Wednesday, November 4, 2015

Professional Societies and Stewardship in Health Care

Three imaging specialists from Johns Hopkins published a short but VERY important article - "Medical-Imaging Stewardship in the Accountable Care Era" - in the October 29 issue of the New England Journal of Medicine. (Unfortunately, the article is available free only to subscribers.)

The authors are leaders in imaging at Johns Hopkins. In their eminently practical article, they recommend that hospitals and medical groups designate internal experts to set standards for "appropriate" use of imaging studies. CT, MRI and other technologies are, arguably, the most important diagnostic advances in the last 25 years. When used "appropriately" they are the source of enormous benefit. When used "inappropriately" they are the source of high costs without concomitant benefit, and sometimes cause harm when incidental findings lead to unneeded biopsies or other interventions.

I put the word "appropriate" into quotes because in health management jargon it's used as if it's a statement of fact. In reality, it's a contestable judgment about value. The term, like its cousin "medical necessity," allows the health system and political leaders to pretend that we're just dealing with science, and not making value judgments about interventions and resource allocation.

Many health insurers have turned to radiology benefit management companies to oversee the use of imaging services. When this function is carried out well it applies evidence-based criteria to the ordering process and offers educational services to the clinicians whose orders they are reviewing. However, no matter how well the external review process is conducted, an unavoidable "us versus them" dynamic often emerges. In principle, self-management within a hospital or medical group is a preferable approach. Put simply, if it's good clinical care and "appropriate" resource allocation, we clinicians should be doing it ourselves, and not require external "disciplinarians" to enforce good practice.

What I just said is not a critique of radiology benefit management companies, but, rather, a reflection on a structural dynamic. In growing up, when we start to do the "right thing" on our own rather than depending on our parents to guide us, we're carrying out the same actions but in a more mature manner. That's what we should be doing as clinicians in our medical practices!

In "Medical-Imaging Stewardship in the Accountable Care Era," the authors are illustrating the kind of leadership professional societies and leaders within a profession can provide. Evidence based use of imaging and "appropriate" resource allocation are what we should be doing because it's the right way to provide health care. A true profession doesn't require or want health insurers to take responsibility for these core elements of professionalism.

The medical profession hated managed care when it emerged in the 1980s and 1990s. But if we had been managing ourselves in a clinically and socially responsible manner, external review would not have been needed. We left a vacuum. External entities then filled it.


Peter Brown said...

As usual your commentary is a very good discussion of the importance of establishing a system wide ethnic. It would be good to know whether new physicians see the issues the same way long time physicians do. As a psychiatrist you must be painfully aware of the depth of this issue in behavioral health. Your observations suggest the value of establishing more data driven and evidence based practice. Thanks very much for leading this crucial effort

Anonymous said...

Hi, Jim. Welcome back. You've been sorely missed!

It is very true that the insurance prior authorization system developed because of a failure to keep our own house in order. But at another level, we are all capable of mistakes, not to mention clinical biases that spring from our anecdotal experience. The wise practitioner recognizes this and tries to be aware of personal bias. As a clinical pharmacist, I learned decades ago the gentle art of questioning physicians that seemed to be doing something "inappropriate". My favorite technique is to be an innocent learner and ask them to explain what they are doing, since I'm unfamiliar with the evidentiary basis. If they are correct, I learn something useful; if not, I've given them a way to confess that what they are doing is seat of the pants without losing face. Then we can discuss the patient productively and arrive at the best answer. Either way, someone learns something useful and the patient (hopefully) gets the best possible care.

My point is that we can all use someone checking to be sure we have it right. I've always let my students and technicians know that if they see me doing something that doesn't look right, they should question me, because I could be doing it wrong!

I'm still hoping that the Affordable Care Act will succeed in bringing providers and payers to work more collaboratively, since they will have aligned financial incentives. The best UM (utilization management) is none at all, because providers are getting it right on their own. Like Goldilocks, we have tried the solution that was too big (fee for service) and the one that was too small (strict capitation). Could we just possibly finally get it right?

- John Watkins

Jim Sabin said...

