One of the more fascinating elements in the current healthcare policy and operational landscape is a pronounced shift that I’m seeing taking place in terms of how providers look at cost-effectiveness issues. In the relatively cash-happy (though only in retrospect, of course!) 1990s, the nearly universally shared perspective among clinicians and medical group and hospital administrators was that health insurer executives, both in the private sector, and in the federal and state governments in the form of Medicare and Medicaid officials as well, were simply trying to either maximize profits (on the private side) or were being parsimonious on behalf of taxpayers (on the public payer side), in their efforts to rein in costs.
But nowadays, with growing clarity on the part of everyone in healthcare that the current healthcare cost trajectory is unsustainable over time, attitudes are shifting, and, particularly since the passage of the Affordable Care Act in March 2010—and most especially since the affirmation of the constitutionality of that legislation on the part of the Supreme Court in late June—more collaborative perspectives have been emerging. After all, the Medicare Shared Savings Program even has the words “shared savings” in its name, while virtually all of the collaboratively based new reimbursement models—accountable care organizations (whether federal or private), bundled payment-based contracts, patient-centered medical homes, and so on—involve strong collaboration between payers and providers, with some combination of rewards to providers for achieving cost savings and improving patient care outcomes.
It is in that context, I think, that we should commend the results of a recent study of diagnostic imaging order management by researchers at Beaumont Health System in Michigan. In that study, a group of researchers led by Kavitha Chinnaiyan, M.D., director of advanced cardiac imaging education at that health system, found that inappropriate imaging study ordering can be reduced by 60 percent through a combination of physician education, physician collaboration, and monitoring of test ordering.
As Dr. Chinnaiyan and her colleagues wrote in an article published online Aug. 8 in the Journal of the American College of Cardiology entitled, “Impact of a Continuous Quality Improvement Initiative on Appropriate Use of Coronary Computed Tomography Angiography: Results from a Multicenter, Statewide Registry, the Advanced Cardiovascular Imaging Consortium,” health system, found that inappropriate imaging study ordering can be reduced by 60 percent through a combination of physician education, physician collaboration, and monitoring of test ordering.
coronary CT angiography is “cost-effective, provides diagnostic rapidity, and has excellent prognostic value in selected patients. Such characteristics combined with improved ease of interpretation have spurred widespread use and increased the potential for inappropriate use. This concern was confirmed by the fact that during the pre-intervention period, 14.6% of scans were inappropriate. However, reduction of inappropriate use to only 5.8% during follow-up is encouraging.” In other words, while many CT scans are ordered appropriately by referring physicians, a good number are not appropriately ordered.
But among the 47 care sites whose physicians took part in an ongoing initiative during the period from July 2007 to December 2010, major changes were effected. “We looked at more than 25,000 patients in the ACIC [Advanced Cardiovascular Imaging Consortium] registry, reviewed data on appropriate use, then had a period of intervention with 5,000 referring physicians across the state offering educational programs, close monitoring and feedback to physicians on CT use,” Dr. Chinnaiyan explained in a Blue Cross Blue Shield of Michigan (BCBSMI) press release also published on Aug. 8.
The long and the short of all this? Dr. Chinnaiyan and her colleagues write that “We found that appropriate use increased and inappropriate use decreased by 60 percent across all referring physician specialties—including cardiologists, internists, emergency room physicians,” Dr. Chinnaiyan said in the BCBSMI press release. “These are very exciting results for doctors, patients, and for payers.”
What’s particularly exciting here are the implications for hospitals, medical groups, and integrated health systems participating in any type of accountable care contracting, whether through the Medicare Shared Savings Program or with a private health insurer. And that’s because the use of the latest diagnostic imaging clinical support tools, harnessed to strong analytics software, could very likely replicate the kinds of results that Dr. Chinnaiyan and her colleagues achieved in their program and study.
So the old “us-versus-them” dynamic, which is beginning to crumble under the pressure of health system-wide imperatives to control costs and improve outcomes, is inevitably leading to opportunities for systemic improvement in areas like this, with clinical information systems and analytics tools an absolutely essential element for success.
Needless to say, CIOs, CMIOs, and other healthcare IT leaders will have to collaborate very intensively with clinician leaders, frontline clinicians, and administrative leaders in their patient care organizations in order to replicate the success of a program like that executed in Michigan. But the possibilities are nearly limitless—and now is absolutely the time for such initiatives to emerge organically out of health system-wide efforts at performance improvement initiatives along all dimensions.
