Radiology Business Journal | December 2013

December 2013

Radiology100 The

The Sixth Annual Ranking of the 100 Largest Radiology Practices by FTE Radiologists

Featured in this issue

I Want It Anyway: Radiology’s Conundrum

page 12

page 27

Two Views of Value: The Practice–Hospital Entente and Kaiser Permanente page 18 Radiology’s Value Proposition: The Massachusetts Experience

page 50

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December 2013

Radiology100 The

The Sixth Annual Ranking of the 100 Largest Radiology Practices by FTE Radiologists

Featured in this issue

I Want It Anyway: Radiology’s Conundrum

page 12

page 27

Two Views of Value: The Practice–Hospital Entente and Kaiser Permanente page 18 Radiology’s Value Proposition: The Massachusetts Experience

page 50

www.imagingBiz.com

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CONTENTS

December 2013 | Volume 6, Number 6

27

Features

18 Two Views of Value: The Practice–Hospital Entente and Kaiser Permanente

By George Wiley

This tale of two models investigates how value is built in radiology through a collaboration between a private practice and a hospital and within a captive-group HMO.

27

The Radiology 100: The Big Get Bigger, Primarily at the Summit

The biggest practices surge in size, but their hospital-contract totals don’t, signaling increased competition ahead.

35

The New Quality Mandate: Demonstrating Radiology’s Value

From perfect imaging execution to implementation of patient-activation programs, demonstrating value in radiology is undergoing evolutionary change.

42

Mount Sinai Medical Center: Implementation of Decision Support for Radiology Orders

and David S. Mendelson, MD, FACR A planned and methodical phase-in process has enabled this institution to prepare for the new era of health-care delivery without disrupting service.

50

Radiology’s Value Proposition: The Massachusetts Experiment

Panelists representing a payor, an outpatient imaging-center chain, and the radiology department of a luminary site provide insight into the specialty’s shifting value proposition under health-care reform.

By Cheryl Proval

By Ben Lauing

18

By Galen Kilroy; Paul Francaviglia; Aditi Vakil;

By Kris Kyes

4 Radiology Business Journal | December 2013 | www.imagingbiz.com

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CONTENTS

December 2013 | Volume 6, Number 6 Publisher Curtis Kauffman-Pickelle · ckp@imagingbiz.com EDitor Cheryl Proval · cproval@imagingbiz.com

Art Director Patrick R. Walling · pwalling@imagingbiz.com

Departments

8

Technical Editor Kris Kyes

AdView

Associate Editor Cat Vasko · cvasko@imagingbiz.com

Use the Best Option First

By Cheryl Proval

10

Online Editor Lena Kauffman · lkauffman@imagingbiz.com

The Bottom Line

The Power of Inefficiency

12

Priors

By Richard Heller III, MD, MBA

12

First Person | I Want It Anyway: Radiology’s Conundrum

Leadership | Is Sustainable Competitive Advantage Enough?

Numeric | Health-care Costs: Slow (but Steady) Growth Ahead

14 16

56 35

By Cullen Ruff, MD

By Cynthia Keen

Contributing Writers Paul Francaviglia; Richard Heller III, MD, MBA; Cynthia Keen; Galen Kilroy; Ben Lauing; David S. Mendelson, MD, FACR; Cullen Ruff, MD; Aditi Vakil; George Wiley Vice President, Sales Scott Andersen · sandersen@trimedmedia.com Production Coordinator Megan Runyon · mrunyon@imagingbiz.com Webmaster Robert Elmquist · relmquist@imagingbiz.com

Advertiser Index 42

Corporate Office imagingBiz 210 W. Main St., Suite 101 Tustin, CA 92780 (714) 832-6400 www.imagingbiz.com PResident/CEO · Curtis Kauffman-Pickelle VP, Publishing · Cheryl Proval VP, Administration · Mary Kauffman

Radiology Business Journal is published bimonthly by imagingBiz, 210 W. Main St., Suite 101, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. December 2013, Vol 6, No 6 © 2013 imagingBiz. All rights reserved. No part of this publication may be reproduced in any form without written permission from the publisher. POSTMASTER: Send address changes to imagingBiz, 210 W. Main St., Suite 101, Tustin, CA 92780. While the publishers have made every effort to ensure the accuracy of the materials presented in Radiology Business Journal, they are not responsible for the correctness of the information and/or opinions expressed.

Please address all subscription questions to Cheryl Proval at cproval@imagingbiz.com.

6 Radiology Business Journal | December 2013 | www.imagingbiz.com

AdView

Use the Best Option First Radiology has a gold-standard opportunity to implement best practices

E

ight years ago, I sent an email to Barry Pressman, MD, FACR, radiology chair at Cedars-Sinai Medical Center (West Hollywood, California).

My 75–year-old mother, a lifelong nonsmoker whose primary-care physician had diagnosed lung cancer (based on a chest radiograph), needed a referral to a surgeon.

Pressman recommended Robert McKenna, MD, who had helped pioneer video-assisted thoracic (VAT) surgery in this country.

VAT surgery, which is recommended for patients with lung cancer at stages I through IIIA, was not new in 2005, but it was far from being the standard of care. At the time, McKenna had performed nearly 1,000 VAT surgeries, but for my mother, having the surgery in California would mean traveling across the country with my father, who was struggling with Parkinson disease and was none too steady on his feet.

The nearest academic medical center to my parents’ home that offered the surgery was 2.5 hours away by car, however, making transportation a major issue. Aside from that, the only surgeon there who performed VAT surgery had been recently recruited and was very young.

My mother made the fortuitous decision to have surgery to remove half of her left lung at Cedars-Sinai Medical Center.

McKenna made three small incisions and inserted a videoscope; a stapling device; and a tool used to capture and remove the explant (in a plastic bag, to prevent cell tracking). If my mother had undergone lobectomy via traditional thoracotomy, the tools used would have been quite different: scalpels, retractors, and other devices that would have caused a longer hospital stay and a more difficult recovery.

Instead, my mother was discharged after two nights in the hospital, although McKenna suggested that she could leave after just one. Within a week, she was walking the hills in my neighborhood.

Eight years later, she is being followed with an annual radiograph and subsequent visit to an oncologist (in addition to completing an annual Cedars-Sinai research form). Knock wood: Hers was an excellent and wholly unexpected outcome.

More Than 17 Years How does this relate to radiology? A window has opened, and radiology now has a unique (and perhaps unprecedented) opportunity to create widespread

implementation of the best evidence-based medicine that the specialty can provide.

What might be lacking is the will, as the responsibility is formidable.

The second way that my personal anecdote relates to radiology could be a bit naive, but it is well intended. It also is in line with the theme of value-added radiology, on which we expend a good many words in this issue of Radiology Business Journal.

One reason that VAT surgery is not widespread is likely to be that it is conducted

If the referring physician doesn’t get it right from the outset, at the point of diagnosis, then the meter starts running on waste. implementation of evidence-based medicine across the health-care delivery system. A commonly held figure for the time that it takes for medical research to translate into practice is 17 years; how long, after that, is the lag between reaching practice and becoming the standard of care?

In a draft version of policy, the House Ways and Means Committee and Senate Finance Committee jointly crafted a remedy for the sustainable growth rate (SGR) formula that includes language promoting the use of appropriateness criteria in ordering advanced imaging. Those who fail to use appropriateness criteria would be penalized, and prior authorization would be mandated for those providers found to be outliers.

Furthermore, the DHHS secretary would be asked to identify the appropriateness criteria to be used (and mechanisms through which they could be disseminated).

Whether this language will survive in whatever solution is brought forth to fix the SGR cannot be predicted. What is known is that the ACR® has made the appropriateness criteria Web based—and therefore, highly available (and updatable). In this digital era, in the highly digital specialty of radiology, imaging professionals have the tools (and therefore, the potential) to begin widespread

8 Radiology Business Journal | December 2013 | www.imagingbiz.com

under image guidance, which is not, for many surgeons, an area of competence.

This is, however, a skill of interventional radiologists, who also are adept at navigating instruments into the human body under fluoroscopic guidance. Could there be a partnership here that would accelerate the availability of VAT surgery, which appears to be taking a languorous route toward becoming the standard of care?

As radiology works to add value to the health-care experience, it will strive to create different value propositions for different health-care stakeholders, including referring physicians, hospitals, payors, employers, and (most important) patients. With 2014 around the corner, let’s make getting it right the first time our New Year’s resolution.

Let’s put an end to poorly selected and unnecessary imaging. If the referring physician doesn’t get it right from the outset, at the point of diagnosis, then the meter starts running on waste—in time, money, morbidity, and mortality. That’s one boatload of value that radiology can provide to patients (and the entire health-care system).

Cheryl Proval cproval@imagingbiz.com

The Bottom Line

The Power of Inefficiency The author extols the virtues of non-RVU work

E

fficiency can be thought of as the volume of work done over a period of time. In diagnostic radiology, that has been interpreted to mean RVUs per radiologist per unit of time. With decreasing per-case reimbursement, we have seen particularly strong pressures to increase efficiency. Unfortunately, some practices have done so at the expense of other important functions.

Those activities, referred to as valueadded or noninterpretive tasks, provide valuable services—but do not generate RVUs, and thus, are not included in efficiency calculations. I (and others)1-3 have written about the critical value of these noninterpretive activities (which, among other things, provide a level of differentiation that protects companies— and our specialty—from commoditization).

For the local radiology practice, the importance of a service culture cannot be overemphasized. When hospital leaders evaluate the value supplied by a radiology practice, they have a lack of quantifiable data. Measures include turnaround time, but a fast report is not always a good report. Price is another objective criterion, but care that is more expensive doesn’t always equate with care that is of higher quality. Unfortunately for hospital and medical-staff leaders, there is no accepted, objective measure of quality.

This means that hospital decision makers are forced to use more limited objective measures and more extensive subjective criteria in evaluating a radiology practice.

When hospitals are approached by an outside radiology-service provider that can promise an improvement in quantifiable criteria, namely turnaround time and price, leaders take notice. We have all heard of radiology practices displaced from their institutions as hospitals seek ways to rein in costs.4-6 Obviously, providing solid interpretive services is a requirement for any radiology practice that expects to have long-term survival, but it’s the noninterpretive services that are key to differentiation. It’s tough to provide those services if the radiology practice is focused solely on maximal efficiency.

An analogy that I like to use is that of a grocery store. In his book How the Mighty Fall, best-selling author Jim Collins writes about formerly iconic grocer Great Atlantic & Pacific Tea Co (A&P)—until 1975, the largest

US food retailer—not adapting to the times and not reinvesting in its stores (instead, returning profits as dividends).7 Eventually, A&P withered away to irrelevance—a victim of shortsighted strategy.

A radiology practice that is overly focused on RVU production and efficiency, in an attempt to maintain incomes, while it neglects clinician and hospital client services is following the well-worn path of companies such as A&P. Instead of building walls to fortify its position, it is inviting competition: a scenario that is far more detrimental to a practice’s long-term health than some inefficiency in the system would be.

Few specialties in medicine are as technologically advanced as radiology, and keeping up to date requires an investment of time and energy. For example, CT and MRI protocols are constantly evolving. A radiologist friend recently lamented the fact that sonographic technologists in the practice were not particularly skillful, and many of their exams were thus read as limited.

I asked how often the practice does tutorials with the sonographers and how it provides instructional feedback. My friend responded that the practice’s radiologists are far too busy to spend time teaching technologists how to do their jobs; why would they waste valuable RVU-producing time on such activities? Practices like this one, in focusing too much on RVU productivity, will find (as A&P did) that they have been left behind by a changing world.

The feared risk of inefficiency is wasted, nonproductive time. Writing about the importance of personnel, Collins says that getting the right people on the bus (and the wrong people off the bus) is a top priority of management.8 The right people don’t have to be reminded to work hard because they are naturally motivated.

The right people know that they might have caught up with the worklist temporarily, but it’s no time to play on the computer. It’s time to do those other valueadded activities. Furthermore, if the practice doesn’t ever build time into the system to allow for such noninterpretive activities, it might find that the right people have migrated to other practices that do provide more comprehensive services.

As you evaluate how your own practice is adapting to the changing tides of health care, remember the cautionary tale of A&P.

10 Radiology Business Journal | December 2013 | www.imagingbiz.com

by RIchard Heller III, MD, MBA Inefficiency might not really be the enemy that some think it is. In fact, with the right people on the bus, it might be the only way forward.

