During the nearly 20 years I practiced as a thoracic surgeon, medical technology and its costs spiraled exponentially. With the growing influence of insurance companies as third-party payers, most physicians have become familiar with the often opaque requirements which accompany requests for expensive imaging studies now used routinely, such as MRI and CT. During a recent attack of recurrent kidney stones, I encountered first-hand how this situation can negatively impact the patient. Even given my intimate knowledge of the inner workings of today’s healthcare system, I was surprised and ultimately frustrated with the myriad problems patients routinely encounter in seeking care.
My experience began as many do when I was forced by circumstance to seek treatment at a local hospital. My condition presented no medical mystery to me; in my judgement, given my classic presentation and well-documented previous history, a simple urinalysis revealing microscopic hematuria demonstrated that recurrent kidney stones was the most likely diagnosis. I felt the treatment pathway was quite clear. Had this not occurred in the middle of the night during a Maine snowstorm, I likely would have gone to my office and asked one of my colleagues to insert an IV for hydration and administer appropriate IV pain medication, an option now available to any layperson given the increasing prevalence of urgent care clinics.
The ER doctor on duty that night, however, reflexively ordered a CT scan. Despite my informed insistence that a CT scan was not of immediate value, as I already had been imaged twice in the previous five years, the treating ER physician acted in a highly paternalistic manner, and made obtaining a CT scan a pre-condition to receiving appropriate pain medication. My right to patient autonomy and informed consent was seemingly brushed aside, as was any discussion of how much such imaging would cost and any consideration of whether other options were viable.
Anyone who has endured the agony of an acute kidney stone attack can understand why I chose to simply acquiesce. Upon receiving the bills for my care over the next several weeks, I was shocked to find that my treatment amounted to $4,600 in charges, or $10 for every minute I was in the ER. For some perspective, the Medicare-allowed reimbursement for a lobectomy to treat lung cancer, which requires about 3 hours of operative time (bundled with 90 days of postoperative care), is about 35 percent of that total. For more perspective, the total cost of the essential elements for treatment in my former clinic would have been a couple of hundred dollars.
An itemized bill revealed that the CT scan represented just about half of the total charges: $1,840 for the scan and $370 for interpretation. Since I was still within my deductible, payment for these services would come directly from my health savings account. An Internet search revealed an abdominal CT scan without contrast would cost between $300-$400 at any of a number of local private imaging centers.
Two questions came to mind:
- What resources are available to a non-radiologist physician when attempting to discern the most appropriate high-quality, cost-effective imaging modality, or even whether imaging is needed at all?
- Would the ability to consult with a radiologist about the cost or appropriateness of imaging have changed the course of my treatment?
When I trained in surgery at New York University (NYU), CT scanning and MRIs were in their infancy. The radiology department prioritized the importance of making a qualified radiologist available 24/7 to surgical residents. Now that these formerly novel modalities are ubiquitous, and patients increasingly are responsible for larger portions of their healthcare charges, perhaps the radiology community at large should take a fresh look at ways to assist both referring clinicians and patients alike in determining how imaging modalities can and should be utilized — much the same way the radiologists at NYU did for us residents.
One straightforward solution would be to revive the concept of a radiology consultation service. Radiologists of all stripes can provide immense value apart from their ability to read images, both by educating colleagues and patients about imaging appropriateness, and by applying experience and judgement to helping form individualized care plans for patients. Such availability would not only further empower patients to actively participate in their healthcare decisions, but would create an essential safeguard to quality and cost-efficiency.
Offering such consultation would surely disrupt the current paradigm of how radiologists structure their workflow. But as technology evolves and costs spiral, a radiologist would not only help patients sort through their treatment options, but also help the larger system become more efficient and transparent.
Informed consent is a fundamental principle in medicine. In an age when medical costs are a leading cause of personal bankruptcy even amongst those who are insured, it is as critically important to inform patients about economic liability as it is to discuss medical risks. A radiology consultation service could provide an important benefit to patients and colleagues, and simultaneously help ensure quality.
Here are some resources to help radiologists advocate playing a consulting role in patient quality and cost conversations.