He sits by the river Styx at the entrance to Hades, a giant, terrifying three-headed dog named Cerberus with huge jaws and a serpent tail. Is this a job for a radiologist? Radiologist as gatekeeper?

In her guest editorial describing the pressure on radiology to control imaging costs, Christie James, MS, who runs the radiology billing service at Massachusetts General Hospital, suggests that radiologists can assist here. Not only should radiologists assume the task of ensuring imaging appropriateness, she writes, but they should do so because they are best qualified for the job. Imaging appropriateness, a charge that lately has been taken up vigorously by the American College of Radiology, Reston, Va, is a delicate subject among radiologists. Depending on which one you ask, radiologists will acknowledge that anywhere from 30% to 70% of imaging ordered is unnecessary. But most are loath to risk offending their referrers by suggesting an alternative or, worse, no service at all.

What is fairly certain is that in the days ahead, imaging appropriateness will become more urgent. Should radiologists step in? There are reasons to steer clear:

1. Medicine knows no wrath like the physician whose personal judgment has been questioned. This needs no exposition.
2. Bad timing. As radiologists watch their colleagues in other specialties forklift imaging technologies into their offices, why risk losing professional services too?
3. Self-interest. With declining pressure on reimbursement rampant, it is unrealistic to expect a specialty to voluntarily agree to an across-the-board reduction in referrals.
4. Cost. In developing a system to ensure appropriate utilization, the radiologist would not only force a market contraction, but also incur the manpower and information technology costs of doing so.

On the other hand, here are a few reasons why radiologists should consider stepping in.

1. If not you, who? As the imaging specialtists, radiologists are best qualified to determine the most appropriate and cost-effective imaging approach to a given question. And what better place to control unnecessary utilization than at the point of purchase?
2. The fringe benefits. Any ordering system, be it manual or electronic, that could force the appropriate patient history from the referrer, would aid both radiologists in their diagnosis and coders in billing, which is good for patients and the bottom line.
3. Value added. A radiology service that can help a payor reduce costs will have a market advantage.
4. Responsibility. The future of our multiple-payor health care system is at stake.

It is something to think about.

Cheryl Proval