Richard Heller III, MD, MBA, is chief of pediatric radiology in the department of diagnostic imaging at Advocate Children’s Hospital and at Advocate Christ Medical Center (Oak Lawn, Illinois) and is a partner with Radiology Imaging Consultants (Harvey, Illinois).

References 1. Heller RE 3rd. The total value equation: a suggested framework for understanding value creation in diagnostic radiology.

J Am Coll Radiol. http://www.jacr.org/ article/S1546-1440(13)00183-X/abstract.

Published August 6, 2013. Accessed November 13, 2013.

2. Heller RE 3rd. Twenty-first century radiology. J Am Coll Radiol. 2013;10(1):57-58.

3. Allen B Jr, Levin DC, Brant-Zawadzki M, Lexa FJ, Duszak R Jr. ACR white paper: strategies for radiologists in the era of health care reform and accountable care organizations: a report from the ACR Future Trends Committee. J Am Coll Radiol.

2011;8(5):309-317.

4. Keen CE. When a hospital replaces a private practice—with a teleradiology company. Radiology Business Journal. http://www.imagingbiz.com/articles/ rbj/when-a-hospital-replaces-a-privatepracticewith-a-teleradiology-company.

Published August 30, 2013. Accessed November 13, 2013.

5. Freeman L. Longtime Naples radiologists go to Physicians Regional; NCI hires national firm.

Naples Daily News. http://www.naplesnews. com/news/2011/nov/20/radiology-NCHPhysician-regional-Radisphere-health/.

Published November 20. 2011. Accessed November 13, 2013.

6. Silva E 3rd, Breslau J, Liebscher LA, et al. ACR white paper on teleradiology practice: a report from the Task Force on Teleradiology Practice.

J Am Coll Radiol. 2013;10(8):575-585.

7. Collins J. How the Mighty Fall: And Why Some Companies Never Give In. New York, NY: JimCollins; 2009:154.

8. Collins J. Good to Great: Why Some Companies Make the Leap . . . and Others Don’t. New York, NY: HarperBusiness; 2001:63-64.

Attn: RBJ Readers

“Any APS billing discrepancy for covered client services will be reimbursed at the allowable provider rate.”

A partner in a 17-person radiology group was surprisingly candid with me about why he had not outsourced his billing to us.

“There are two main reasons,” he said. “First, I’m concerned that the billing-department head will be out of a job. There’s also this feeling that if we don’t directly control the billing and collections, we’re not going to get what is coming to us.”

“There is something I want you to understand,” I replied. ”APS is directly involved in a crucial aspect of our clients’ businesses. If you don’t get every penny that is coming to you, I’m going to hear about it—and fast—because we hold ourselves accountable to you.

We would not have been in business for over 30 years if we made those types of mistakes.”

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That department head who’d been there for years is now the liaison between the practice and APS. Today, outsourcing your billing comes down to the fact that in the current health-care environment, conducting business as usual is not a good growth strategy.

Here’s my guarantee to you: We are so confident in our systems and service levels that any billing discrepancy generated by APS for covered services will be immediately reimbursed to you at the allowable provider rate. to find out how to get started, call me directly at (866) 914-8719.

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{priors} first person

I Want It Anyway: Radiology’s Conundrum

S

by Cullen Ruff, MD

aying, “I want it anyway,” the ICU physician insisted that his patient with breast cancer should get an MRI exam to look for lung metastases. My years of experience as a radiologist did not dissuade him; such a test would be a poor way to evaluate his patient’s lungs, even under ideal circumstances (which hers were not).

She was on a ventilator, incoherent, and unable to hold her breath, rendering the study a useless waste of time and money.

More important, her lungs, just days earlier, had been clear on a chest CT exam—the gold standard for detecting lung nodules. We already knew that she had no lung metastases.

Repeating, “I want it anyway,” the ICU physician became emphatic and slightly frantic, desperate for information on why his patient was doing poorly.

Unfortunately, that happens sometimes with critically ill patients, and ordering unindicated tests rarely helps.

Medical-imaging utilization has increased exponentially in the past few decades, for reasons both good and less so. Radiography, CT, MRI, ultrasound, and nuclear-medicine exams can create incredible visual roadmaps of the human body, dramatically helping us diagnose and treat the sick.

We rightfully investigate the benefits of various studies as technology continuously evolves. With trepidation, we sometimes look at costs, biological risk, and the patient experience when tests are performed. Many studies are ordered not because an abnormality is truly expected to be found, but just to make sure that it won’t be. Putting aside that ever-elusive issue of defensive

medicine momentarily, can we at least do something about the most blatantly unnecessary tests, which we know will provide virtually no useful information at all?

Scope of the Problem This happens daily, and the costs add up: Expensive imaging studies ordered for outpatients often require preauthorization from insurance providers, but preauthorization is rarely required for patients already hospitalized or in an emergency department. For example, a physician might order an ultrasound exam to rule out gallstones for a patient whose gallbladder was removed previously—or for one who already had gallstones diagnosed, using the same study, last month. A question or two—or a look at the medical record (electronic or not)—would be all that’s required to curb this waste.

A patient with impaired kidneys has an ultrasound exam to rule out urinary obstruction—but the kidney-stone CT acquired yesterday already showed that there was none. At my hospital practice,

12 Radiology Business Journal | December 2013 | www.imagingbiz.com

unnecessary ultrasounds like these are ordered a couple of times a day, on average. To see how the dollars add up, multiply that by the days in the year, the number of hospitals in the country, and the fee per study. Sometimes, clinicians simultaneously order several studies of the same body part, not waiting to see whether radiography, CT, MRI, PET, or bone-scan results give us the diagnosis (so that the rest of the tests could be avoided).

I once saw the CT study of a habitual drug seeker who presented to different emergency departments on a regular basis, complaining of flank pain.

Unknown to the emergency-department staff, she would prick her finger and put a drop of blood in her urine specimen, creating evidence that she might have a kidney stone.

This allowed her to get a narcotic injection, but with each emergencydepartment visit, she also automatically had a CT exam to rule out kidney stones.

I read her 35th negative CT exam (in our system alone) in five years. She came back every month or two, though, and each time, tests were ordered as reflexively as pulling a hand off a hot stove. There was no review of past records or prior imaging, nor was any thought given to whether this additional test could provide any new information.

Ordered tests keep me (and the technologists) employed, but hardly help the patients who do not need the exams.

We all pay more taxes or higher insurance premiums as a result, and we certainly don’t do the patients any good—yet if an imaging study (or almost any laboratory test) is ordered in a hospital or emergency department, it usually gets done.

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priors

One reason for the problem: There is no disincentive to discourage physicians from ordering the tests. The patients’ insurers (if they have any) might deny payment after the fact, if a study is retrospectively deemed unnecessary, leaving patients with the bills. There is usually no real consequence to the physician who ordered the test, however—no cost, no radiation exposure, and no injection risk.

If physicians want exams, they usually get them, even if the specialists who know more about radiology try to dissuade or redirect them. This leads to the fundamental issue: To change behavior, we have to know what motivates people.

Without disincentives, unnecessary tests will only continue.

Like most physicians, I went into medicine because the field is interesting and because it is rewarding to help people get better (or to comfort those who will not). It is also rewarding to work together with colleagues, rather than having adversarial interactions.

We learn from each other and from the patients we treat. Most physicians are quite good at what they do, including choosing the tests they order—yet there are times when I would like to see physicians ordering truly unindicated tests feel a consequence just big enough to get their attention.

Changes in health care might still be taking shape, but change is coming.

Maybe an offending ordering physician

will receive a required phone call from a government or insurance-company employee (with no medical training) asking why he or she ordered a study that could not realistically have provided any beneficial information. Perhaps the bad-order police will deduct $5 from a physician’s reimbursement every time a truly unnecessary test is ordered.

A system penalizing egregious ordering might be complicated, tedious, and unwelcome for various reasons.

Sometimes, though (when I see the worst of the waste), I want it anyway.

Cullen Ruff, MD, is associate professor of radiology at Virginia Commonwealth University.

leadership

Is Sustainable Competitive Advantage Enough?

I

t’s the assumption at the core of GE, IKEA, and Unilever’s strategies; its presence, or lack thereof, guides the investments of billionaire Warren Buffett, among others. Sustainable competitive advantage sounds like something that every business, in every industry, would want to secure. With the advent of digitization and globalization, however, along with continual emergence of disruptors from every corner, is focusing on sustainable advantage still the best way to achieve success?

Writing in the June 2013 issue of Harvard Business Review, Columbia Business School professor Rita Gunther McGrath, PhD,1 argues that organizations should shift their focus to the constant pursuit, development, and exploitation of transient advantages. Her primary reason will sound familiar to leaders in the turbulent radiology industry.

“In a world where competitive advantage often evaporates in less than a year, companies can’t afford to spend months at a time crafting a single longterm strategy,”1 she writes. Instead, if they are to stay ahead, they must begin new strategic initiatives over and over, constantly.

Most organizations have become so rooted in the sustainable-advantage approach that they have become blind

to the single most important means of identifying transient advantages: frontline employees. They, McGrath notes, “are rarely rewarded for telling powerful senior executives that a competitive advantage is fading away.”1 Instead, obtuse administrations continue to pursue dated initiatives until it’s too late. As examples of companies that have fallen prey to this vulnerability, McGrath cites IBM, Sony, Nokia, and Kodak, where sustainable-advantage strategies ran aground, she observes, “despite ample early warnings from those working with customers.”1 Risks and Misconceptions In fact, McGrath reports, as a business or industry’s offerings become commoditized—a process that has been underway in imaging for some time— transient advantages become more and

14 Radiology Business Journal | December 2013 | www.imagingbiz.com

more important. She offers a series of questions designed to provide warning signs that an organization is at risk of succumbing to sustainable-advantage myopia; here, these have been rephrased to apply to imaging.

The first question that leaders should ask is whether they would turn to their own facilities for their care (or that of a loved one). Has the organization been investing in equipment, IT solutions, and personnel at the same or higher levels, only to continue losing market share?

Are patients finding cheaper providers to be good enough, even if the quality associated with them is lower? Is competition emerging from unexpected corners? Here, McGrath cites Walmart’s planned entry into the clinic market.

Circling back to the importance of frontline staff, is the organization not considered a top place to work by the

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kinds of employees it would like to hire—and, similarly, are the most valued current employees abandoning ship? Is your reputation continually undervalued?

McGrath also outlines common misconceptions held by leaders still struggling to liberate themselves from the sustainable-advantage mindset. These include the beliefs that being first to market will guarantee success; that investment in established offerings can be minimal; that higher quality will always pay off; that resources should be committed to existing offerings, not new ventures; that innovation and experimentation are intangible concepts that don’t need a formal position in the organization’s structure; and that sporadic innovations will be enough to keep the strategy fresh.

Transitioning to Transience To counteract some of these ingrained behaviors and misconceptions, McGrath offers specific steps for developing a pipeline of transient advantages, as opposed to relying on a single sustainable advantage that is anything but. Her first recommendation is to think of the marketplace in terms of arenas,

not industries—for it is arena thinking that allows players such as Walmart to encroach swiftly on the health-care market. “Indeed, the very notion of a transient competitive advantage is less about making more money than your industry peers . . . and more about responding to customers,”1 she explains.

This will be music to the ears of those already pursuing patient-centered models that focus on enhancing the customer experience of care. In fact, many of McGrath’s steps for the transition to transience focus on the customer experience; she points out that while products and services are easily duplicated, a well-designed experience is a customer craving that is rarely satisfied. She also highlights the value of employees who are gifted at understanding and responding to customers’ needs, and cautions businesses against the kind of drastic restructuring that can upend these gifted individuals’ confidence and undermine their initiative.

McGrath emphasizes the importance of codifying, systematizing, and orchestrating innovation by building it into the governance and resource structures of the organization. “A big

mistake companies make all the time is planning new ventures with the same approaches they use for more-established businesses,”1 she writes.

Instead, new approaches should be funded separately to avoid destructive resource competition, and they should be treated as experiments until their success has been proven. Most important, they should be cultivated and nurtured, on an ongoing basis, to ensure a healthy pipeline of overlapping transient advantages.

Managing all of this will, of course, require a new kind of leader, and it is this concluding portion of McGrath’s prescription that will resound most deeply with those in the health-care field. “A strong leader seeks contrasting opinions and honest disagreement,” she concludes.

“Fast and roughly right decision making will replace deliberations that are precise but slow. In a world where advantages last for five minutes, you can blink and miss the window of opportunity.”1 —Cat Vasko Reference 1. McGrath RG. Transient advantage.

Harv Bus Rev. 2013;91(6):62-70.

numeric

Health-care Costs: Slow (but Steady) Growth Ahead

A

s citizens and the media debate the cost and growing pains associated with the Patient Protection and Affordable Care Act (PPACA), Cuckler et al1 (at the CMS Office of the Actuary) predict that aggregate health-care spending will grow at an average annual rate of 5.8% from 2012 to 2022, outpacing the projected growth rate of the US gross domestic product (GDP) by 1%. In 2022, nearly one-fifth of the GDP (19.9%) will be spent on health care, they estimate.

This increase, according to a detailed economic forecast1 published in the October 2013 issue of Health Affairs, is attributed (in part) to the escalating enrollment in Medicare of the aging baby-boom generation. This population will require more (and more expensive) health-related services.

Another factor cited by the authors

is the impact of the implementation of the PPACA. By 2022, an additional 30 million people are expected to have health insurance. The analysis predicts that cumulative health spending, by this date, will have increased $621 billion beyond the estimated $2.8 trillion spent in 2012.

A healthy dose of optimism factors into the third driver: economic recovery.

Cuckler et al predict that as the US economy improves over the next 10 years, more people will have disposable income to spend on prescription drugs and health services.

The projections do not include any impact of scheduled Medicare Physician Fee Schedule rate updates under the sustainable growth rate’s formula. The authors presume that Congress will modify these to be less drastic in their effects on health-care providers, starting

16 Radiology Business Journal | December 2013 | www.imagingbiz.com

by Cynthia Keen

in January 2014, by adjusting the automatic 24.7% fee reduction. They do, however, include the impact of the US Supreme Court ruling, made in June 2012, that makes the expansion of

Medicaid eligibility (under health reform) optional for state governments.

The Near Future For 2013, the authors project, total national health spending will be found to have risen at a rate of less than 4%, reflecting consumer/business price sensitivity due to continuing economic sluggishness. Medicare expenses are expected to have increased by 4.2%, slightly less than 2012 growth, and to have been offset by the automatic budget cuts of March 1 (sequestration).

Growth in spending by private insurance companies will be seen to have slowed to a projected 3.4%.

The initial impact of expanded insurance coverage for an estimated 11 million individuals is the primary reason that the authors predict an increase to 6.1% for the 2014 growth rate. The authors expect a spending increase of 12.2% for Medicaid patients—to reach $490 billion. The increase for patients with private health insurance is estimated at 7.7% for the year. Both increases are attributed to the PPACA. Patients will benefit from a 1.5% decline in out-ofpocket spending due to the law’s coverage and cost-sharing provisions.

The authors predict more of the same for 2015: a 6% increase due to the addition of an estimated 8 million new enrollees in health-insurance programs, with the assumption that the economy will grow 5%. With more disposable income available, consumers will spend more on health-care services, the authors project.

Annual total health-care spending growth from 2016 to 2018 is projected as moderating slightly (at 5%) as the effects of the health-insurance expansion begin to subside in 2016. The authors believe that health-care spending will be fueled by an improving economy and by increases in disposable income.

The increase in Medicare spending is projected at 7.3% per year.

Beginning in 2019 and extending through 2022, Medicare spending is expected to increase at a rate of 7.9% (compared with 7.3%, for the three previous years) as the enrollment in Medicare of the baby-boom generation builds. The end of sequestration in 2022 was also factored into the greater growth rate.

By 2022, 49% of the nation’s estimated $2.4 trillion health-care cost will be paid for by government agencies. The largest contributor will be the federal government, at an estimated $1.5 trillion. This will pay for growth in Medicare enrollment, expanded Medicaid eligibility, and premium and cost-sharing subsidies available through health-insurance exchanges.

Hospitals and Physicians Total hospital spending seems to have reached a plateau, with an annual growth rate of just 4.9% in 2012 (the third year that the growth rate was below the 5% mark). The authors anticipate that it will be even lower for 2013 (4.1%) and in 2014 (4.7%).

Sequestration reduced growth in Medicare payments to hospitals by 3.2% in 2013, but the authors predict that newly insured patients will offset lower hospital-payment updates in 2014.

For 2015, however, the authors expect growth of 5.6%, increasing to 6.4% in ensuing years. Costs related to coverage of increasingly elderly Medicare patients will result in a 7.8% increase in hospital payments, compared with an estimated annual 5.9% growth rate for privately insured patients needing hospital services.

As in the hospital sector, spending on physician services has remained below 5% for several years. The authors cite the economy, the high unemployment rate (and its impact on the number of insured patients), a low inflation rate, and the impact of sequestration on reimbursement for Medicare/Medicaid services. The 2013 growth rate is expected to be 3.9%—a reduction from the 4.6% rate of 2012 and the 4.3% rate of 2011.

Physicians are expected to feel an upswing in 2014, a year before hospitals experience a bump in revenue. Growth in spending is predicted to accelerate to 7.1% as a result of services being provided to the newly insured. This group will include a higher proportion of healthier patients who do not require hospital services, but will take advantage of access to physicians and clinics for treatment that they would have forgone, without private insurance.

By 2015 and through 2018, the average annual growth in physician and clinical services is expected to be 5.5%.

The authors attribute this increase to the PPACA expansion in insurance coverage and to the anticipated improvement in the economy. Growth will rise, for 2019 through 2022, to 6.6% annually, thanks to Medicare payments for care of the baby-boom generation.

With insurance making prescription drugs more affordable for many, drug spending is predicted to soar. It will reach 5.2% in 2014 and then climb to 6.5% thereafter—through 2022—fueled by rising prices and utilization.

Payors and Patients It is no surprise that growth in private health-insurance spending is expected to accelerate in 2014 (to 7.7%), declining to 6.2% in 2015 and to 5.8% for ensuing years. In 2012, the growth rate in private-health insurance spending had moderated to 3.5%, contributing $813.9 billion to health spending that year.

The authors report that out-of-pocket spending reached $320.2 billion in 2012, growing at a rate of 4.1% (compared with 2.8% in 2011). The authors project a more moderate 2.7% growth rate for 2013. By 2022, they expect out-of-pocket expenses to account for 9.1% of total health-care spending; in 2012, patients are believed to have contributed 11.4% of the total.

Cuckler and her colleagues warn their readers that their projections and estimates remain subject to substantial uncertainty. They cite lack of historical experience of the impact of many of the health-care reforms being undertaken.

The CMS Office of the Actuary does not have a way to predict the future (or the volatility) of the economy—within the nation or globally. Neither does anyone else.

Cynthia E. Keen is a contributing writer for Radiology Business Journal.

Reference 1. Cuckler GA, Sisko AM, Keehan SP, et al.

National health expenditure projections, 2012–22: slow growth until coverage expands and economy improves. Health Aff (Millwood). 2013;32(10):1820-1831.

www.imagingbiz.com | December 2013 | Radiology Business Journal 17

Two Views | Radiology’s Value Proposition

Two Views of Value:

The Practice–Hospital Entente and Kaiser Permanente This tale of two models investigates how value is built in radiology through a collaboration between a private practice and a hospital and within a captive-group HMO

By George Wiley

W

hat policymakers and payors want from radiology departments is not volume, but value. If radiologists can help hospitals contain costs, improve quality, and increase market share, then these radiology providers will be well positioned to carry their hospitals—and themselves—into the era of quality- and performance-based pay.

Determining the exact nature of valuebased radiology, however, is a work in progress (and that nature is likely to vary, depending on location). Although they aren’t sure how these changes will play out, hospital administrators and radiology chiefs have already seen that value will be the new king.

On December 1, 2011, at the annual meeting of the RSNA in Chicago, Illinois, Vijay M. Rao, MD, presented “Value-added Services of Hospital-based Radiology Groups,” an influential paper defining what value-based radiology tries to do. Rao highlighted six action areas: patient safety; exam quality; radiologyreport quality; service, especially reportturnaround time; cost containment; and building hospital business.

Perceiving value-based imaging in the big picture is one thing, but what does that mean on the ground? How do radiologists and radiology departments go about delivering value-based care? What are the expectations of hospital administrators?

What must radiology groups demand of themselves? Radiology Business Journal interviewed representatives operating in two very different models—the private practice–hospital collaborative and Kaiser Permanente’s captive-group HMO—to

Preload: Preview v Deciding that alignment was the best strategy for retaining independence, Radiology Associates of Northern Kentucky (RANK) in Edgewood entered into an agreement with its primary hospital client to formalize service standards in 2008. v With significant income tied to both external and internal measures, the practice is making—and tracking— progress against ambitious goals.

understand how these questions are being answered in practice.

The Hospital–Practice Collaborative In 2008, administrators at St Elizabeth Healthcare (Covington, Kentucky)—the oldest and largest health-care provider in Northern Kentucky—and the leaders of RANK, a 29-radiologist private practice, signed an agreement laying out financial incentives and goals to be met. Once the original radiology-services agreement (which simply delineated services to be provided) had been executed between St Elizabeth Healthcare and RANK, discussions between the partners soon turned to working toward higher levels of collaboration.

These were based on definable measures that, if achieved, would result in a higher-quality product and experience for the patient community, with a lower cost of delivery. The partners then created a leadership agreement that would define a series of operational and strategic

18 Radiology Business Journal | December 2013 | www.imagingbiz.com

v At the nation’s largest captive-group HMO, value in radiology is tightly aligned with mission: affordability, access, quality, and patient satisfaction. v Southern California Permanente Medical Group (SCPMG) radiology is mining its electronic health records to improve breast-cancer survival and to ensure follow-up care for incidental findings.

measurements—with significant financial incentives attached. It was collectively decided that the original leadership agreement would have six measures: reduction in average turnaround time; percentage of self-edited reports; results of a survey program (involving technologists, emergency-department staff, hospitalists, and patients); development of an interventional-radiology oncology program; creation of a continuing-education program for technologists; and development of a comprehensive coronary CT angiography program.

Upon completion of the first year and significant progress toward the six original goals, the partners expanded the leadership-agreement efforts to include 14 measures, ranging from continued decreases in turnaround time and increases in the percentage of self-edited reports to spine service-line collaboration, a comprehensive cardiacimaging program, reduction of inpatient PET volumes, and strong programming

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these arrangements. Through aggregation and utilization of the correct measurements and analytics, the affiliation can demonstrate that it is committed to the quality-of-care objectives being promoted by the hospital (for the hospital’s benefit). It is imperative for the affiliation to demonstrate its contribution to the hospital’s objectives continuously, through its reporting capabilities.

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Two Views | Radiology’s Value Proposition

All of those goals are tied to monetary values. We don’t get the money unless they are met. The money is actually significant.

—James Roebker, MD

This really is a collaborative effort, and the outcome is a better product: better outcomes and lower cost to the patient. The overall transition is one that’s forward thinking in working for payors and consumers.

—C. Chad Wiggins, MHSA Radiology Associates of Northern Kentucky

in management of the quality of image interpretation and delivery.

RANK provides 24/7 subspecialized imaging-exam interpretations for St Elizabeth Healthcare’s four hospitals and three outpatient imaging centers (in 2012, interpreting half a million studies). The practice also operates its own vascular/ interventional center and reads for a smattering of nonradiologist practices that have their own imaging equipment.

Brad Miller, MD, an interventional radiologist and RANK’s president, says that the 2008 agreement through which the radiology group formalized its relationship with St Elizabeth Healthcare came after years of reading for the hospitals, based (more or less) on a handshake. “We both agreed to formalize an agreement,” Miller says. “RANK wanted to put skin in the game.” The practice committed itself to developing measurements to improve service, and it sought to tie compensation to performance.

RANK’s CEO, C. Chad Wiggins, MHSA, adds, “We recognized that St Elizabeth Healthcare does well when we do well. We have a symbiotic relationship.” Wiggins says that the practice also believed that a closer collaboration would make it easier for the group to maintain independence.

External and Internal Benchmarks The leadership agreement came just at the time that St Elizabeth Healthcare was implementing a PACS tied to a voicerecognition system for radiology reports.

“We built that into the equation as well,” Miller says.

