A computer's advice to cut medical costs

MINNEAPOLIS — Do you really need an MRI for that aching back or sore shoulder? How about a CT scan?

For the last three years, thousands of doctors have been using a computer program to help answer those questions. They plug in information about an individual patient, and a computer using national guidelines tells them if a CT or MRI is a good choice — or if there's something better.

That simple step has helped save an estimated $28 million a year by eliminating thousands of unnecessary tests, according to the Institute for Clinical Systems Improvement, a health research group in Bloomington, Minn.

Starting next year, ICSI will make it available, free of charge, to doctors throughout Minnesota, in what some say could be a national model for curbing health costs.

"Doctors aren't infallible ... sometimes, they choose the wrong thing," said Cally Vinz, a vice president at ICSI, which sponsored the project with some of Minnesota's largest health plans and medical clinics.

In this case, she said, they discovered that physicians were choosing high-tech tests "that weren't useful" about 10 percent of the time. Not only is that a waste of money, she said, but it also exposes patients to radiation unnecessarily.

The project, which was funded by health insurers, was such a success that the federal Medicare program is considering following in Minnesota's footsteps, Vinz said.

In some ways, the project began as an act of desperation. Insurers were alarmed by the skyrocketing cost of CTs and other high-tech scans, which were growing by double digits nationwide.

At the same time, doctors were alarmed by the insurers' attempts to crack down on those tests — hiring consulting firms to screen all requests in advance. In effect, doctors would have to call an 800 number and beg for permission, said Vinz, with little insight into how the decision was made. "The doctors call it a 'black box,"' she said.

Both sides realized "there's got to be a better way to do this," Vinz added. In 2007, they joined with ICSI to launch an experiment. Allina, Fairview and three other medical groups agreed to try a computerized program, developed by HealthPartners, to guide doctors when they order CTs, MRIs and sophisticated heart scans. In exchange, the health plans agreed to waive the "prior notification" requirement for doctors in the pilot project.

"I know a lot of (doctors) were skeptical," said Dr. Barry Bershow, vice president at Fairview Health Services. But for many, it was the lesser of two evils. "When they saw the alternative, they were really horrified and came to love this quickly."

Instead of waiting hours or longer for approval by phone, the doctors get an answer instantly. A pop-up screen invites them to fill in patient symptoms and other information, and the program rates the usefulness of the proposed test, based on guidelines from the American College of Radiology and other medical specialty groups. If another test is an option, that will pop up, too.

Not long after the pilot project started, Bershow said, one colleague came up to him with a surprise admission. "I've been ordering the wrong test," the doctor told him, but didn't realize it until he started using the program.

That's not surprising, Bershow said, given the amount of information overload in medicine. "It's pretty hard for doctors to keep up with everything new in every field."

Among the common mistakes, he said: Doctors were ordering too many MRIs, particularly for headaches and low back pain, that had little chance of affecting treatment but cost an average of $1,000.

In some cases, experts say, doctors order needless tests out of fear of lawsuits, or because a patient demands it.

Dr. Keith Wittenberg, a St. Paul radiologist who collaborated on the project, said the computer program helps weed out the wasteful tests by showing doctors the scientific evidence. "(It's) a very valuable feedback tool," he said

Still, some are dubious about a computer program second-guessing their decisions. "Everyone's goal is to keep health care costs under control," said Dr. Daniel Randa, a neurologist who was not part of the ICSI project. He said it can be hard to convey a doctor's instincts on a computer form, and he worries that any such system could be "too rigid and unyielding."

Some doctors will probably embrace the new technology, but not everyone, said Randa, 64. "My generation of doctors are probably not going to, how should I put this, feel totally comfortable having a machine making decisions for them."

Under the program doctors are still free to order the tests they want. But it's clearly affected their decisions, according to ICSI. In 2007, for the first time in years, the number of high-tech scans in Minnesota stopped growing, and has stayed roughly the same for four years.

ICSI officials say that's at least partly due to the computer project. Overall, they said, the numbers appeared to level off equally at the participating clinics and other clinics, which had to screen their requests through health insurers. Starting in January, Minnesota health plans will pick up the cost of a new computerized system, from a Massachusetts company called Nuance. Any doctor who uses it will be able to bypass the health plans' prior notification process.

Wittenberg, the radiologist, said it was obvious a change was needed because the growth rate was unsustainable.

"You may get an MRI for free, but ... it costs somebody somewhere," he said. "It's not an endless bucket of money."