AJR: Rads at mercy of external forces
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| Image source: Cedars-Sinai Medical Center |
Eight major forces, many of them external to radiology and all of them interrelated, hurl radiology into "a situation that is unique to our history," offers the article's author, Eugene Lin, MD, of the department of radiology at Virginia Mason Medical Center in Seattle. These driving factors include utilization and cost, value and quality, innovation, self-referral, specialization, commoditization, competition and corporatization.
With Medicare spending on imaging more than doubling between 2000 and 2006, Lin echoed most in the field in calling this ongoing trend unsustainable. But Lin proposes the possibility, admittedly an unproven one, that defensive imaging has brought about improved patient outcomes. As the bulk of the U.S. population ages, the government and payors will likely deploy significantly tighter measures to cut reimbursements and drive down the growth of imaging.
Pointing to the Centers for Medicare & Medicaid Service's (CMS) recent denial for CT colonography reimbursement, Lin predicted that the already high bar that new imaging devices must surpass for approval will climb even higher. One reason for this is that "[w]e have a plethora of technology and applications, much of which has been fully integrated into patient care, but these tools are expensive and have typically been used in the absence of rigorous proof of value," argued Lin.
With reimbursements for high-end imaging dropping steadily or exponentially and many imaging technologies reaching a high level of diminished returns, Lin projected the implementation of substantially fewer imaging advancements into radiology. In his opinion, this deflated innovation will hamper the improvements to patient care experienced across many medical fields of late.
In disagreement with many in the field, Lin believes that self-referral will present only a minor issue to radiology in coming years. For one, increasing imaging standards will curb the practice by clinicians and likely promote the need for specialized reading by subspecialty radiologists.
"Commoditization may be the most commonly cited threat to our profession," Lin wrote. "However, the interesting question is not whether radiology is a commodity but rather, what factors will facilitate the process of commoditization." In Lin's view, the development of teleradiology will dominate the commoditization trajectory. Teleradiology bodes well for commoditization in that it strips facilities of their geographic monopoly and doctor-patient relations. Slowed innovation and payors looking to slash costs will also support generic practice, while growing competition and corporatization all point in the direction of a commoditized field.
Aside from supposed hindrances to self-referral and competition-driven specialization, about the only tool radiologists have left is standards for quality and value. Although Lin believes higher standards may drive down self-referral and demonstrate the clinical value of imaging, the standards are by no means a panacea
"The most important question is how these forces will affect our patients," Lin emphasized. Control over utilization and costs will likely have downsides for patients, but if radiologists can strengthen the standards and implementation of quality and value, the effects of these trends on patient outcomes could be mitigated or even overshadowed.
"It seems customary in articles of this type to conclude with a statement to the effect that our individual and collective efforts can play a major role in shaping our future," finished Lin. "However, many of the forces shaping the future of our profession reflect broad societal interests and are to a large extent outside our control."