A key benchmark in the original agreement established an ambitious turnaround time of 90% of exams being reported in less than three hours, according to James Roebker, MD, diagnostic radiologist and St Elizabeth Healthcare’s system director of imaging.

A related benchmark is producing 90% self-edited radiology reports. Selfediting speeds up turnaround time and holds down costs for St Elizabeth Healthcare, which needs to employ fewer transcriptionists when more reports are self-edited, he explains.

“All of those goals are tied to monetary values,” Roebker says. “We don’t get the money unless they are met. The money is actually significant.”

The practice has made considerable progress in reducing turnaround times since the agreement was put into place.

When first measured, the turnaround time for 75% of reports was less than five hours. Through September 2013, the

20 Radiology Business Journal | December 2013 | www.imagingbiz.com

turnaround time for 91% of reports is less than 2.2 hours.

Miller uses the emergency departments at St Elizabeth Healthcare as an example of how well the measurements in the leadership agreement have served patients and the hospital. Turnaround time in the emergency departments is now 30 minutes or less.

“By using the metrics, we have increased the value of our product to patients and to physicians in the emergency department,” Miller says.

“Triage is much quicker now because the exam reports are available to the physicians by the time they see patients.”

The agreement has had the effect of creating value for health-care consumers, Wiggins believes. “The beauty of this relationship is that it’s not just the classic interpretation and dictation,” he says.

“This really is a collaborative effort, and the outcome is a better product: better outcomes and lower cost to the patient.

The overall transition is to one that’s forward thinking in working for payors and consumers.”

RANK holds itself accountable for meeting performance measures both with its external business partners and within the practice through a program that holds the radiologists to rigorous standards of quality production. A tiered system with radiologist scorecards for performance assessment was adopted in 2009 to improve the alignment of physicians’ quality and productivity efforts with the practice’s goals.

The system works in conjunction with quality programs, overlaying the worklist with the goal of peer review and resulting in reduced variability in reading outcomes. The practice maintains peer review as a core recurring goal and has amassed in excess of 100,000 peer-review data points.

The tiered system evaluates radiologists’ performance (both quality and productivity) compared with the group’s median; this results in a significant portion of personal income being tied to individual performance. For 2014 and beyond, RANK is working to develop a collaborative approach to quality management by collaborating with other large national practices to benchmark

performance across all modalities (in preparation for entering risk-based payor agreements).

Regional Impact RANK has cut turnaround time to the point that 95% of all exams are now finalized in under four hours, with emergency-department and criticalfindings reports in the hands of ordering physicians in less than 30 minutes. With turnaround time under control, the focus has shifted to some of the other measures to which RANK committed itself under its leadership agreement, according to Jason Wessel, MBA, St Elizabeth Healthcare’s assistant vice president of patient-care services. Wessel previously served as health system radiology director.

To understand the importance and potential impact of the collaboration between the radiology practice and the hospital, it’s important to understand the nature of the Greater Cincinnati region; for example, as Wessel says, “The Cincinnati airport is actually in Northern Kentucky.” Southwestern Ohio, Northern Kentucky, and Southeastern Indiana converge near Cincinnati.

St Elizabeth Healthcare is the dominant provider on the Kentucky side of the Ohio River, Wessel says, but it faces competition from five major health-care systems operating in Greater Cincinnati.

To stay dominant, St Elizabeth Healthcare is relying on RANK for more than aroundthe-clock coverage in its facilities, Wessel says. It wants RANK to be involved in hospital leadership in a variety of ways.

In addition to undertaking the initiatives outlined in the leadership agreement, RANK has already trained CT technologists for cardiac screening, which is underway. Wessel says, “It’s a program that saves lives. The patient pays $300 for the cardiac screening, typically out of pocket. There is a consultation with radiologists—and a high-quality image, acquired with a low radiation dose.”

St Elizabeth Healthcare and RANK are also working on a new intervention collaboration that will allow the health system to expand services and stay competitive in its market—or (better yet) ahead of the game. “It’s an effort to offer more advanced procedures,” Wessel says.

The collaboration is more about reducing the cost of care to the consumer.

We try to remain cost competitive in the market. The way to do that proactively is to reduce cost. RANK has been a big part of that.

—Jason Wessel, MBA St Elizabeth Healthcare

Radiology is being viewed as a commodity, but we view that as both a threat and an opportunity.

—Brad Miller, MD

“One of them is an yttrium-90 treatment for metastatic disease of the liver.”

RANK, Wessel adds, has been helpful in the way that it has designated a single member of the radiology practice to administer each quality/performance initiative with St Elizabeth Healthcare, whether it’s the yttrium-90 program, turnaround-time reduction, cardiac screening, or something else. “I only need that one opinion,” Wessel says.

Standardization and Cost Containment Cost containment through standardization is another key initiative that is tied to the agreement. “We have developed committees composed of all the frontline technologists and radiologists for each modality,” Wessel explains.

“The goal is to define best practices and then work with those for better prices in return for market share. By allowing our frontline staff and radiologists to take leadership, we’ve accomplished—in about a year—what I thought would take years. We’re about 95% standardized, across the system.”

Wessel reports that his assessment was confirmed by the Advisory Board Co; following a review of the imaging-service

line, it described RANK as meeting bestpractices criteria for all benchmarks.

Wessel adds that St Elizabeth Healthcare’s cost-containment efforts are not undertaken to enrich the organization.

“The collaboration is more about reducing the cost of care to the consumer,” he says.

“We try to remain cost competitive in the market. The way to do that proactively is to reduce cost. RANK has been a big part of that.”

St Elizabeth Healthcare has not yet formed an accountable-care organization.

The hospitals are collecting the technicalcomponent reimbursement for imaging exams, and RANK is billing for the professional component. The future, however, is clearly going to bring some other payment model. “I think it’s inevitable,” Wessel says.

Wessel adds that the collaborative agreement between St Elizabeth Healthcare and RANK leaves the radiology group at risk for the loss of financial incentives if the established levels for performance/ quality measures aren’t met—but that’s not the biggest risk that the group faces.

“They are at risk financially, but they are more at risk on the exclusivity side,” he says. “We could always open ourselves up to an outside group. As long as the

www.imagingbiz.com | December 2013 | Radiology Business Journal 21

Business Intelligence Series #12

Intelligently leveraged billing data reveals changes in Pueblo Radiology’s market—and measures the impact of its response Like most radiology practices nationwide, Pueblo Radiology Medical Group, based in Ventura, California, is facing the imperative to do business differently than in the past. Wayne Baldwin, CEO of the 18-radiologist practice, attributes the shift to changes in the regulatory environment that have made today’s radiology marketplace anything but “business as usual.”

“How you operate now has to be different. You have to figure out how to modify your operations to survive in the new world” —Wayne Baldwin, CEO, Pueblo Radiology Medical Group

“Radiology has been in the crosshairs for at least five years—we’ve faced annual reductions in our fee schedules, and health plans have increased deductibles and introduced special co-pays for advanced imaging,” Baldwin says. “When patients come in now, it’s not like the old days, when we simply billed them. In far too many circumstances now, that would mean we would never get paid.”

In short, Baldwin says, business intelligence information provided by Pueblo’s billing provider, Zotec Partners, showed that the economic downturn was correlated with an uptick in bad debt—and if the trend continued, the practice’s financial health could be at risk.

“How you operate now has to be different,” he says.

“You have to figure out how to modify your operations to survive in the new world.”

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Adapting to Radiology’s ‘New World’ Pueblo Radiology covers five hospitals and owns three outpatient imaging locations, one of which is dedicated to open MRI. Since entering into a partnership with Radiology Associates of San Luis Obispo in 2010, Pueblo also acts as the southern division of a newly formed larger entity, Central Coast Radiology Associates.

The expansion reflects a trend toward consolidation in the imaging marketplace—and that’s not the only trend Baldwin has seen impacting the practice in recent years. Comprehensive monthly reports produced by Zotec revealed a few trends gaining ground, including an increase in bad debt.

“Maybe you used to bill patients $25 and now you’re billing $150, and that’s not an insignificant change,” Baldwin says. “When we looked at our data, they showed what looked like a hockey stick on the bar chart that indicated the increased value of patient responsibility dollars. And surprise, surprise, that was correlated with the economic downturn.”

Leveraging Business Intelligence Once Pueblo Radiology had identified the increase in bad debt, it was time for the practice to consider its options. “Most of the issue could be tied to failure to collect dollars at the time of the service,” Baldwin says. “We knew we had to handle our cash collections at time of service differently.”

Pueblo Radiology instituted a new training procedure for its front office staff aimed at facilitating better

Sample view of Zotec client cZAR business intelligence platform.

interactions with patients regarding payment. The results, Baldwin says, have been nothing short of dramatic. “Our new hockey stick is cash collections at time of service,” he says. “Bad debt has decreased by about 75%. That’s a significant amount of money to the practice—it represents hundreds of thousands of dollars.”

Baldwin says, “The data also allowed the practice to measure the impact of the changes it had made in operations, enabling leadership to know whether their efforts were gaining traction.”

“We changed how we operated to address a problem,” Baldwin says. “And we used the data not only to identify the problem, but to measure our progress.

Our results have been remarkable.”

A Data-driven Future As the health care marketplace continues to evolve, Baldwin predicts that business intelligence will be increasingly vital to practices’ continued success—especially radiology practices, which have already seen their fair share of reimbursement-related challenges.

“When you talk to anyone who is involved in accountable care organizations at this early stage, it’s clear that success will revolve around integrating the providers in the continuum of care so that their decisions are all based on the same set of data,” he says.

“How does radiology fit with that? We have to look more closely at productivity and cost—to marry our financial and clinical data.”

“We’re not all the way in the new world yet,” Baldwin concludes. “But when we start looking at ACOs, utilization management, decision support, and other initiatives that are in the pipeline, we know it’s going to be a data-driven world.”

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Two Views | Radiology’s Value Proposition

If we see something abnormal, we’re committed to working patients up in radiology in three days, and then getting them to a surgeon within another three days. We want to decrease the waiting time, when the patient has cancer.

—Danny N. Chang, MD

goals and metrics, with RANK, are met, we have no reason to do that. I’ve worked with a lot of radiology groups, and they’re one of the best.”

It doesn’t seem to bother the RANK administrators that so much of their practice is tied to a single client. “The reality is that we don’t think in terms of seeing them change radiology providers,” Wiggins says. “When a medical practice thinks it’s irreplaceable, that is when it’s most vulnerable. We believe that how well St Elizabeth Healthcare does is how well RANK does.”

Miller adds, “When it comes to bundled payment and those kinds of models, we clearly see that. We’re not blind to the things in front of us. Radiology is being viewed as a commodity, but we view that as both a threat and an opportunity.

With our coverage, and with the valueadded services we provide, St Elizabeth Healthcare can’t get anything better than what we give it.” That is one on-theground view of value-based radiology: When services are so good, there is no reason to change.

Kaiser Permanente In 1945, when Henry J. Kaiser founded Kaiser Permanente (Oakland, California) to provide health care for his employees and their families, he was a shipbuilding, steel, aluminum, and automobilemanufacturing magnate. Now, the Kaiser industries have been absorbed into history, its cars are collectibles, and the Kaiser name is best known in association with the country’s largest provider of managed care.

Kaiser Permanente has grown to be huge: It serves nearly nine million plan members through 37 hospitals and medical centers and 611 medical

offices. According to the company, it has about 168,000 employees and 14,600 physicians on staff. In its most recent reporting year, Kaiser Permanente had operating revenues of $47.9 billion, with net income of about $1.6 billion.

SCPMG is just one of the health-care giant’s regional entities; its 12 hospitals and medical centers are administered both corporately (from Oakland) and regionally, in southern California, by SCPMG. Danny N. Chang, MD, an interventional radiologist, is regional chief of radiology for SCPMG. He is also chief of radiology at Kaiser Permanente Riverside Medical Center (KPRMC), a hospital and integrated-care center that serves about 350,000 Kaiser Permanente plan members.

Chang is busy: He practices interventional radiology full-time and handles his administrative duties parttime, he explains. “I meet with the other radiology chiefs once a month to go over regional directives,” he says. “I report to SCPMG. The management of the radiology service is in the hands of the medical group.”

