Radiology: Hear the Call to Action in Overcoming Health Care Disparities
Experts discuss the role of radiology in leveling the playing field in patient care
This is the first in a series of articles addressing inequity in health care and solutions radiology can implement. Read part two, part three and part four. View the health care equity infographic for details on how RSNA is working to promote diverse representation across the profession and within its leadership.
What can radiology do to address disparities and promote equity in health care? There are a number of ways the specialty can take action to even the playing field, according to presenters of an RSNA 2020 session.
Increasingly, it is recognized that social determinants connected with health care play a large role in health outcomes, said Ruth Carlos, MD, professor of radiology, University of Michigan, Ann Arbor.
For example, the type of neighborhood a person lives in can impact health care in numerous ways. As the pandemic illustrated, maintaining safe distances and protecting at-risk family members is a challenge in high-density urban areas and in multigenerational housing. Safety may be a concern in such neighborhoods.
And often, those who live in high-density neighborhoods work in similar packed work environments (an Amazon fulfillment center, for example) on zero-hour contracts with no sick leave or employer insurance.
“All of which leaves families financially fragile,” Dr. Carlos said.
Dr. Carlos also emphasized that the social determinants of health and the financial burden patients may face are not necessarily race-based.
“Studying social determinants of health tells us that it is not always biology that determines destiny — it may be a ZIP code,” she said. “The impact of lower social determinants of health are more prevalent among self-identified African Americans and Hispanics, but what we may be attributing to race may in fact be due to their ZIP code.”
For example, a black person not getting screened for cancer may not have that option because he or she lives in a neighborhood that doesn’t offer reliable public transportation and can’t make it to doctors’ appointments.
“Focusing solely on race only partly explains why disparities exist,” Dr. Carlos said. “Factors also may be specific to their local environment or neighborhood in which they live.”
And in the process of care patients can experience a degree of financial fragility, she said. Tests or treatments can be financially toxic. An inability to afford care often leads to debt or bankruptcy.
“Even when we attempt to give guidelines, patients can still experience financial toxicity,” Dr. Carlos said.
In the case of cancer survivors, for example, the financial burden is severe, often leading to high out-of-pocket costs, unemployment, asset depletion and medical debt and bankruptcy in as much as 1.7% of cancer survivors within five years of diagnosis.
“There are opportunities for radiologists to take action,” Dr. Carlos said. “Can we screen for financial fragility in our outpatient imaging setting? Can we integrate one to three questions into our system work process to screen out patients?”
And, by identifying patients who are financially fragile and instituting a referral pathway to institutional financial navigation services, the result would be measured in practice-level outcomes, such as the reduction in unrecovered patient cost share, Dr. Carlos said.
"America has a fantastic health care system, if you can access it."
Richard Heller III, MD
Access to Care — Or Lack of It
In his presentation, Richard Heller III, MD, associate chief medical officer: communications and health policy and national director of pediatric radiology at Radiology Partners, Chicago, agreed that ZIP code is a better predictor of health than a person’s genetic code.
“America has a fantastic health care system, if you can access it,” Dr. Heller said.
Dr. Heller suggested the American health care payment system has exacerbated the problem of access to care. He referenced a recent study by the Medicaid and CHIP Payment and Access Commission (MACPAC) showing that a private payor will pay twice what Medicare pays for hospital services, while at the other end of the spectrum, Medicaid will pay just a fraction of what Medicare pays. These differences are reflected in access to care.
“The lower the payment the worse the access,” Dr. Heller said.
For example, the same MACPAC study showed that just 70% of providers accepted Medicaid and just 36% of psychiatrists accepted new Medicaid patients.
How Can Radiology Help?
Other than improving the rates of public payors, what can radiology do to confront these barriers to care? Drs. Carlos and Heller say radiologists can take action on a number of fronts.
“Regardless of the policy issues, there is a role for radiology,” Dr. Heller said. “Particularly when it comes to providing value for service.”
He said we should think of health care as a limited resource — like the environment. “In that respect, we want to protect that resource and not waste it.”
How can radiologists promote good stewardship of health resources? One answer is to limit unnecessary downstream costs — something radiology is well-positioned to do, Dr. Heller said.
“We exist in radiology at the fulcrum of health care,” he explained. “Whether it is a screening, diagnosis, therapeutic or follow-up examination, all of these flow through radiology. This means that radiology has a tremendous impact on what happens ‘downstream’.”
Dr. Heller referred to a recent study in the American Journal of Roentgenology that makes his point. Researchers found that there was a variation in the likelihood of a brain MRI being performed within 72 hours of a CT for headache based on which radiologist read the CT.
“An individual radiologist’s CT reports had an effect on downstream utilization,” Dr. Heller said. “The patient outcomes did not vary, but the costs did. And that variability is the calling card of waste. If we take that waste out of the system, patient care remains the same and we lower costs and improve value.”
AI-Powered Solutions Reduce Waste
Dr. Heller also pointed to the evidence-based guidelines available to radiologists that often are not utilized. As a solution, Dr. Heller’s practice developed an artificial intelligence (AI)-powered technology, recoMD, that reads along as the radiologist is dictating, recognizes when there are evidence-based guidelines pertinent to the report and prompts the radiologist to use them.
“For example, if I’m describing a thyroid nodule, the AI software can tell me if a follow-up is needed and I can put that in my report,” he said. “More importantly, if a follow up is not required, that automatically goes into the report.”
But if a radiologist were to simply describe the thyroid nodule with no further explanation, there is a chance the referring physician would recommend follow-up care. In this case, however, the radiologist can prevent unnecessary intervention.
“You’ve helped the patient and you’ve saved money,” Dr. Heller said. “You’ve harnessed technology to help radiologists use evidence-based medicine, and the impact is better stewardship of our resource dollars.”
In the complex, ever-evolving health care landscape, radiologists can always strive to limit waste and be respectful of health care resources, he said.
Dr. Carlos finished her presentation with a quote from Benjamin Franklin: “Justice will not be served until those who are unaffected are as outraged as those who are.”
“For those of you who are listening, I urge you to be outraged,” Dr. Carlos said. “And work for a better future.”
For More Information
View the full RSNA 2020 presentation, “A Call to Action in Health Equity: An Interactive Session on Health Disparities and Health Equity in Radiology,” at RSNA2020.RSNA.org.
Access courses on diversity, equity and inclusion at RSNA.org/Learning-Center-Diversity.
Read previous RSNA News stories on health care equity and diversity and inclusion within radiology: