Preparing for managed care in emergency radiology

s we l o o k toward the nex t few years, the environment in emergency radiology will probable undergo the same types o f changes that the rest o f radiology experiences. D i s c o u n t e d pa yme n t plans inc lude emergency services, and the same may be true o f capitation. As these changes unfold, there will be increasing pressure from payers and hospital administrations to cut back on utilization, even in tile emergency department. In order for us in emergency radiology to cope with these changes, two goals should remain foremost in our minds. The first is to have as our primary focus the welfare of the patient. We in radiology should do all we can to see that the patient gets the best care possible. There may be constraints on capacitywhich will prevent immediate access to certain diagnostic tests, but wi th in the budget available, the patient's interest should come first. This goal also is one o f the goals of our clinical colleagues in emergency medicine. The second goal as we face the future will be to work in coordination and cooperation with our clinical colleagues. We must focus on areas of potential agreement rather than becoming divisive. There is a lot of colnnlon ground: ensuring that patients receive the best possible care in terms of radiologic examinations and providing the best level o f service to tile patient that is possible in the emergency setting. Focusing on the patient and working in concert with our clinical colleagues may take concrete f o r m in the development o f standards or pathways for patients in tile emergency setting that inc lude the role o f diagnost ic imaging. In tile short run, such standards could lead to a decrease in util ization. In the long run, however, such standards would help to avoid underut i t izat ion o f radiology services. Underutilization clearly would not be in the best interest of the patient. Also, as we work in con junc t ion with our clinical colleagues, it ought to be possible to have a reasonable discussion abou t the a m o u n t o f capaci ty needed in the emergency radiology setting. It is total operational nonsense to make radiology a bot t leneck in tile evaluation of an acutely ill patient. Several studies have demonstrated a linkage between the rapidity of diagnosis and treatment and the patient's outcome in terms of morbidity and mortality. Optimal use o f limited resources would not only result in better patient care, but would also ensure that radiology would never be a bottleneck preceding surgical treatment in the operating rooms. The operating rooms are much more expensive than the supporting radiology facilities, and running the operating rooms at an unnecessar i ly low utilizatiou rate is extraordinarily disadvantageous from an economic perspective. This sort of bottleneck analysis is even useful within tile emergency clinical area and the emergency radiology area. For example, if the CT scanner in which emergency patients are examined has to wait because there is no attendant available to transport the patient, the institution is imposing upon itself a very costly and serious inefficiency. It is absurd to have ally personnel become a bottleneck to the very high fixed-cost CT operation if the CT is operating near capacity. A third area ill which some rational p l a n n i n g may be d o n e as we face changing times involves the development o f a curriculum for those who plan to practice emergency radiology. It is clear that the specific areas of knowledge which are necessary to function well and efficiently have a scientific basis and can be delineated. If the best interests of the patient are kept foremost as a priority, those with adequate knowledge of emergency diagnosis and radiologic therapy will be the individuals credentialed to practice in this arena. So, as we look to tile future, all is not gloomy. If we manage to keep the patient's interest as the top priority in discussions, we will have very strong arguments in our favor. I f we approach the future with an eye toward coordinating our efforts wi th those o f our clinical colleagues, we are much more likely to be able to preserve the quality o f emergency radiology service. We can look forward to discussions with our clinical colleagues coucerning the development of standards or pathways for patients in the emergency setting, analysis of capacity decisions, and, especially, avoidance of expensive bottlenecks. Finally, we must maintain discussions centered around the body of knowledge necessary to interpret and perform radiologic studies.