SCPMG, Chang says, is a key segment of the Kaiser Permanente administrative structure. It is a for-profit partnership composed of Kaiser Permanente physicians. SCPMG has about 5,500 physician partners, about 200 of whom are radiologists, Chang says. He adds that the SCPMG radiologists read about 3.5 million exams per year—approximately one exam for every Kaiser Permanente plan member in Southern California.

Physicians hire into Kaiser Permanente as employees and follow a three-year track to partnership in the medical group. With partnership comes voting

24 Radiology Business Journal | December 2013 | www.imagingbiz.com

rights in leadership decisions, Chang says. The actual operational decisions are in the hands of the medical chiefs and (in the case of radiology) of the radiologydepartment chiefs, he adds.

KPRMC’s staff includes about 15 radiologists, Chang says. He reports that each hospital carries out an SCPMG regional policy directive that addresses affordability, access, quality, and patient satisfaction.

Screening As Value One of the organizational goals for SCPMG radiology is mammography screening, Chang says. As Kaiser Permanente is a managed-care company with a set yearly patient-care budget, almost every department—including radiology—becomes a cost center, Chang says. As a result, Kaiser Permanente puts emphasis on preventive care, and at KPRMC, Chang has gained a reputation for pushing the mammography-screening program hard.

In 2003, Chang says, mammographyscreening rates for SCPMG were considered low; about 75% of eligible women, aged 52 to 74, were being screened. Chang began aggressively pushing mammography first at KPRMC. Kaiser Permanente, he says, had the advantage of robust electronic medical records for each of its plan members.

The record keeping is integrated, and plan members, based on the nature of their health coverage, are basically locked into the Kaiser Permanente network of facilities. The mammography-eligible women essentially couldn’t escape being flagged. If they showed up for an appointment for some other condition, they were reminded that they hadn’t had a mammogram yet and were encouraged to schedule one.

Chang went so far as to assign staff to call patients at home to schedule mammograms. He worked with the SCPMG radiology directors to extend the effort regionwide. In less than a decade, SCPMG had achieved the highest screening-compliance rates in the nation, at around 90%, Chang says. Mammography has since become somewhat controversial, and the screening rate now is about 88%, he adds.

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Two Views | Radiology’s Value Proposition

Mammography and follow-up care belong to radiology at the outset, Chang says. “For any abnormal findings, the radiologists are responsible for doing further imaging and conducting a biopsy before referring the case to a surgeon. If we see something abnormal, we’re committed to working patients up in radiology in three days, and then getting them to a surgeon within another three days. We want to decrease the waiting time, when the patient has cancer. The outside world is not as integrated as we are.”

Chang says that the value of mammography screening has shown up as a better rate of breast-cancer survival for Kaiser Permanente’s patients. Outside radiology, Kaiser Permanente also has emphasized colonoscopy screening for its plan members, with good results.

It is now implementing ultrasound screening for abdominal aortic aneurysms, Chang says. “If you have hypertension, there will be an alert for the physician to order an abdominal ultrasound,” he explains. “If the aorta is abnormal, a surgeon is contacted, the patient goes to immediate surgery, or the patient is flagged to be followed in our safety net.”

Incidental Findings Another regional initiative that SCPMG is wrestling with is how to handle incidental radiological findings, Chang says. This involves not only radiology, but multiple medical specialties in which images are reviewed. The question is what guidelines Kaiser Permanente should implement to address specific findings.

“We pick up a lot of incidental findings.

How do we track that? How do we make sure that the patient doesn’t get lost?

There’s not that much information out there on how to do that,” Chang notes.

He uses the example of kidney lesions of indeterminate malignancy. Should they be followed up in six months or a year?

To whom should the follow-up alert go?

Should it be flagged for the urologist when the patient schedules an exam?

Should radiology keep the alert on its monitors?

“We need to meet and discuss how to work up this lesion. We want to make sure it’s not forgotten,” Chang says.

Guidelines will differ, depending on the nature of the incidental findings.

While many guidelines are in place, “It’s a work in progress,” Chang says.

Imaging Uniformity Radiation exposure is an obvious value parameter for the patient—and for the institution where the exam is performed.

Kaiser Permanente is no different from other institutions in giving radiation dose close scrutiny. While radiation exposure is highlighted, however, it is just one utilization measurement of importance.

“We are an integrated service, with all the subspecialties, and we want to make sure utilization is optimized,” Chang says.

SCPMG has implemented a radiologyutilization action team; Chang says, “We have a regional committee, and each local area has a team of radiologists and clinicians based on each of the modalities.

We have MRI of the lumbar spine as one initiative. Our goal is to educate the clinician on when to order that exam.”

Another team effort is standardization of the way that specific exams are ordered within each subspecialty. “There was significant variation in how physicians in a practice would order imaging,” Chang says. “We need to share our data with the clinician so they know what to order. We have to come to an agreement on how to work up certain types of pathology. It’s a continuous effort, but we want to promote safety. If the patient had an MRI exam, he or she shouldn’t need a CT exam.”

There have been instances where patients were given CTs too frequently,

26 Radiology Business Journal | December 2013 | www.imagingbiz.com

Chang says. “We pay a lot of attention to CT dose, to make sure there are no outliers,” he reports. “The good news is that we all have almost the same type of equipment. We have a committee to come up with a standard equipment pool for the national program, so you don’t have a surprise when you order something: You know what you are going to get.”

In the big picture, Chang says, Kaiser Permanente radiology measures performance in terms of access, the cost of providing the service, and patient satisfaction. “We survey our patients and our referring physicians on how they like our service. We collect the surveys, and we score and grade them,” Chang says.

“We anticipate more members coming in under the Patient Protection and Affordable Care Act, and we want to eliminate waste in our practice,” he adds. “This is our challenge: to improve efficiency, eliminate waste, and improve access and affordability. I’m sure this will be the challenge, in the next few years, as Medicare continues to decrease reimbursement.”

Chang is right. With downward pressure on health-care spending likely to continue, maximizing value to patients and payors and eliminating unnecessary expenditures are about the only ways that providers—within or outside radiology— can expect to run in the black. Volume was once the focus of imaging delivery; now, it’s value.

George Wiley is a contributing writer for Radiology Business Journal.

Radiology100 The

The Sixth Annual Ranking of the 100 Largest Radiology Practices by FTE Radiologists

Sponsored by

Foreword

Closing the Gap on Technology

By: Hélène Gey Vice President, Marketing Intelerad Medical Systems

It isn’t news that in the last few years, the healthcare industry has gone through a revolutionary phase, as it tries to address the cost versus quality issue. What is new though is the rapid pace at which healthcare organizations are now adopting technologies that are already used in other industries. By leveraging these technologies, healthcare practices can reap the same benefits as companies in other markets, becoming more agile and in tune with their environment. This includes areas such as:

Big data: Being able to extract and intelligently leverage meaningful business data metrics from large volumes of information allows organizations to optimize business operations, and provide higherquality services with more transparency. For example, some of the KPIs that solutions like Intelerad® Analytics™ and InteleConnect® Patterns™ provide include radiologist productivity metrics (study volumes, turnaround times, etc.), quality assurance metrics (peerreview and image quality review), departmental workflow (tech workflow, the patient journey/timeline, etc.), system level data (study volumes, data volumes, performance metrics, etc.), referrer metrics (usage metrics, referral frequencies, study types, study volumes per referrer, etc.), and user population metrics (usage metrics, technologies used, etc.).

Workflow automation: Developing tools that streamline the diagnostic reporting workflow, such as template-driven reporting, importing measurements in reports directly from the modalities, integrating peerreview workflows and intelligent workload balancing and distribution directly improves the bottom line, making software smarter and users more efficient.

Self-service and Universal Access: Enabling external users to self-provision services and access their information from anywhere, a capability that is widespread in high-confidentiality industries such as financial services, now allows healthcare providers to make significant efficiency gains. Referrers’ Portals such as InteleConnect Clinical Hub™ provide streamlined and mobile access to images and reports, enabling stronger communications between referrers and radiologists. Scheduling Portals let physicians and patients request and schedule exams online.

There is no doubt in my mind that the leading groups in this year’s list of The 100 Largest Radiology Practices will proactively adopt these new technologies, positioning themselves to deliver higher value care.

Take Control of Your Performance ▪ Foster productivity and improve radiologist utilization ▪ Raise your practice’s operational excellence and attract new business ▪ Increase your quality of service

Get Closer to Your Referrer Base ▪ Analyze usage of your portal features ▪ Develop strategies based on referral performance ▪ Leverage mobile device adoption Visit us at RSNA 2013 | Booth 2165 Hall A

Radiology 100 | The 100 Largest Radiology Practices Introduction Welcome to the results of the sixth annual radiology-group survey. Recently, I had lunch (at a conference on health care’s future) with the former CEO of a large teleradiology company, and he asked how radiology groups were responding to changes in the marketplace.

Over the years, we had discussed that we both felt that radiology groups would get larger and that we would see national radiology groups, in the future. The question was never whether this would happen—but rather, when. I think that the answer is either soon or now.

Many leaders of great companies feel that one of the key reasons that they were successful is that they were in the right place at the right time. Now appears to be that right time, for radiology groups. You can see, in the survey’s results, that many groups are greatly increasing in size. How are they doing this? Mergers are the main method, because many groups are not replacing radiologists as partners retire. Productivity increases are allowing the same groups to read more exams with fewer radiologists. The number of radiologists might not be the best measurement for the size of a practice, but it is a starting point.

In 2012, the 100 largest groups represented 4,602 radiologists, and the 20 largest groups represented 1,504 radiologists. In 2013, the 101 largest groups represent more than 5,000 radiologists (a 9% increase), and the 20 largest groups represent more than 1,700 radiologists (a 13% increase). The average group in the top 20 has more than 85 radiologists.

It appears that the drive for size is real.

We hear groups talk about the need to reach a size of about 250 radiologists in order to provide 24/7 subspecialty interpretations.

These groups see the advantages of size, allowing them to focus time and resources on the service and quality measurements that are being promoted in the marketplace. There is little doubt that the bar has been raised. The great groups will step up to the table.

We also are seeing many mergers of groups of 10 to 50 radiologists that will be completed in 2014. As these groups walk through the process, it is apparent that there are many synergies and cost savings available.

We continue to be very optimistic about the future for private radiology groups. Leadership will be one of the keys to success. Consider looking into the ACR® Radiology Leadership Institute®, if you have not done so already.

Thank you for your participation in the survey.

Joseph P. White, CPA, MBA CliftonLarsonAllen CPA Consultants and Advisors

The Big Get Bigger, Primarily at the Summit

The biggest practices surge in size, but their hospital-contract totals don’t, signaling increased competition ahead By Cheryl Proval

T

he consolidation trend gathered steam in the radiology privatepractice sector in 2013, a year in which the average and median sizes of the nation’s largest private practices increased from 46 (in 2012) to 50 and from 40.5 to 42, respectively.

Administered by CliftonLarsonAllen and Radiology Business Journal, the sixth annual survey also reveals that the growth was fueled by the very largest practices (those with more than 65 FTE radiologists), with relatively insignificant median growth seen in the smaller-practice cohorts.

Financial information submitted by the practices is confidential, so the criteria used to rank them were number of FTE radiologists and (if two practices had the same number of radiologists) FTE employees. We included 101 practices this year because the three smallest practices all had 29 FTE radiologists.

The Web-based survey was made available to readers of Radiology Business Journal and ImagingBiz. com, and an effort was made to rank all practices in the United States by gathering data from practice websites and soliciting input (via telephone) from practice representatives. The names of those practices that did not confirm their information are printed in light blue (see table), and their rankings are likely to be undeservedly high because they are ranked by total (not FTE) radiologists.

We welcome your assistance in getting us closer to a complete,

accurate list. Our smallest practice had 23 FTE radiologists in 2012. This year, the smallest practice had 29 FTE radiologists.

In 2013, there was continued attrition in the number of employees in all practice cohorts (except those with 50 to 65 radiologists); this is likely to be a response to persistent reimbursement cuts. We also saw revenue per FTE employee increase in practices with fewer than 49 radiologists, but decline in the larger practices, which employ three to five times as many people as the smaller practices.

With imaging-center ownership up in the larger two practice cohorts and down in the smaller two groupings, it is not surprising that the larger practice groups are much bigger employers.

One of the most curious findings, however, is that last year, groups in the largest practice cohort had the greatest revenue per FTE radiologist; this year, they had the lowest.

