Everybody wants to go to heaven, but nobody wants to die.

After slamming the gavel down convening the July 18 House Committee on Energy and Commerce hearing on diagnostic imaging, Rep Nathan Deal (R-Ga), chairman of the Subcommittee on Health, summarized the upcoming debate with prescience: This imaging issue reminds me of a favorite old country song, he said. “Everyone wants to go to heaven, but nobody wants to die.” The packed hearing room erupted with muffled laughter, yet with a silent, unanimous sense that this chairman knew the issue as well as anyone in the room.

Several opening salvos from committee members followed, lambasting the tenets of and process leading to the Deficit Reduction Act (DRA) legislation. Members also predictably voiced concern over potential access ramifications and the possibility that valuable diagnostic imaging care could be withheld from Americans. The proceeding flowed into presentations by CMS and MedPAC representatives, who underscored the enormous financial burden that exploding high-tech diagnostic imaging utilization is placing on America’s health care budget. Proliferating equipment deployment, pockets of irrational reimbursement, and vexing self-referral loopholes were cited as prime culprits. Incredibly, the magnitude of CMS’ high-tech imaging spending and staggering inflationary trends continue to accelerate with each analysis the General Accounting Office prepares.

And then the fun began. The assembled panel, including leaders of the American College of Cardiology, American College of Radiology, American College of Obstetricians and Gynecologists, and several other stakeholders, spoke their piece. As one listened, you could not miss the uncanny consistency reverberating among the professional societies:

“Our members are uniquely credentialed and positioned to provide diagnostic imaging care. We have established professional, evidence-based standards and guidelines to direct the appropriate use of imaging care. The DRA reimbursement is unfair to our membership.”

As you reflect on the statements and listen to the powerful, well-supported, and articulated arguments of the spokespeople, you arrive at one irrefutable conclusion: They are right, academically and consistently right. The ACC, ACR, and ACOG membership stand as among the most highly trained, skilled, and respected clinicians in American medicine. I, for one, have the utmost respect and professional admiration for the leadership and membership of these societies. On point two, the guidelines that each of these societies has put forth stand as paragons of clinical virtue and best practice. And finally on point three, yes, any reasonable person would agree that the DRA reimbursement methodology will have a detrimental economic impact on many physicians.

Skirting the Real Issue

However, being right, even academically and consistently right, does not solve the problem that the committee was convened to address: High-tech diagnostic imaging costs are trending at three times overall medical inflation and raising quality, safety, economic, and clinical appropriateness concerns nationwide. Being right also does not get you “to heaven” on this issue. Being right without proposing a viable solution to a multibillion-dollar health care resource crisis does result in some unsavory and arguably draconian DRA measures. We have to be more than right to avoid further proliferation of the problem and more harsh legislated attempts at solutions.

Let us forget about being right on the merits of our professional societies. We have to embrace a laudable goal that transcends provincial professional domain and focuses on the greater good of the patient and our nation. We have to find a solution and band together to develop a sound national health care policy for clinically appropriate, accessible, safe, and affordable diagnostic imaging.

A unified focus on sound national imaging health care policy must begin with a sober, evidence-based assessment of the causal factors driving imaging quality, safety, economic, and inflationary concerns. For as we would all agree, this is far from a simple challenge. It is a multivariate perfect storm of factors that include:

  • innovative and therapeutically helpful new imaging technology flooding the marketplace;
  • frequent lack of clinical consensus or understanding of the technology from ordering physicians;
  • malpractice concerns encouraging the defensive ordering of multiple diagnostic imaging examinations;
  • patient-driven demand, fueled by direct-to-consumer advertising;
  • proliferating imaging capacity driven by entrepreneurial zeal versus clinical access demands; and
  • exploding self-referral, in and of itself not a demon unless it opens up economic versus clinical incentives.

As you look at each of these factors, you see another remarkable consistency. Each factor is rooted in an incoming order for a high-cost diagnostic imaging study. Our nation’s imaging care delivery system is defined by three separate events: the ordering of a study, the rendering of a study, and the payment for a study. Although most of the debate and focus among professional societies and in Washington have been on who renders and how much is paid for a study, the data overwhelmingly show the explosion in high-tech imaging cost is driven by skyrocketing ordering patterns.

Incoming orders for high-tech diagnostic imaging studies should now become the focus of debate and analysis. Assuring the clinical appropriateness of these orders must be the cornerstone of sound national imaging health care policy. This is the ultimate solution. Professional societies, CMS, and health care organizations need to achieve high-tech imaging studies that are consistently ordered in the pure clinical and safety interest of the patient. Imagine if all high-tech imaging orders were subjected, at the point of ordering, to immediate Web-based clinical decision support validating that the request met the latest clinical guidelines of our esteemed professional societies? We would all be more than right. We would be putting our standards and guidelines into a solution that assures the safety, quality, and clinical appropriateness of care. We would avoid unwarranted imaging care and protect ourselves from future draconian reimbursement actions. By assuring the clinical appropriateness of imaging orders, we would all “go to heaven” on this imaging issue, and nobody would have to die.

John Donahue, MBA, is president and CEO of National Imaging Associates/Magellan, Avon, Conn, a nationwide radiology benefits management company, and a member of the Axis Imaging News editorial advisory board.