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From Gatekeeper to Steward: The Evolving Concept of Radiologist Accountability for Imaging Utilization

2015; Elsevier BV; Volume: 12; Issue: 12 Linguagem: Inglês

10.1016/j.jacr.2015.06.031

1558-349X

Daniel J. Durand, Geraldine McGinty, Richard Duszak,

Medical Malpractice and Liability Issues

As the US health care system transitions away from fee-for-service toward value-based payments, specialty thought leaders have challenged radiologists to assume accountability for imaging appropriateness [1Levin D.C. The 2014 RSNA Annual Oration in Diagnostic Radiology: Transitioning from volume-based to value-based practice—a meaningful goal for all radiologists or a meaningless platitude?.Radiology. 2015; 275: 314-320Crossref PubMed Scopus (14) Google Scholar, 2Jha S. From imaging gatekeeper to service provider—a transatlantic journey.N Engl J Med. 2013; 369: 5-7Crossref PubMed Scopus (19) Google Scholar, 3Allen Jr., B. Levin D.C. Brant-Zawadzki M. Lexa F.J. Duszak Jr., R. ACR white paper: strategies for radiologists in the era of health care reform and accountable care organizations: a report from the ACR Future Trends Committee.J Am Coll Radiol. 2011; 8: 309-317Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar]. Helping radiologists transition from a role perceived as limited to interpretation, however, will require more-effective strategies to improve the ordering behavior of referring physicians. To accomplish this goal, a variety of models exist. As radiologists collectively emerge from their PACS-induced exile to re-engage their clinical colleagues with renewed vigor, they will find that much has changed since their old analog days. One particularly relevant development is the growing movement within medical ethics toward the concept of “stewardship” [4Saltman R.B. Ferroussier-Davis O. The concept of stewardship in health policy.Bull World Health Org. 2000; 78: 732-739PubMed Google Scholar, 5Kapoor N. Kumar D. Thakur N. Core attributes of stewardship; foundation of sound health system.Int J Health Policy Manag. 2014; 3: 5Crossref Scopus (7) Google Scholar, 6Coggon J. What help is a steward? Stewardship, political theory, and public health law and ethics.N Ireland Legal Q. 2011; 62: 599PubMed Google Scholar]. The affiliated—but distinctly different—concept of “gatekeeping,” on the other hand, has become highly stigmatized [7Grumbach K. Selby J.V. Damberg C. et al.Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists.JAMA. 1999; 282: 261-266Crossref PubMed Scopus (252) Google Scholar, 8Dawber C. “Gatekeeper versus concierge: reworking the complexities of acute mental health care through metaphor.Social Alternat. 2014; 33: 53Google Scholar, 9Fang H. Hong L. Rizzo J.A. Has the use of physician gatekeepers declined among HMOs? Evidence from the United States.Inter J Health Care Finan Econ. 2009; 9: 183-195Crossref PubMed Scopus (10) Google Scholar]. This opinion piece is intended to help explain the difference between these two terms and to encourage the radiology community to embrace the concept of imaging stewardship in both word and deed. The word “steward” is Old English for “ward of the house” [10Saner M. Wilson J. Stewardship, good governance and ethics.Institute On Governance Policy Brief. 2003; : 19Google Scholar]. The first stewards were educated servants who helped the landed gentry make the best use of their resources. Because the lord was too busy with other pursuits and lacked logistic expertise, the steward had de facto control of day-to-day household operations. Over time, “steward” became a general term for one who manages or looks after another’s property, and eventually the concept of stewardship evolved into a system of moral reasoning describing the prudent management of commonly held resources [11Davis J.H. Schoorman F.D. Donaldson L. Toward a stewardship theory of management.Acad Manag Rev. 1997; 22: 20-47Google Scholar]. Over the past 20 years, stewardship has been incorporated increasingly into medical ethics and professionalism. Although the term has gained use by other specialties (eg, in the allotment of organs for transplantation [12Poggio E.D. Braun W.E. Davis C. The science of stewardship: due diligence for kidney donors and kidney function in living kidney donation—evaluation, determinants, and implications for outcomes.Clin J Am Soc Nephrol. 2009; 4: 1677-1684Crossref PubMed Scopus (36) Google Scholar]), the most prevalent example is that of antimicrobial stewardship [13McGowan Jr., J.E. Gerding D.N. Does antibiotic restriction prevent resistance?.New Horizons. 1996; 4: 370-376PubMed Google Scholar]. More recently, the Choosing Wisely campaign originally began as a smaller initiative called “The Good Stewardship Project” [14Good Stewardship Working GroupThe“ top 5” lists in primary care: meeting the responsibility of professionalism.Archiv Intern Med. 2011; 171: 1385Crossref PubMed Scopus (169) Google Scholar]. The word “gate” dates to the thirteenth century and is thought to have originated from the Norse gata for “road,” although the concept of a “gate” is clearly far older still. Simply stated, gatekeepers decided who got inside and who stayed outside of the city walls. In the context of health care, the term “gatekeeper” was most famously applied to the role of primary care physicians (PCPs) in health maintenance organizations (HMOs) [7Grumbach K. Selby J.V. Damberg C. et al.Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists.JAMA. 1999; 282: 261-266Crossref PubMed Scopus (252) Google Scholar]. In its purest form, the “gatekeeper model” dictates that a patient will receive coverage only for nonurgent specialist services after obtaining a PCP referral. Like the acronym “HMO,” the term “gatekeeper” was especially prevalent during the rhetoric-laden legislative battles over healthcare reform in the early 1990s. More than a decade later, “gatekeeper” was one of several terms to re-emerge as near-epithets during the contentious passage of the Affordable Care Act. Apart from their political associations, it is important to understand why these two concepts are fundamentally different. By considering the themes inherent in each metaphor, we can identify several reasons why radiologists who model themselves after stewards are likely to have more long-term success than those who adopt a gatekeeper mentality. The most important distinction between the two terms lies in their different degree of alignment with other key stakeholders. Stewards are on the same team as those whose resources