The Top Five Radiology Associates of North Texas (Fort Worth, Texas), held onto the summit that it claimed last year after the merger of three North Texas practices, adding two FTE radiologists—for a total of 124. Texas has six practices in the upper half of the ranking (more than any other state). Is the market ripe for consolidation, or is there something to the notion that Texas inspires activity on a grand scale?

Advanced Radiology Services (ARS),

About the Survey The survey to rank the 100 largest radiology practices is the result of a collaboration between CliftonLarsonAllen and Radiology Business Journal. CliftonLarsonAllen is a nationwide professionalservices company counted among the top 20 accounting firms.

Radiology Business Journal is a next-generation bimonthly economics journal serving leaders in medical imaging.

East Brunswick, NJ

Harvey, IL

Advanced Radiology PA

Austin Radiological Association

Charlotte Radiology

University Radiology Group

5

6

7

8

Spokane, WA

Murray, UT

Drs Harris, Birkhill, Wang, Songe and Associates PC

Quantum Imaging & Therapeutic Associates Inc

Radiology Associates of Florida/Tower Radiology Center Tampa, FL

Medical Imaging of Lehigh Valley PC

Radiology Alliance PC

Medical Center Radiologists

47

48

49

50

51

52

Jacksonville, FL

Virginia Beach, VA

Nashville, TN

Allentown, PA

Lewisberry, PA

Dearborn, MI

Richmond, VA

MBB Radiologists

Radiology Associates of Richmond

Greensboro, NC

45

Greensboro Radiology

44

Greenville, NC

Germantown, TN

Indianapolis, IN

Tampa, FL

Las Vegas, NV

Pembroke Pines, FL

Houston, TX

East Providence, RI

Powell, OH

Houston, TX

Lakewood, CO

Raleigh, NC

46

Memphis Radiological PC

Eastern Radiologists Inc

42

43

Radiology Associates of Florida PA

Northwest Radiology Network PC

40

Desert Radiologists

39

41

Singleton Associates

Radiology Associates of Hollywood PA

37

38

Radiology Inc (OH)

Rhode Island Medical Imaging

35

36

Synergy Radiology Associates PA

34

Tacoma, WA

TRA Medical Imaging

Diversified Radiology of Colorado PC

32

33

Walnut Creek, CA

Wake Radiology

Bay Imaging Consultants Medical Group Inc

30

31

East Hartford, CT

Dallas, TX

Jefferson Radiology

American Radiology Associates PA

28

Garden City, NY

Phoenix, AZ

Maitland, FL

Minneapolis, MN

Novato, CA

Englewood, CO

San Antonio, TX

Miami, FL

Minneapolis, MN

St Paul, MN

Peoria, IL

South Portland, ME

Springfield, IL

Columbus, OH

Plano, TX

29

Southwest Diagnostic Imaging LLC

NRAD Medical Services PC

Radiology Specialists of Florida

25

26

Suburban Radiologic Consultants

24

27

Radiology Imaging Associates PC

California Advanced Imaging Medical Associates Inc

22

23

Radiology Associates of South Florida PA

South Texas Radiology Group PA

20

21

St Paul Radiology PA

Consulting Radiologists Ltd

18

19

Spectrum Medical Group

Central Illinois Radiological Associates Ltd

16

17

Mountain Medical Physician Specialists PC

Clinical Radiologists SC

Radiological Associates of Sacramento

13

14

Riverside Radiology & Interventional Associates

15

Sacramento, CA

Texas Radiology Associates

11

12

Fairfax, VA

Radiology Imaging Consultants SC

Fairfax Radiological Consultants PC

9

10

Charlotte, NC

Austin, TX

Baltimore, MD

Everett, WA

Integra Imaging PS

Grand Rapids, MI

Fort Worth, TX

Radia Medical Imaging

Advanced Radiology Services PC

2

3

Radiology Associates of North Texas PA

1

Location

4

Practice

2013 rank

Kirk A. Hintz

Ray A. Beauchamp, MD

Worth Saunders, MHA, FRBMA

Vincent Mathews, MD

Larry Smith

William P. Moore II, MBA, CRA

Stephen C. Dalton, MD

Chris (Kip) McMillan

Dennis Carter

Mary Gerard

Ethan B. Foxman, MD

Jim Tierney

Michael Belick, CRA

Ricardo C. Cury

Neeraj Chepuri, MD

Greg Q. Hill, JD

David Landry

Thomas C. Dickerson, FACHE

Clark Davis

Neil Miller

Marcia Flaherty

Jay Bronner, MD

Thomas Dunlap

Mark Jensen

Doyle W. Rabe

Bart Keogh, MD, PhD

Steve Duvoisin

Richard Moed

Mark J. Kleinschmidt

CEO

Michael Belick, CRA

Phil Russell, MBA

Charles Engmark II

Mark Martin

Gregory Q. Hill, JD

David Landry

Thomas C. Dickerson, FACHE

Marcia Flaherty

Lynn Elliott, MBA, CPA

Dawn E. Portelli

Gregory Lassiter, MD

Kirk A. Hintz

Robert Kricun, MD, and Elliot Shoemaker, MD Greg Palmieri

Elizabeth Bergey, MD

David S. Yates, MD

Jason Carter Bryan Larsen

Jeffrey West, MD

Worth Saunders, MHA, FRBMA

Walter Lindstrand

Linda Wilgus, CPA

Larry Smith

William P. Moore II, MBA, CRA

Dan Strub

Mary White

Wayne Arruda

Michael Murphy

Harley Robinson

Chris (Kip) McMillan

Dennis Carter

Mary Gerard

Margaret King

Craig Cunningham

Jonathan Pine

Jonathan Friedman

Val Cina

Ray A. Beauchamp MD

Eric Mansell, MD

Michael G. McLaughlin, MD, MBA

Vincent Mathews, MD

Krishna Nallamshetty, MD

Randal G. Shelin, MD, MPH

Benjamin Freedman, MD

Edward B. Singleton, MD

Richard Noto, MD

G. Patrick Cain, MD

Stephen C. Dalton, MD

Steve George

Michael T. Dowd, MD

Ira Finch, MD

Robert E. Schaaf, MD

J. Mark Fulmer, MD

Ethan B. Foxman, MD

Geraldine McGinty, MD; Paul Lang, MD; and Jay Bosworth, MD

Rodney Owen, MD, and Chris Dewald, MD

Josiah Bancroft III, MD

42

42

42.5

43

43

43

44

44

48

49.5

50

50

50

50.85

51

52

54

55

55

55

55

55

55

57

58

58

58

62

63

64.51

67

67

69

69

69

70

71

73

75

75.6

79

80

81

82

83

84.5

86.05

94.25

97

97

111

124

2013 FTE radiologists

Tara McKennie and Kyle Dwoichak

Thomas Dunlap

Mark Jensen

Doyle W. Rabe

Kenneth E. Ames

Steve Duvoisin

Mark J. Kleinschmidt

Lead nonphysician

Aaron Binstock, MD, and Rich Thompson, MD Jim Tierney

Jay A. Kaiser, MD

David Golden, MD

Ricardo C. Cury, MD

Neeraj Chepuri, MD

Michael T. Madison, MD

Sean Meagher, MD

Daniel Landry, MD

Charles E. Neal, MD

Michael Webb, MD

Jonathan Breslau, MD

Mark Alfonso, MD

Marshall C. Mintz, MD

Jay Bronner, MD, and Perry Gilbert, MD

Robert E. Epstein, MD

Robert Mittl Jr, MD

Gregory C Karnaze, MD

David Safferman, MD

Bart Keogh, MD, PhD

Jayson Brower and Kristin Manning

Steven Waslawski, MD

David Phelps, MD

Lead physician

44

40.5

33

43

44

42

50

49.5

45

50

46

51.03

53

54

56

51

55

52

56

55

56

54

42

57

62

63

62

65

68

66

66

70

67

60

71

68

64

75

68.4

85

85

83.25

86

108.08

122

2012 FTE radiologists

51

35

42

41

49.1

48

42

53.2

61

55

52

56

55

57

50

39

65

63

62

66

71

63

55

73

63

60

85

81.5

80

113

105

2011 FTE radiologists

45

43

41

47

38

58

50

55

50

56

53

54

50

33

67

63

65

67.7

80

56

60

64

72

61

80

80

76

105.7

2010 FTE radiologists

60

13

55

69

55

65

167

138

115

394

260

48

178

0

52

56

200

215

300

12

340

560

618

250

490

25

127

170

23

36

79

200

788

115

450

16

400

305

617

0

152

567

101

213

1

2

1

0

0

4

7

3

12

5

2

0

0

7

5

19

1

11

25

7

23

14

3

7

0

4

0

2

21

0

17

0

10

15

16

32

3

9

0

13

11

4

6

6

7

10

11

12

18

3

11

6

8

9

14

9

10

5

6

7

6

15

15

14

5

37

15

16

17

27

12

5

25

3

21

7

14

19

8

14

18

13

24

1

769,000

635,000

650,000

942,000

630,000

–

852,000

782,205

865,000

1,005,571

1,264,848

802,373

855,000

1,044,497

780,000

750,000

902,604

600,000

800,000

860,000

1,000,000

800,000

1,027,000

1,055,000

1,300,000

987,400

1

1

4

1

1

2

1

1

1

3

1

1

4

2

1

2

2

1

1

16

1

4

3

2 3

1,000,000

3

2

1

4

4

2

1

1

3

1

1,007,334

646,000

1,083,573

–

1,200,000

1,419,000

1,187,377

1,800,000

1,300,000

1,325,000

1,600,053

2,100,000

2013 FTE 2013 imaging 2013 2013 2013 states employees centers hospitals served procedures served

Radiology 100 | The 100 Largest Radiology Practices

Table. The 100 Largest Private Radiology Practices for 2013 (Ranked by FTE Radiologists)

Dearborn, MI

Galloway, NJ

Radiology & Imaging Inc

Radiology Consultants of Iowa

Professional Radiology Inc

92

93

94

South Bend, IN

Newport Beach, CA

Radiological Associates of Albuquerque

Radiology Inc (IN)

