NeuroNews

Healthcare Reform and MRI

  

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The following comment originally appeared in the The Annals of Neurology in the comments section from an article titled "NEUROIMAGING TURF BATTLES FLARE".

The neuroimaging turf battle between neurologists and radiologists is typical of the turf battles between other disciplines.  These battles are fostered by the hospital systems we have in America, and the desire of these systems to dominate the health care landscape.  The irony is that most health care is, and should be, delivered to outpatients to prevent hospitalization.  Hospitals should have little to do with most health care in America.

Turf battles, fostered by our hospital system, almost guarantee that the significance of important and elegant diagnostic testing, as well as new procedures, will be lost in the smoke and mirrors of politics.  Witness what is happening to MRI.  The issue has become one of cost and not of quality, one of accounting and politics, and not one of patient care. 

As a physician taking care of patients, the critical factors important to me in the consideration of any testing, like MRI, are the following:

1.  The appropriateness of the test ordered in any particular patient

2.  The quality of test performance

3.  The quality of the interpretation of the test results

4.  The translation of those results for quality care of the patient.

Our current environment almost guarantees that MRI, the most elegant and important diagnostic advance in neurology since neurology's inception, will be inappropriately ordered, inadequately performed, inadequately interpreted, and inadequately translated to patient care. 

By way of background, when the federal government became involved in health care with Medicare and Medicaid, it became obvious to business interests that the business of medicine was far too big and financially rewarding to be left in the hands of doctors, nurses, and patients.  Hospitals and hospital systems were overbuilt, and their economic engines had to be fed. 

New diagnostic testing and treatment procedures became profit centers instead of advances in patient care.  Men and women who had never taken care of patients in their lives became the spreadsheet guru managers of medicine.  And because they were able to speak the language of business to bureaucrats, their loud financial voices were heard in the halls of congress, and amplified by their lobbyists and political patrons.

Because these hospitals and hospital systems need to have physicians to carry out their business, they developed alliances with certain groups of physicians and disciplines who were dependent on them, and favored these groups with their blessings.  Like a new imaging toy for the radiologist group who could guarantee they would use hospital facilities, or a new surgical toy for surgeons who would shun the freedom and improved quality of outpatient surgical centers in favor of hospital based operations.  

These hospitals, which have driven up the cost of care to astronomical levels, still charge far more than outpatient centers for imaging through facility fees, and receive large sums from governmental subsidies for their "losses".  They are buying up general practices to guarantee that their bloated budgets, which amazingly still contain building line items, can still be balanced.

It is in this tension between the business side of medicine, and the patient care side of medicine, that turf battles really find their germination and grow. 

So, in the case of MRI, we have a situation where:

1.  Any provider (family practitioner, internist, nurse practitioner, or physician's assistant) can order an MRI (sometimes of the appropriate body part, sometimes not) though these providers have no training in performance of the MRI or in the interpretation of the study.  These providers do not know when to order contrast with the MRI, cannot judge the true quality of the exam, and have no way of knowing what the interpretation means. 

2.  The programs run on the MRI are usually off-the-shelf programs, and the decisions about which programs to run on any particular patient are usually made by general radiologists on hospital staffs who know very little neuroanatomy and less about MRI physics.    

3.  Dr. Atlas (a renowned neuroradiologist and expert in MRI imaging of the nervous system) makes a clear and compelling point that there are not nearly enough neuroradiologists to interpret the MRI scans of the nervous system already being done, and that there is no way a general radiologist, with little training in MRI of the nervous system, can compete with someone who deals with the clinical anatomy of the nervous system day in and day out. 

4.  Lastly, an MRI exam of any part of the nervous system always has to be interpreted further by a clinician caring for the patient.  In our current environment, we can only hope that this clinician actually looks at the MRI and knows how to interpret the MRI for him or herself. 

If we really want to curb imaging costs, we need to take profit for imaging out of the hands of hospitals and hospital systems, require that any ordering provider be at least a specialist in the area being imaged, and require that interpretation only be carried out by those trained or certified in neuroimaging subspecialties.  Then, and only then, can costs for neuroimaging be appropriately controlled, while maintaining quality patient care. Hospitals need to be paid for the important work they do, but need to stay out of most of the health care delivered in America.

Vernon Rowe, M.D.

Fellow, American Academy of Neurology

Certified, UCNS, in Neuroimaging

Diplomate, American Board of Sleep Medicine