Diagnostic Imaging Requests by Mid-Level Providers: Challenges and Opportunities
The second installment of the Radiology Firing Line podcast debate series tackles another thought-provoking topic.
In the name of addressing the cost and access components of the elusive health care trifecta (low cost, high quality, and fast access on demand), more clinical care is being shifted to mid-level providers. This shift brings with it a host of questions. What are the opportunity costs of substituting mid-level providers for physicians? What is the impact on imaging services and radiologists? Has the overall cost of an episode of care changed, or are savings from lower-cost providers offset by increased utilization of other health care services such as imaging?
A 2012 report brief from the ACR's Harvey L. Neiman Health Policy Institute (HPI) indicated the medical image growth boom is over. "Data from a variety of sources reveal a dramatic and sustained slowing—and now a decline—in both [medical imaging] utilization and spending. The outcomes and cost implications on individual patients and the health care delivery system at large are not yet known," according to researchers. The report cited multiple factors for the end of the boom, such as payment reductions for Medicare beneficiary imaging services, the rise of radiology benefit managers, the introduction of real-time clinical decision support systems, and greater radiation safety awareness among patients and ordering providers.
Another HPI study published earlier this year demonstrated that mid-level providers order more diagnostic tests after comparable office visits than primary care physicians according to a 5 percent sample of 2010–2011 Medicare beneficiary claims, but only by a modest 0.3 percent. Interestingly, this effect reflects a difference in ordering studies for new patients and for ordering radiographs but not for advanced imaging studies.
The authors concluded the slight increase "may have ramifications on care and overall cost at the population level." But they also believe that clinical decision support software tools may help bring mid-level order patterns more in line with those of physicians. The study found that "clinical decision support has demonstrated a decrease in imaging procedure growth" among all providers.
Radiologists may also have concerns based on their own recent experiences. Some worry mid-levels may not only be ordering more diagnostic imaging examinations than their physician counterparts but, perhaps more importantly, are more likely to order a test when not indicated or order the wrong test.
If mid-level providers have less education and training and are less confident, they may have an over-reliance on clinical algorithms as a substitute for critical analysis and evidence-based decision-making. The flip side of this is the notion that mid-level providers with many years of health care experience may have greater knowledge and judgment than medical residents or newly minted attending physicians when it comes to requesting the right imaging test at the right time.
Some may see opportunities here for radiologists to serve in the dual roles of consultant and gatekeeper, intervening before or after test is ordered. This may be great for demonstrating our value as good stewards of resource utilization, but how much time can or should be devoted to this service versus other equally compelling demands?
So join the Radiology Firing Line team regulars Saurabh Jha, MBBS, C. Matthew Hawkins, MD, and Colin Segovis, MD, PhD, and their guest debaters, private practice neuroradiologist David Nussbaum, MD, and University of Pennsylvania and radiology resident Shuai Wan, MD, as they share their perspectives on these and other questions surrounding the impact of mid-level provider ordering habits on radiologists.
Now it's your turn to chime in. How do we factor in mid-level providers who are actually members of radiology teams? Do our relationships with mid-level providers in our own professional sphere color our view of mid-levels in other domains? Do we view primary care mid-level providers differently than mid-levels who are part of specialty teams?
Read More in the JACR