Newport Harbor Radiology Associates Medical Group Inc

99

100

101

Boise, ID

Albuquerque, NM

Fresno, CA

Boise Radiology Group

California Medical Imaging (CMI) Radiology Group

97

East Syracuse, NY

Washington, DC

Cincinnati, OH

Cedar Rapids, IA

Springfield, MA

Lancaster, PA

Trumbull, CT

Cincinnati, OH

Crestview Hills, KY

Mission, KS

Akron, OH

Huntsville, AL

Winter Haven, FL

Columbus, OH

St Louis, MO

Little Rock, AR

Clearwater, FL

Tucson, AZ

Hamilton, NJ

98

Center Radiology PC

Lancaster Radiology Associates Ltd

91

Crouse Radiology Associates

Advanced Radiology Consultants

90

95

ProScan Reading Services

89

96

United Imaging Consultants LLC

Radiology Associates of Northern Kentucky PLLC

87

Akron Radiology

86

88

Sunshine Radiology LLC

Radiology of Huntsville PC

Columbus Radiology Corp

83

84

West County Radiological Group Inc

82

85

Radiology Associates PA

81

Easton, PA

Progressive Physician Associates Inc

Radiology Associates of Clearwater PA

79

Radiology Ltd

Summit Radiology PC

77

78

80

Fort Wayne, IN

Radiology Affiliates Imaging

76

Bayside, WI

Winston-Salem, NC

Triad Radiology Associates

Wisconsin Radiology Specialists SC

Memphis, TN

75

Mid-South Imaging & Therapeutics PA

73

Hackensack, NJ

Nashville, TN

Greenville, SC

Atlanta, GA

Neenah, WI

74

Advanced Diagnostic Imaging PC

Hackensack Radiology Group

71

72

Atlantic Medical Imaging LLC

Greenville Radiology PA

69

Northside Radiology Associates PC

Medical Center Radiology Group

67

68

70

Orlando, FL

Radiology Associates of the Fox Valley SC

66

Knoxville, TN

Mesa, AZ

Vista Radiology PC

EVDI Medical Imaging

64

Pittsburgh, PA

Northridge, CA

Asheville, NC

Phoenix, AZ

Voorhees, NJ

Milwaukee, WI

Marietta, GA

Ann Arbor, MI

Charlotte, NC

Lindenhurst, NY

Lowell, MA

Virginia Beach, VA

Nashville, TN

65

Renaissance Imaging Medical Associates

Allegheny Radiology Associates Ltd

62

63

Medical Diagnostic Imaging Group

Asheville Radiology

60

61

Milwaukee Radiologists Ltd SC

South Jersey Radiology Associates PA

58

59

Huron Valley Radiology PC

55

Quantum Radiology

Mecklenburg Radiology Associates

54

56

Zwanger-Pesiri Radiology

53

57

Medical Center Radiologists

Commonwealth Radiology Associates

52

Radiology Alliance PC

51

Allentown, PA

Radiology Associates of Florida/Tower Radiology Center Tampa, FL

Medical Imaging of Lehigh Valley PC

50

Lewisberry, PA

49

Drs Harris, Birkhill, Wang, Songe and Associates PC

Quantum Imaging & Therapeutic Associates Inc

47

48

John Waltz, MD

Mary Ann Drumm

Laurie Hunt

Alan Kaye, MD

Stephen J. Pomeranz, MD

C. Chad Wiggins

Roberta Cove

Charles McRae

Mark Schaefer

Robert Carfagno

Brian Barbeito

Chad Calendine, MD

Robert M. Glassberg, MD

Bryon Dickerson

Eric C. Ferguson, MD

Kirk A. Hintz

David S. Yates, MD

Dawn E. Portelli

Michael Roossin, MD

Pedro Miro

Brian Potts, MD

John Waltz, MD

James W. Sherwood, MD

James Jelinek, MD

Brian C Randall

Laurie E. Gianturco, MD

Paul Leslie, MD

Alan Kaye, MD

Stephen J. Pomeranz, MD

Bradley L. Miller, MD

William Chase

Scott Tucker, MD

David Rippe, MD

Jason H. Fox

Jeffrey Thomasson, MD

Kathleen Sitarik, MD

John Bormann, MD

Edward J. Woolsey, MD

Benjamin G. Broghammer, MD

Dexter Witte

Joel Rakow, MD

Chad Calendine, MD

Robert M. Glassberg, MD

Steve Moss

Marc J. Miller, MD

Marvin Tam, MD

Paul M. Kiproff, MD

Andrew Deutsch, MD, MBA

Bryon Dickerson

Barry Sadegi, MD

William Muhr, MD

Robert Breger, MD

Alan Zuckerman, MD

Eric C. Ferguson, MD

Robert Barr, MD

Steven L. Mendelsohn, MD

Allan Hoffman, MD

Gregory Lassiter, MD

Michael Madler

Sheila Witous

Sara Rhodes

Lisa Smith

Mary Ann Drumm

Laurie Hunt

Kathy Epley

Vasilios Tourloukis

Bob Still

Judith Turner

C. Chad Wiggins

Mike Parsa

Ken Hohman

Joseph Serio

Roberta Cove

Charles McRae

Carol Hamilton, MBA

Alicia Kunert

Mark Schaefer

Chip Hardesty

Al Jensen

Brian Barbeito

Donald Elting

Michael Moreland

Daniel H. Seiders, CMA, MBA

Nancy Holland

Monica Nichter

Dean W. Marks

Steven Hamel

Claudia Kazanjian

John Brazil

Russell M. Lein

Adam Fogle, MBA

James Knauf

Joseph D. Barbee, MBA

Robert Day, RT

Jerry Fosselman

Kirk A. Hintz

Robert Kricun, MD, and Elliot Shoemaker, MD Greg Palmieri

Elizabeth Bergey, MD

43

29

29

29

30

30

30

30

30

30

30

30

30

30

30.5

30.9

31

31

32

33

33

33

34

34

34

34

35

35

36

36

36

36

37

37.6

38

38

38

38

39

39

39

39.5

40

40

40.33

40.5

41

41

41

42

42

42

42.5

43

43

34

29

31

28

27

28

30

30

30

29.5

30

28

29.5

31

30

50

32

33

33.5

36

27

34.35

40

31

37

37

28

36

40

37.5

34

38

32

41

38

35

42

45

40.4

39.3

40

46

38

44

40.5

33

43

34

28

30

24

28

32

30

28

30

33

34

36.35

31.8

34

40

45

36

30

34.8

40

32.5

36.2

31

38.4

40

47

51

35

42

31

22

28

26

27

34

36

37.5

39

32

30

36

40

39

35

39

40

45

43

69

5

28

144

3.5

4

4

32

50

51

109

200

375

11

6

36

10

37

79

129

95

308

7

19

115

314

286.4

11

39

195

10

–

160.21

24

410

34

58

16

42

609

60

13

55

0

2

1

0

1

1

6

27

0

0

7

0

0

0

8

0

1

2

11

9

0

6

1

7

5

10

2

3

1

0

12

1

2

1

6

3

3

7

5

2

17

2

16

7

9

5

9

2

18

2

5

14

2

5

2

3

7

4

7

4

3

7

5

6

11

4

6

942,000

490,000

410,000

302,921

405,000

550,000

400,000

550,000

250,274

595,000

620,000

360,000

468,616

680,000

690,000

511,000

370,000

504,346

515,000

665,000

550,000

–

481,758

–

–

560,410

721,909

760,250

575,000

769,000

635,000

650,000

1

1

1

1

1

1

2

1

7

1

2

1

1

2

1

1

3

1

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1

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4

Radiology 100 | The 100 Largest Radiology Practices 100

15

12

79.5 71

Key

35–49 FTE radiologists

> 65 FTE radiologists

0

Figure 1. Median FTE radiologists per practice-size category, 2011–2013.

250

6

125

87.5

400,000 62

Figure 3. Median imaging centers, 2011–2013.

Grand Rapids, Michigan, number two in 2013 (with 111 FTE radiologists), has been a top-ranked practice since the survey was initiated in 2008. ARS serves 13 hospitals; does not own any imaging centers; and employs 101 people, many of whom are likely to be employed in the practice’s managedservices organization (which handles the group’s billing). ARS added slightly more than two FTE radiologists in 2013.

Integra Imaging (Spokane, Washington) is new to the list, but the two practices that merged to create this monolith have ranked among the largest radiology private practices since

860,000

1,187,377

1,177,500

200,000

37

Figure 4. Median FTE employees, 2011–2013.

2008. Integra Imaging was the result of a 2012 merger between Inland Imaging and Seattle Radiologists, and with a combined 97 radiologists, it debuts at number three in the ranking.

Even though Radia Medical Imaging (Everett, Washington) added 11 radiologists in 2013, it slipped from third to fourth on the list, underscoring the rapid rate of growth in the top quartile of the list. Radia Medical Imaging ranked below Integra Imaging (also weighing in at 97 radiologists) because it employs 152 people, compared with Integra Imaging’s 567.

With two practices ranking among the largest five in the country, Washington

0 Figure 5. Median procedures performed, 2011–2013.

appears to inspire size.

One of the 12 practices new to the ranking this year was fifth-ranked Advanced Radiology (Baltimore, Maryland), with 94.25 FTE radiologists.

Although Advanced Radiology doesn’t have even one employee, it does have an ownership interest in 30 imaging centers, which its business partner, RadNet, operates (and presumably owns as well).

The practice serves eight hospitals.

Top-heavy Growth Our 2013 survey validates the fact that consolidation is underway among radiology practices, resulting in a growing number of megagroups—

Gain Powerful Analytics on the Usage of Your Referrers’ Portal RSNA Booth 2165 (Hall A)

2011 2012 2013 2011 2012 2013

0

47

2011 2012 2013 2011 2012 2013

2011 2012 2013 2011 2012 2013

2011 2012 2013 2011 2012 2013

0

50

56.5

2011 2012 2013 2011 2012 2013

50

2

600,000 101

100

4

800,000 632,500

161

150

733,329

170

8

887,500

190

837,500

1,000,000

207.5

200

1,007,731

1,200,000

646,306

10

Figure 2. Median hospitals served, 2011–2013.

490,000

12

2011 2012 2013 2011 2012 2013

3

2011 2012 2013 2011 2012 2013

2011 2012 2013 2011 2012 2013

20

0

6

50–65 FTE radiologists

30

486,750

27.5 30

2011 2012 2013 2011 2012 2013

40 40.2 40

40

9

< 35 FTE radiologists

56 55.5 55

454,162

60

2011 2012 2013 2011 2012 2013

80.8

80

including 11 private practices with 80 or more FTE radiologists. The median practice size grew by 1.5 FTEs— considerably less than the average size grew (four FTEs).

The reason is clear. Most growth took place in the upper ranks of the radiology 101.

The median number of radiologists in the cohort representing the largest groups (with more than 65 radiologists) increased by much more than 1.5 FTEs (Figure 1), leaping from 73 to 79.5.

The average size of this group increased from 78.9 to 82.

The median size of the cohort with 50 to 65 radiologists, however, remained the same (at 55). The average size declined from 55.9 to 55.4 FTEs. There was not much change in average size of practices in the 35to-49–radiologist cohort, either; the median and average sizes of these practices were 40.2 and 40.7 in 2012, but 40 and 40.1 in 2013. The cohort of the smallest practices grew slightly, with the median and average sizes increasing from 30 and 29.7 to 30 and 31.1.

Hospital Contracts on Hold Only the largest and smallest practice-size cohorts eked out increases in the median number of hospitals served (Figure 2). The group having more than 65 radiologists saw its median number of hospitals served increase from 14 to 15; the group with fewer than 35 radiologists increased the median number of hospitals served as well, from five in 2012 to six in 2013.

The median number of hospitals served by the 50-to-65–radiologist group declined by two, to nine; the median number of contracts held by the 35-to-49–radiologist cohort remained stable, at six. Clearly, competition for hospital contracts is keen, as that universe has not expanded since it peaked at 5,010 (in 2008). It had declined to 4,973 by 2011, according to the most recent data1 from the Henry J. Kaiser Family Foundation.

This year’s survey confirms that the nation’s largest radiology practices continue to be interested in the imaging-center business. Imagingcenter ownership has increased in

the two largest practice-size cohorts (Figure 3), from a median of seven to nine in the group with more than 65 radiologists and from five to seven in the 50-to-65–radiologist group.

The median number of imaging centers owned by the smallest group stayed the same, at two. It dropped significantly in the 35-to-49–radiologist cohort.

The median number of employees decreased in every practice-size cohort except the 50-to-65–radiologist group (Figure 4), where it more than doubled.

Perhaps this reflects the increase in imaging centers owned by practices in this cohort.

Concluding Numbers and Thoughts With consolidation underway among radiology practices and median annual procedures flat in all cohorts (Figure 5), it is safe to assume that competition for hospital contracts will heat up, particularly as practices become more efficient, more highly subspecialized, and better equipped with IT. The need to subspecialize has been cited as a factor in increased practice size, and this year’s survey demonstrates that practices are making significant headway toward this goal.

Only 13% of the practices that reported coverage patterns acknowledge using a combination of in-house and outsourced 24/7 subspecialized coverage. The rest provide in-house 24/7 coverage with no outside assistance.

Most of the 101 largest radiology practices do business in just one or two states, but 23% reported doing business in three or more states—and one does business in 16.

This year, 28 of 101 practices contributed financial data (on the condition that the data would not be shared). We are grateful for this trust, as it enables us to share broad trends that might resonate with the group. We hesitate to read too much into trends suggested by such a small sample, but the reporting practices were fairly evenly distributed and represent about 25% of each practice-size cohort.

Based on reported revenues per radiologist and per employee, it could be that the increased costs of running a large organization—including IT, professional management, imagingcenter operations, and marketing—are outrunning the number of studies that radiologists can read (and the contracts that leaders can secure). It is likely, too, that larger practices are making greater investments in activities that do not generate RVUs directly. It is apparent that more of the practices on the lower half of the list are divesting themselves of imaging centers and employees, perhaps in an effort to maximize revenue for partners—with no thought given to the longer term.

In conclusion, we congratulate the practices included among the 101 largest. Growing and prospering in a time of shrinking reimbursement are not easy things to do. Navigating a changing and demanding regulatory environment is challenging; charting a course into an uncertain future takes courage. We salute your practicebuilding skills and extend our gratitude to the practice leaders who took the time to participate in the annual survey.

Cheryl Proval is editor of Radiology Business Journal. The sponsors gratefully acknowledge the assistance of Laura Tierney, manager, health care, and Kathy Bartels, client service assistant, CliftonLarsonAllen LLC, who provided the computations and research for this survey.

