enough as it is - and none of those have been helpful. As a medical community, as a citizen/patient community, we need to decide how to best spend our resources. This is big picture, not doctor-by-doctor problem.
Very interesting concept. I am not sure doctors and patients would go for it though but I do like it in theory. It's like when I broke my radio head and was going back for my 6-week follow-up I said why do I need an x-ray and my doctor said well. We always take an x-ray. But I agree. I guess you don't need it. Most people would have just gotten the X-ray. My armed healed. I didn't need the X-ray
Medical students and residents in training need to be expose to this kind of analysis. We must find a way -- this one or another -- to make physicians responsible for use and overuse of expensive diagnostic testing. Because I had a history of a traumatic hemorrhagic stroke, when I showed up in an excellent hospital's ER four times over six months with various confusing neurological symptoms, I received a head CT and head MRI each and every time with clear reports of "no interval change". None of my presenting symptoms were really stroke-like! There was no downside for anyone involved in the ordering of these testing. I was discharged within 48 hours in each hospitalization.
For ED it starts at 911! Who needs to get an ambulance ride? I like the concept! Starting my career without CT and ending it by consulting on every "multitrauma" patient with any degenerative or mild traumatic spinal CT finding was a stark contrast. Removing all the neurosurgery consultation costs alone would probably be significant $avings!
Hmm… does this mean radiologists will stop pushing yearly mammography for low risk patients…? What about CT lung cancer screening ( questionable evidence to support)? In my world, radiology directly benefits financially from the amount of studies done.
Very interesting - worth testing...
I love the creativity and innovative thinking, targeting incentives.
Stop the endless hedge readings that put ordering docs in a legal predicament.
While I am not sure that the solution is practical, there is ample evidence in behavioral science that small negative incentives for patients (and probably doctors) can affect utilization decisions. I agree completely that overutilization is both wasteful and harmful. In addition, there are aligned perverse incentives among practitioners, patients, and institutions to promote overutilization. Incidentalomas particularly gripe me. I would be supportive of patients having informed decision-making prior to advanced imaging to allow opting out of any interpretation beyond the area of clinical concern. So there would not be any interpretation of the lungs when a CT of the abdomen was ordered for example. This would have saved me an unnecessary MRI with contrast. Probably just as impractical as the suggestion put forward by the author.
Homo Economicus strikes again!
Nice article with innovative thinking.
Unfortunately, this has been tried. It’s the capitation model. Misalignment of incentives between patients and physician in terms of dollars has never worked well. It might be interesting to see if incentives changes in states with malpractice caps but I doubt there is much difference in ordering. It is almost impossible to leave an emergency room without getting a CAT scan. To change physician behavior you must have measurement tools in place with subsequent wide dissemination of the data. Simply measuring and reporting the number of scans done per ER doctor per month will reduce the number of scans. In addition reviewing protocols to make sure they don’t include routine and unnecessary testing as mentioned is helpful. Finally feedback in terms of outcomes completes the loop -If it’s determined that CT in trauma has value within limits.
When you’re dealing with doctors, what you incentivize you achieve, what gets measured gets done, and what you permit you promote. I have enough gray hair to promise you this is true. Paying doctors who are more consistently following the written guidelines with ongoing data- as opposed to a per click arrangement will change behavior.
And finally, any time a radiologist suggests ordering a different study in their report- that is reported as well. If you complete a loop you get an award. The doc orders at CT the CT reader says get an MRI. The MRI reader says get an ultrasound. The ultrasound reader suggests ordering a CT. When this occur occurs a public award is given!
What has been glaringly left out of this solution is the push from large hospital systems to do more tests so they can make more money. This is not addressed at all. How does that figure in? My doctor ordered a bone density scan - I had 3 texts and 2 phone calls within 3 days from the hospital system to set up the appointment. They were quite anxious to have me do this test.
Who would control the RAD dollars? The government, the hospital system? How would they be allocated? Would you have to prove you need a certain amount? Would different specialties get different amounts (orthopedics vs. cardiologists)?
Really, allocating RAD dollars is just another way of controlling the physician's practice; it's a surreptitious way of doing it, but still controlling. What will be missed because a physician is waiting for the "right" patient to spend them on? Or what happens if the physician isn't willing to spend money to buy more RAD dollars?
The biggest complaint I have heard from physicians is that they are not trusted to do the right thing by insurance companies, hospital systems, etc. How would this help?
The problem is more complex than just doctors ordering too many tests.
While I applaud the out-of-the-box thinking, this is not the right direction.
I like the attempt to handle the problem by means of micro-incentives that encourage better choices. But the root cause of this problem is excessive reliance on 3rd party payment arrangements that insulate patients from costs. A market-based system would create appropriate incentives automatically.
Or national health like the rest of the world..
Sorry, government run health system do not create desirable incentives automatically or, usually, ever. They incentivize opportunism. The point is obvious but proponents of public pograms refuse to acknowledge it.
I agree patients need to be brought into the mix. After all, in your proposal what would prevent patients from gaming the system by visiting their clinician early in the month, when the "Rad Dollar" balance has been replenished. Also, pity the poor patient who gets sick on the 31st of the month and every scan ordered is going to cost the doctor some real money. Different standards of care based on the day of the month. Hmmmm........
Thank you for this article. so thought-provoking. agree with comment from George. Let’s bring the patients in to the mix also and they should get a certain amount of lab/rad/diagnostic testing dollars. Insurance companies are already capping PT visits, home healthcare visits, skilled nursing stay days. Let’s take it farther. I love this out of the box thinking. Let’s be open to fixing a system That doesn’t quite work as well as it should.
I agree! In the emergency department patients are often driving the imaging utilization.