At the time of this writing and probably, too, at the time you are reading this, health care reform will remain a hot political issue. President Obama, having placed it at the top of his domestic agenda, will still have to contend with strident criticisms about it throughout his second term. The problem is both chronic and acute. Although health care costs are not rising as steeply today as they were several years ago they are still going up. The organizational problem inherent in the way we allocate payment for the ill and injured and how we seek to prevent disease in the United States will most likely not be ameliorated by any legislation because the philosophical polarities are too great and political infighting too intense to achieve anything more than piecemeal changes, obamamania notwithstanding. But one of those bigger pieces could involve radiology.

In fact a conventional metaphor that has now become a cliché is that imaging is in the “crosshairs”. It has increased too much in volume and is now too expensive and, in contrast to drug therapies, it is too unregulated. By and large the remedies are two in number. First, policy wonks want to decrease imaging expenditures through the mechanism of prior authorization, allowing only certain tests in certain situations to be paid for by Medicare and Medicaid, with the expectation that private insurers would follow suit. Such an initiative for cost saving at first will work from an accounting perspective. It certainly will reduce test volume. And given the fact that many of these procedures are over-utilized and often, per case, lack medical justification, an across the board refusal to pay will stifle demand. But at the same time, prior authorization lacks sophistication as applied to medical management decision-making.

A one size fits all solution takes the referring physician and the radiologist out of the care-rendering scenario. It will undoubtedly lead to the harm of some individuals who may really need the “blackballed” test or procedure. Furthermore, authorization is so hostile to the status quo it is bound to have vociferous critics who will “hype” the negative consequences its implementation will induce.