Addressing the Clinical Question

Marti L. McCulloch, BS, MBA, RDCS, FASE
How do you respond when someone asks you what you do for a living? A typical response is generally along the lines of “perform sonograms of the heart,” but the truth of the matter is that we do so much more than basic image acquisition. As cardiovascular sonographers, we investigate the heart and vessels based on the indication provided; we abstract the patient’s history and obtain vital signs— all in effort to present the interpreting physician with a comprehensive story so he may effectively answer the clinical question. Knowing why the exam is performed is crucial to getting an accurate answer and essentially characterizes quality and efficient care.

Obviously, in an altruistic world, all diagnostic studies would address the patient’s need for the exam, yet there are far too many tests (not necessarily cardiovascular ultrasound) interpreted as “cannot rule out, would recommend another test.” Non-diagnostic studies are both ineffective and inefficient and are most likely perpetuated by the fact that non-diagnostic, 5 minute studies performed on 15-year-old equipment are reimbursed the exact same amount as clinically diagnostic, 50 minute studies performed on state-of-the-art equipment. The financial incentive to improve the diagnostic accuracy is not present in the current environment. Things may change, however; for instance, the Centers for Medicare & Medicaid Services (CMS) have stopped paying for several hospital acquired conditions such as air embolism and catheter-associated urinary tract infections (UTIs) and plan to add more to the list. As a result, hospital quality has improved, with a reduction in the number of embolisms and UTIs, because there was a financial disincentive. This algorithm could work similarly for diagnostic testing.

Reimbursement for a non-diagnostic test has always seemed a bit unfair and doesn’t necessarily work outside of health care. It would be like going to a restaurant, ordering the special and paying for it but not actually getting any food (suppose the cook didn’t have the special ingredients), then needing to go to another restaurant to order and pay for another dinner. The fact that nobody would accept paying for something and not receiving a tangible item is a given, but the cost related to an additional purchase rapidly becomes expensive. Take the downstream effects of clinically irrelevant tests, which are costly, and more importantly, can negatively impact patient care. Kurt et al. illustrated the economic significance of additional diagnostics tests (TEE or nuclear) to be approximately $77k within a 5 month period for non-diagnostic echocardiograms. Keep in mind that the study only took into account the financial impact of additional studies using 2008 Medicare reimbursement rates. Additionally, Kurt et al. noted important changes in patient medical management based on the quality of the exam that included the addition or cessation of hemodynamically active drugs and/or anticoagulation. The Kurt study put the patient into perspective with respect to performing a diagnostic exam as opposed to a sub optimal exam, which implies that the performance and interpretation of the test directly impacts patient management.

Sonographers have constantly struggled to balance quantity and quality. Keeping true to quality and always addressing the clinical question is challenging, especially with the threat of shrinking reimbursement. However, if the echocardiogram doesn’t answer the clinical question, then the answer will come from the competition (cardiac CT, nuclear cardiology, and cardiac MRI), as it does an excellent job in imaging and would gladly accept an increase in volume from cardiovascular ultrasound.

Although the threat of alternative imaging is real, the future reimbursement landscape presents a greater opportunity to the field of cardiovascular ultrasound because of the cost relative to other cardiovascular imaging. Last November, there was a University HealthSystem Consortium (UHC) Webinar in which Richard Wild, MD, JD, MBA, FACEP, the Chief Medical Officer of CMS, gave a presentation entitled “ CMS Value-Based Purchasing Initiatives ” (future direction for reimbursement). Dr. Wild stated that value-based purchasing had replaced pay-for-performance, and that there would eventually be DRGs for outpatients. In the long run both inpatient and outpatient DRGs would be replaced by an episode of care payment (shared payment between office and hospital). With an outpatient DRG and/or a single episode of care payment, the natural progression would be to order the most cost effective and accurate exam. Cardiovascular ultrasound has an opportunity to be the leader, but only if quality persists and the clinical questions are answered.

With this in mind, it is important to remember the reason the ASE was established in 1975, which was to pursue excellence in the ultrasonic examination of the heart. The pursuit of excellence must be continued in the best interest of the patient, regardless of reimbursement. Therefore sonographers and echocardiographers need to be diligent in utilizing all of the tools in our toolbox, such as contrast and novel technology, including tissue Doppler, strain/strain rate, and 3D imaging.

Thank you to Robert Davis, Peg Knoll and David Adams for their input and advice.

Please visit the ASE Website to read about David B. Adams, our sonographer volunteer of the month.

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Jun 16, 2018 | Posted by in CARDIOLOGY | Comments Off on Addressing the Clinical Question

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