they manage. They work for and with others within their respective communities to ensure a mutually beneficial outcome. Gatekeepers, on the other hand, are most important during times of war and conflict. Their decisions inherently result in winners and losers. Given that health care is increasingly recognized as a “team sport,” adopting the steward’s spirit of collaboration seems a far better strategy. Stewards assure the highest possible quality of life and services for all members of the household, making sure that everyone lives as well as they can within the means of the group. Gatekeepers are sentinels tasked with guarding against specific rare events with potentially disastrous consequences (eg, plague victims entering the city). Stewards are focused on consistently ensuring the best outcomes, while gatekeepers are inordinately focused on avoiding catastrophe. Although both are important, the task of engaging referring physicians on issues of appropriateness is more akin to quality assurance than disaster avoidance. The authority of a steward derives from her expertise and knowledge, not from any innate privilege or sense of absolute power. The only way a steward can ensure her desired outcome is to consistently win over the hearts and minds of key stakeholders with her skillset, securing the trust of the community. Gatekeepers, on the other hand, have the power to open and close the gate at will and hold nearly absolute authority in each transaction. Given the highly matrixed organizational environment of most health care systems, the ability to be persuasive in the delivery of one’s expertise is arguably the most valuable skill a utilization manager can possess. Those who think of themselves as stewards will pride themselves on their ability to not only ensure the “right test at the right time for the right patient,” but to achieve this outcome in a manner that leaves their relationship with the referring physician stronger each time. A similar but distinct concept relates to the manner in which the radiologist determines what she thinks is the right test initially. Appropriateness Criteria and the like are valuable tools, but they are only guidelines. What distinguishes local radiologist stewards from imaging gatekeepers (eg, the nonradiologists who handle the phones at most radiology benefit management [RBM] firms) is that practicing radiologists have a deeper level of imaging expertise and a better understanding of the local care model that allows them to determine both when society guidelines are appropriate and when deviations are necessary. In an era with so many options for imaging, the metaphor of a steward as an intellectual worker and one who can propose many potential solutions to a problem seems highly preferable to that of the gatekeeper, who simply makes the binary decision of whether or not to lift the gate. Stewards are a central part of the estate or community and cannot be effective in their role unless they are well connected and well informed about household affairs. Gatekeepers reside in a fortified tower removed from the fray. Although this might be a minor point for other disciplines within medicine, any metaphor linked to remoteness is especially dangerous to radiologists. Many physician colleagues already consider radiologists as separate from “real doctors” due to perceptions of easier schedules, higher incomes, lack of direct contact with patients and other providers, and freedom from middle-of-the-night calls from distressed patients and their families. By casting themselves as stewards of imaging, radiologists can signal their desire to become better integrated into the medical community. In a closely related point, it is important to note that stewards were generally servants of those whose resources they managed. Gatekeepers are servants as well, but they serve a community of privilege inside the gate rather than the stakeholder outside the gate whose fate they will decide. One can decry the aforementioned perceptions of radiologists as highly paid shift workers as untrue, but acting as a steward—a servant of the patient and the care team—is a far more powerful way to undermine this fallacy and reshape these perceptions than simply debating them. In fact, many of the world’s most successful (and powerful) leaders have subscribed to this notion of servant leadership [15Greenleaf R.K. Servant leadership: a journey into the nature of legitimate power and greatness. Paulist Press, New York2002Google Scholar]. Stewards must live in the estate they manage. If the holiday feast is too big and everyone goes hungry by the end of the winter, they must endure hunger with everyone else, in addition to the long stares of their housemates. Gatekeepers, on the other hand, are beneficiaries of a physical boundary that reinforces an asymmetric power structure. They are faceless and unaccountable to the people who live on the “wrong” side of the wall. In the era of accountable care, in which physicians will be increasingly assessed and compensated in a transparent fashion, it seems wise to emphasize the steward’s ethos of “eating one’s own cooking” (or not eating at all!) and to accept accountability for organizational performance on imaging appropriateness. Stewards serve communities for long periods of time. Each decision they make is inexorably linked to the ones that came before it through the never-ending threads of culture, personal relationships, and institutional memory. Over time, stewards can strategically shift mindsets and move their respective communities in particular directions. Gatekeepers, on the other hand, merely engage in an unending series of transactions. They can affect the makeup of the community by deciding who stays in and who stays out, but they cannot develop longitudinal relationships, and they cannot advance their own agenda. In the era of value-based care, radiologists must expand beyond their traditional roles as imaging interpreters to become managers of the entire imaging value chain. Ensuring imaging appropriateness is an essential part of that process. In making this transition, it will be increasingly important for radiologists to avoid being cast as gatekeepers and instead pursue the mindset and ethos of imaging stewards. This is a strategic opportunity because stewardship is an inherently local concept and it creates a role for which practicing radiologists are uniquely qualified. If radiologists can find success as stewards, then gatekeeping—along with its associated historical baggage—can be left to the RBMs.