Hi Peter and John
Thank you for your very thoughtful comments.
Peter - my impression from the medical students and residents I meet through teaching is that young physicians are much more attuned to the concept of group practice and collaborative professional responsibility than earlier generations were. They've grown up professionally in an environment that emphasizes the importance of clinical science and evidence. I expect that as they move into their careers they will endorse the perspective of the Johns Hopkins radiologists.
John - I agree completely with the idea that we're all fallible and are fully capable of getting things wrong. You are clearly a master of tact in raising questions with prescribers. In a well-functioning group practice, in addition to the ease of asking for help when we're not sure what to do, the group will develop its own approaches to education. When clozapine was first available and my colleagues and I were getting the hang of when to use it and how to use it safely, we designated a member of our group to develop expertise and act as a coach and "checker" for the rest of us.
The longstanding tradition of physician autonomy can, however, be a barrier to this kind of collegial exchange. Physicians could benefit from your tactful but direct way of raising questions.
I believe the ACA adds to the momentum towards the kind of clinical standard setting and collegial self management that should be a reliable component of professionalism.

Unknown said...


Great to see you back, even if it’s just online.

I’m with you about the need for management processes, but I think it’s important to distinguish when management is applied to “clinical” practices and when it’s applied to resource allocation. The two are often conflated, and sometimes on purpose to obscure allocation decisions, that is, a clinical objective is given to justify an allocation decision, and alas, becoming a palimpsest at best, a ruse at worst.

This scenario manifests vividly in prior authorization for certain drugs. Payers establish limits to coverage for certain drugs that can only be adjudicated accurately through prior authorization processes because ordinary electronic claims transactions cannot accommodate all the information needed. As you know, these limits can be entirely reasonable but still never welcome and thereby often generating unhappiness. In the payers’ (and administrators’) natural reflex to avoid conflict, they will cop to a clinical reason for the coverage denial rather than explaining how the request is outside the scope of the health plan (and thus asking others in the plan to pay for something they didn’t sign up to pay for).

The ruse is often easily discerned by either the line of inquiry taken to determine coverage or by the list of drugs in the program. In all my years managing the clinical elements of these programs at Medco, the extent of questioning for coverage rarely went to the level required to make clinical judgments. I also never saw a payer implement prior authorization requirements for inexpensive generic drugs that are among the most dangerous in clinical use, like digoxin, warfarin, insulin, cyclosporine and others. If coverage management programs are really about managing the clinical use of drugs, then why aren’t inexpensive but dangerous drugs included? Also, how is it that a payer or administrator can have all the information necessary to assess a particular clinical situation if the decision is based on clinical dimensions? Getting a few answers over the phone, fax, EHR is not the same as a full medical record, patient interview, family input and all that clinicians need to make these judgments. Why should a prescriber accept a clinical assessment from a payer/administrator with a very patchy set of information and no personal knowledge of the patient (not to mention the requisite clinical expertise)?

But, even if the payer/administrator has adequate information to make a clinical assessment and the issue becomes a disagreement on grounds of clinical “appropriateness” (the A-word), the payer/administrator has an unfair advantage of holding coverage over the head of the prescriber. The payer/administrator can coerce the prescriber with the threat of coverage. That ain’t right, and surely not clinical.

I should hasten to add that integrated health systems and other forms of risk-bearing providers can combine clinical assessment and allocation policy because they are formed jointly and with the input of prescribers who will be affected by them. This is more the exception than the rule, however. Insurance carriers and administrators should stop hiding their allocation decisions behind clinical assessment functions. Leave those to well established organizational processes and accreditation agencies. It’s hard to say no, but it should be harder to deceive.

Russell Teagarden

Jim Sabin said...

Hi Russell
Thank you for your very thoughtful comment. It's always great to hear from you! I appreciate all I've learned from you over the years.
Twenty five years ago Kevin Grumbach & Thomas Bodenheimer published "Reins or Fences: A Physician's View of Cost-Containment" (available free at: They argued that the right way to control costs was to have physicians manage the practice of medicine within a budget ("fences") rather than monitoring and controlling them through external utilization review ("reins"). You add the sad fact of duplicity, which I've seen in mental health utilization review much as you have in pharmaceutical utilization review. As you point out, we often dress the financial limit as a clinical judgment to avoid open discussion of what a health system should cover, given resource constraints.
I hope I'm right in believing that we're moving towards "integrated health systems and other forms of risk-bearing providers." It's in systems of that kind that the excellent guidance of the article I wrote about can best be implemented.