Guest Editorial: To serve man

Recent health care events bring to mind a short story from the 1950s that describes a group of pig-like aliens, the Kanamit. They land on earth with a mission to “bring to you the peace and plenty, which we ourselves enjoy.” Despite the Kanamit offers of free drugs to prolong life, inexpensive health care for all and unlimited energy sources, many world leaders are skeptical. However, after a UN translator deciphers the title of a stolen Kanamit handbook as To Serve Man, they put aside their reservations and embrace the alien offer. The plot was also adapted for an episode of The Twilight Zone and later, The Simpsons.

For a number of years, I worked in a busy private practice in suburban Philadelphia. One of our offices was in Blue Bell, Pa. During the 1980s, Blue Bell could be considered ground zero for the then-new concept of HMOs. The founder of one of the first HMOs was a local pharmaceutical salesman. The company he created was eventually sold to Aetna for over $8 billion. His name now proudly adorns a cancer research institute at a prestigious local university hospital. He did quite well. For many of the physicians (and their patients) laboring under this arrangement, however, not so much. In the HMO model, rather than fee-for-service payments, clinicians were reimbursed on aper-member-per-month formula. The larger the patient cohort, the higher the reimbursement, regardless of the amount of care provided. It quickly became obvious to primary-care physicians that it was advantageous to sign up a large number of patients and see them as little as possible. Patient waiting times became excessive. Office managers sent patients for CT scans before they would consent to schedule a clinical appointment. Gynecologists refused to see patients until they had a pelvic ultrasound. Our technologists in many cases became the first health care professionals to lay hands on a patient.

Radiologists were also paid in a per-member-per-month capitation arrangement. Their role reverted to that of gatekeeper, trying to manage the deluge of sometimes ill-advised and unnecessary imaging. As you might imagine, keeping this gate without taking the occasional lead-pipe massage often proved problematic.

Sound familiar? Many of these policies are now being recycled in the Affordable Care Act (ACA) with further shifts away from the fee-for service model. The nascent Accountable Care Organizations (ACOs) now being created are little more than a rehash of full-risk capitation, with each specialty negotiating for their piece of a shrinking pie. Back in the 1980s, there was an actual pie. The Advisory Group, a Washington-based consulting company, published a white paper describing what an equitable distribution of reimbursement among different stakeholders might look like, accompanied by a pie chart illustration. I kept this on file for a number of years thinking that I might need it during future negotiations.Long gone now, it must be hopelessly outdated, but it would be interesting to have it today if only for historical reference. We radiologists will certainly need to demonstrate our collective value as imagers in the near future.

So where was I? Oh yeah, back to the Kanamit. The visitors settle in as acceptance of their new public service paradigm increases. Leaders of all nations can scarcely believe their luck. Finally, hunger, health, and poverty issues will be solved immediately and painlessly. But as the world, in ovine docility, opens its collective kimono to the aliens, our UN hero continues painstakingly to translate the purloined handbook. After a few more paragraphs are completed, the true meaning of the title becomes clear. To Serve Man is not the humanitarian manual it at first seemed. As the story ends, he rushes from his office toward a group of earthlings about to board the alien transport, waving the text and shouting a belated warning: “It’s a cookbook!”

The recent ACA of 2010 runs nearly 2000 pages. Few have read the entire law and fewer still fully understand the arcane details. Many claim it promises better and less expensive health care for millions of Americans. The clichés of the current era sound eerily familiar to the1990s—alignment of incentives, shared risk, improved patient outcomes, quality ahead of quantity. Some of these changes, if initiated properly, will undoubtedly represent an improvement in health care. However, if past attempts are any indicator, many of the new incentives, as they did previously, will result in a further shift of diagnostic responsibility away from clinicians and toward our imaging specialty. This may in fact be beneficial for some patients, but will surely add to an already overwhelming workload for radiologists. I cannot predict how much the ACA and its provision for ACOs will serve the common good, but I strongly suspect that unless we have a seat at the table, radiologists will be featured prominently on the menu.