Reform's Caveat Emptor

In 2009, we find ourselves in more than just another new year. A new presidential administration is about to take office, bringing with it a clean sweep of the various government bureau heads and cabinet secretaries who have been in charge of the levers of power for these past eight years. Along with the freshness, optimism, and hope that a new president brings, we are going to see, very shortly, just how the Obama administration will confront the incredible list of problems and opportunities that are stacked and awaiting the new president on his Oval Office desk. Reality is likely to bite all of us a little. Among these challenges will be a major effort to move reforming the nation’s health system to the very top of the president’s agenda. One need look no further than the appointment of former Senate majority leader Tom Daschle as incoming HHS secretary to find clues about how this reform strategy will play out; indeed, Daschle has given some rather specific hints about what he thinks the problems are with our health care system, and what should be done to correct these. Imaging providers, beware: You remain in the reimbursement and regulatory crosshairs. When I learned of Daschle’s appointment, I thought it best to investigate his health care views in preparation for the discussions that I have with the imaging providers, radiologists, and hospital executives with whom I regularly come in contact. When asked what I see on the horizon for medical imaging, I always like to be prepared with information culled from as many direct sources as possible. In this case, the preparation wasn’t hard at all, as Daschle published a well-publicized book in 2008: Critical: What We Can Do About the Health-Care Crisis (Thomas Dunne Books). In it, one can find the likely legislative and regulatory road map for the next few years. From the opening pages, it is clear that this book is a treatise on what Daschle would do with the health care system, were he given the opportunity to reform it. It is not surprising at all, therefore, that he was the first choice for HHS secretary, especially since the promotional cover blurb is from then-Sen Obama. The book is extremely revealing about what are likely to be the incoming administration’s attitudes about how our country will pay for and provide health care. Some of the ideas are obvious, some innovative; others reveal a bit of contempt for those making money off of the system. A few of these points are downright worrisome. Here are a few excerpts that are likely to raise eyebrows among my friends and colleagues in our profession: “Every player in our health care system is intent on shifting costs rather than reducing them. . . . In many American communities hospitals are engaged in a technology arms race, competing to attract aging baby boomers with the latest diagnostic imaging machines. PET and CT scans can help doctors estimate the spread of cancer or the extent of cardiac disease without surgery or invasive procedures. But according to National Imaging Associates, a New Jersey firm that handles radiological benefits for health plans in 30 states, about a third of the advanced imaging tests that doctors order are unnecessary. PET scanners can cost up to $3 million each to install, but they are a good investment because they bring in high payments from Medicare and private insurers. A single scan can cost as much as $3,000. Medicare has pumped up demand by increasing the number of approved uses for the machines. Between 2000 and 2005, it expanded the number of diagnostic tests for cancer that require PET scanners from 3 to 23.” Wow. It looks as though it’s all about providers making money from PET and MRI in his mind. One person’s demand-creation model is another person’s lifesaving scan (especially if you are the one with the disease that was not previously covered). There are several other examples in the book about what the author sees as a money-driven profession, especially in one chapter where he provides a glimpse of a surgical conference that is “as much trade show as teaching conference,” where drug companies “spent millions wooing doctors, plying them with fancy dinners and rewarding them with bonuses when they prescribe their products . . .” My view is that since his primary source for his story of medical imaging is coming exclusively from a prominent radiology benefit management company, it is high time that providers and other stakeholders, associations, and professional groups get the full story to the incoming HHS secretary. CMS has continued to expand the list of disease conditions for which PET is reimbursed primarily because the clinical case for its efficacy has been made. This should not be seen only through the lens of pumping up new demand, and therefore new revenue streams. A bright spot in the book is Daschle’s emphasis on the opportunity to invest further in health care IT. It is clear that PACS, RIS, and other informatics-infrastructure investments have created platforms upon which our complex health care system can be streamlined and made more productive, and which can link patients, payors, and providers in a model that can build a true 21st-century system. Indeed, Daschle cites a landmark report issued by the Institute of Medicine in 2001 as a reason that we must continue robust investment in the IT sector: “Health care delivery has been relatively untouched by the revolution in information technology that has been transforming nearly every other aspect of society.” The report indicates, “The meticulous collection of personal health information throughout a patient’s life can be one of the most important inputs to the provision of care. Yet for most individuals that information is disbursed in a collection of paper records that are poorly organized and often illegible, and frequently cannot be retrieved in a timely fashion . . .” Other thought leaders such as Mark McClellan, MD, former CMS secretary, concur with this view and underscore the need for interconnectivity among the nation’s health providers as a mandate for change that will succeed. He and others have applauded medical imaging as one profession that has led the way toward true interconnectivity and electronic health records through the industry’s investment in and focus on teleradiology, PACS, and other digital modalities, systems, and services. Imaging informatics promises to be a continuing catalyst for positive change and a beacon for imaging providers in their quest for winning solutions. 2009 is going to be a very interesting year for all of us.