As we continue to focus on the cost of healthcare and delivering value, there has been an ongoing interest in ordering ambulatory testing, especially regarding musculoskeletal complaints. What is driving this cost, is the volume of tests ordered and the unit price of those tests. Undoubtedly, it’s worth spending time discussing the degree of pricing; however, it is also prudent to focus on the utilization component.
In our training as clinicians, currently, there isn’t a shared “gold” standard regarding when to order musculoskeletal diagnostic imaging for patient complaints. Nor is there consistency regarding who should be requesting the tests, whether it is the primary care physician or the specialist after receiving a referral. Throughout the years, our professional societies have made numerous attempts to set guidelines and unfortunately no meaningful change has occurred.
One approach that could help improve the system is the model of audit and feedback. This method asks, “How am I doing compared to my peers, concerning ordering tests for a set of diagnoses? And how am I different from that?” A recent study in the Journal of the American Medical Association for O’Connor et al. analyzed research conducted in Australia and discovered that such auditing and feedback significantly decreased the rate of targeted musculoskeletal imaging tests ordered over 12 months compared to a control group.
The intervention was a letter that stated the variation and shared the information needed that might improve outcomes. Furthermore, this letter originated from the country’s Chief Medical Officer, consequently highlighting an interesting dynamic. Does it matter who the sender is who shares the information? Here in the United States, we usually obtain similar information from the insurance companies on the lives they manage, which also creates an interesting scenario. For instance, we do not know if this is just for cost-cutting measures, a sample size problem, or if the information provided is genuinely in the clinical best interest of those the clinician serves versus the financial interests of the payer. And though they will provide guidelines, our medical societies do not seek to be the enforcers.
If we genuinely seek to drive our destiny as clinicians, we must take ownership of monitoring ourselves. As healthcare professionals, we are obligated to assist each other in improving and adjusting for the betterment of all, including improving costs. If we do not worry about the affordability of what we deliver to those we serve, we are causing more harm, both financially and to their care, since it can drive people to make unfortunate choices.
Let’s take the lead and work with each other, including steering our peers toward better decisions. No doubt we can do so; the question is, do we have the stomach? Clinically Integrated Networks have taken on this role and have made a meaningful change. However, not all clinicians are part of such networks, and not all networks have the data to share. It may be prudent to consider stepping back. Let’s stop focusing on shiny objects such as artificial intelligence and instead, concentrate on the areas that are easier to accomplish – creating clearinghouses of information to share with our professional societies, who have the ability to influence us in a more meaningful way. Unquestionably, we do listen to our peers and are naturally highly competitive. Let us capitalize on those facts in a manner that benefits all.