Reference 1. Henry J. Kaiser Family Foundation.

State health facts: total hospitals. http:// kff.org/other/state-indicator/totalhospitals/. Published 2013. Accessed November 14, 2013.

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The New QUality Mandate | Demonstrating Value

The New Quality Mandate: Demonstrating Radiology’s Value From perfect imaging execution to implementation of patient-activation programs, demonstrating value in radiology is undergoing evolutionary change

I

f someone asked you to define quality in radiology, what would you say? The precise definition of quality is certainly nebulous, but it has never mattered too much— until now.

Under fee-for-service reimbursement, imaging programs measured quality as performance in patient safety, efficiency, and volume growth.

These measures were sufficient for the stakeholders radiology served— patients knew they were safe, referrers received reports quickly, and hospitals reveled in financial growth—and nothing more was expected of us.

Fee-for-service reimbursement, however, is disappearing. In this era of value-based payment, we must actively combat the risk of commoditization (including payors’ steering of patients to the lowestcost site of care—regardless of quality—and patients’ heightened price sensitivity as high-deductible health plans proliferate). Imaging leaders must demonstrate the quality of their programs if they wish to remain providers of choice. Efficient service and healthy growth, while still necessary in this value-based world, don’t go far enough. Imaging has to help its stakeholders achieve their goals in the accountable-care environment: We have to prove our value.

While value, like quality, can mean many things, radiology’s value proposition now hinges both on its ability to deliver the best possible product and on its willingness to

By Ben Lauing

Preload: Preview v As health care transitions from transaction to value, quality measurements also are undergoing an evolution.

v Some radiology services are going beyond critical-results communications to ensure that patients receive the recommended follow-up care.

v One hallmark of that change is the willingness of the radiologist to assume new responsibilities, resulting in imagequality oversight and the development of interpretation-support tools.

v Implementation of patient-activation programs and demonstrations of the value of imaging-based care pathways are raising the quality bar further.

www.imagingbiz.com | December 2013 | Radiology Business Journal 35

The New QUality Mandate | Demonstrating Value

One common criticism of peer review is that it can create a competitive environment and strain personal relationships.

assume new responsibilities. Success in both components will improve care and control cost—the primary goals of accountable care.

What does this look like? First, we have to elevate our core competency: the interpretation and report. Next, we must extend our roles to include participation in care coordination and, more broadly, population-health management.

Perfecting Image Quality The first step in creating radiology’s core product is image acquisition. Any error in acquisition can affect the ability of physicians to interpret the exam, delaying patient care and increasing costs.

To ensure image quality, strong technologist performance must first be secured. While many programs formally evaluate technologists using various measurements, it is time to move beyond conventional review grids (Figure 1).

UCLA Health (Los Angeles, California), for example, reviews technologists annually on high-risk, low-volume exams; these assessments ensure that technologists retain those rarely required (but critical) competencies.

The person best suited to evaluate image quality is a radiologist; as one study1 shows, however, radiologists and technologists might have very different opinions. When presented with the same 122 CT exams of the head, technologists rated image quality as poorer than radiologists rated it. In addition, technologists indicated that they would opt to repeat exams at twice the rate that radiologists would.

To address this discrepancy, radiologists at Magee-Womens Hospital of UPMC (Pittsburgh, Pennsylvania) alert administrators if they notice any exams with high repeat rates or frequent technologist errors. Then, managers review a sample of three to five exams for each technologist and organize an education session for the whole team. The facility’s PACS also allows radiologists to provide feedback to technologists in real time.

Repeating exams can result in unnecessary costs, time, and radiation dose. Allowing radiologists to provide feedback, both positive and negative, can simultaneously educate technologists on proper image acquisition and alert program leaders, if remedial action is necessary.

Image quality

92%

Radiologist feedback

92% 90%

Protocol adherence 71%

Patient safety 63%

Communication skills Throughput/efficiency

55%

Figure 1. Research by the Advisory Board Co demonstrates that performance measurement of clinical competency (three bars at top) is widespread, but measures that focus on other quality values (three bars at bottom) are less common in the 51 organizations surveyed.

36 Radiology Business Journal | December 2013 | www.imagingbiz.com

Improving Interpretation Accuracy Once the image has been acquired, the next step is the radiologist’s interpretation.

Peer review is perhaps the most common way to evaluate radiologists’ accuracy; however, some programs are starting to take a more expansive view of radiologists’ performance by soliciting external feedback.

The peer-review process has traditionally taken one of two forms: retrospective workstation-integrated review or prospective double interpretation and review. The lack of standardized methodology across programs and the inherent subjectivity of peer review make it an imperfect measure, however.

One common criticism of peer review is that it can create a competitive environment and strain personal relationships. Providing the opportunity to give positive feedback can shift the culture to one of collaborative, nonpunitive improvement. Consulting Radiologists (Minneapolis, Minnesota) added a Great Catch button to the peerreview system so that radiologists can commend each other for exceptional work.

Some organizations are moving beyond peer review by providing tools prior to interpretation, as a noncompetitive tactic for preventing errors. One major teleradiology provider has created structured report templates, both to guide radiologists through the interpretation and to standardize the report framework.

In addition, if the study is one of 25 considered to be at highest risk for radiologist error, a risk-assessment box with Do Not Miss recommendations alerts the radiologist before he or she begins the interpretation. Providing these tools has allowed this provider to improve accuracy proactively—and without targeting individual radiologists.

Another way to support the interpretation is to provide radiologists with comprehensive patient-history information. Massachusetts General Hospital in Boston created an IT platform called the Queriable Patient Inference Dossier, or QPID, which allows radiologists to request additional patient information (such as chronic-disease

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The New QUality Mandate | Demonstrating Value

history, pathology reports, and even operative results). While there has been debate over whether this information can create bias in the interpretation, the transition to population health necessitates a patient-centered approach; in turn, this calls for access to any relevant patient information.

Ultimately, if you want to confirm that your radiologists are doing a good job, you need to ask your stakeholders.

Spectrum Medical Group (South Portland, Maine) sends out 360-degree reviews (multisource assessments) to various stakeholders who are in regular contact with each radiologist. These subspecialtyspecific surveys are sent, every other year, to referrers, peer radiologists, hospital radiology directors, technologists, and others who evaluate radiologists on clinical, service, and interpersonal skills.

These results are then incorporated into formal radiologist reviews.

Coordinating Patient Care To demonstrate value in today’s world, traditional interpret-and-report radiology is insufficient. Imaging programs must now look beyond the core product and consider how imaging fits into the larger care continuum. Once you have elevated clinical performance to demonstrate value, it is time to add value.

One method is verifying the referrer’s comprehension of the radiology report. If the referrer does not see the report, patient care might be completely ignored—and the radiologist’s work rendered useless.

Gundersen Health System (La Crosse, Wisconsin) recently introduced a comprehensive case-tracking program for follow-up contact with referring physicians. If follow-up care is needed, the radiologist makes a note during dictation. A staff member runs weekly reports from the PACS, compiles a list of cases that require follow-up care, and sends messages to the appropriate referrers through the electronic medical record.

These messages don’t just ask referrers to confirm that reports have been received; they require referrers to indicate their plans of action. Asking for this level of detail does two things. First, it ensures the active engagement of physicians in

patient care, making sure that physicians have actually read through, absorbed, and acted on the radiology report.

Second, it closes the communication loop between the referrer and the radiology department; the department keeps a record of each physician’s response as documentation that the patient’s care was successfully handed off to him or her.

This follow-up system relies on the coordination of care (from the radiology department to the referrer), but what if the patient comes to the radiology department from the emergency department and has incidental findings that need follow-up care? In this case, the radiology department contacts the patient’s primary-care physician, rather than the referrer from the emergency department. If a patient doesn’t have a primary-care physician to receive results and coordinate follow-up care, the radiology department sends the patient a letter instructing him or her to call and schedule an appointment with an internal-medicine resident.

In this way, the radiology department has gone from just producing reports to making sure that they have been properly used. The program looks beyond the walls of the department and assumes responsibility for connecting patients with downstream care.

Managing Population Health Risk-based payment models—and value-based care, more broadly—require

NO 68.4%

YES 31.6%

providers to zoom out from individual, episodic patient care and manage the health of populations across the larger care continuum. Radiology is not exempt from this mandate; in fact, as a diagnostic service, its importance is heightened. If radiology programs remain segregated from the systems that they serve, they run the risk of being excluded from reform strategy and might miss the opportunity to share expertise. Two ways that radiology can add value in population-health management are the promotion of patient activation and the demonstration of the impact of imaging on a care pathway.

Patient activation is a measure of engagement in (and general ability to manage) one’s personal health care; improving patient activation has been shown2,3 to increase satisfaction, medication adherence, and quality of life significantly—while lowering patient costs. Inactivated patients, in contrast, might not show up for imaging exams and might not return to their physicians following their exams.

Imaging providers must prevent this from happening by actively engaging patients—from scheduling to results delivery. Staff members can call patients ahead of time to answer questions, technologists can confirm the patient’s comprehension of the exam, radiologists can explain results, and front-desk staff can encourage patients to call with questions after the exam (Figure 2).

YES 78.9%

NO 21.1%

Figure 2. Institutions that require technologist consultations before exams (right), at 78.9%, far outnumber those that offer radiologist consultations (left), at 31.6%, according to an Advisory Board Co survey of 38 facilities.

38 Radiology Business Journal | December 2013 | www.imagingbiz.com

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The New QUality Mandate | Demonstrating Value

In addition, radiology programs are beginning to add value for risk bearers by demonstrating the impact of imaging on specific care pathways, for both screening and diagnostic exams.

When Baptist Health South Florida in Miami launched an initiative to improve quality and cost, radiologists took a proactive role by identifying clinical areas where imaging could affect those goals. They found that about 80% of emergency-department patients with chest pain were undergoing coronary

Baptist Health South Florida isn’t the only organization evaluating CCTA to optimize care. Many institutions are instituting similar CCTA pathways, as multiple trials and studies4-6 have now revealed the significant benefits of using CCTA for specific patient indications (Figure 3). A study6 published just months ago found that the standard of care, when compared with the level 4 CCTA diversion, was associated with a 5.5 times greater risk of admission, a 1.6 times longer expected length of 24.8

Standard CCTA

18 9

6.3 2.9 Hours to diagnosis4

3.5 Cases of coronary-artery disease detected (percentage of patients)5

Median length of stay (hours)5

Figure 3. Impact of the coronary CT angiography (CCTA) pathway on patient outcomes.

angiography; this rate far exceeded the proportion of patients expected to be at high risk for coronary-artery disease.

The radiologists created a new multidisciplinary committee to review the evolving research on the benefits of using coronary CT angiography (CCTA) to evaluate the need for invasive treatment. Ultimately, the committee drafted guidelines whereby emergencydepartment physicians assign chestpain patients to one of five levels, corresponding with their risk of acute coronary syndrome. Often, level 4 patients (those at low-to-moderate risk) do not need coronary angiography and are thus diverted to CCTA first.

The results of the CCTA exam then indicate the appropriate action plan for the patient—catheterization-laboratory procedures, additional imaging, or discharge. After a year, 60% of the emergency department’s chest-pain patients—triple the previous number— were undergoing CCTA, and both costs and lengths of stay decreased significantly for those patients.

emergency-department stay, a fivefold greater likelihood of returning to the emergency department within 30 days for recurrent chest pain, and a sevenfold greater likelihood of invasive coronary angiography.

Research on care pathways for certain populations clearly can add tremendous value for both patients and providers.

One central tenet of population health is that homogeneous care does not sufficiently serve heterogeneous populations: Radiologist involvement in patient-centered, pathway-specific research is increasingly important as radiology faces commoditization and as population-health management demands innovation across the continuum of care.

According to Richard Duszak Jr, MD, CMO and senior research fellow of the ACR® Harvey L. Neiman Health Policy Institute, if radiology doesn’t prove its value, it’s just a commodity. In order to survive, radiology must exhibit both clinical excellence and a commitment to improving the entire patient-care continuum. In doing so, it will present

40 Radiology Business Journal | December 2013 | www.imagingbiz.com

itself as an indispensable partner in providing high-quality care.

Ben Lauing is a research analyst with the Imaging Performance Partnership at the Advisory Board Co. References 1. Chong J, Gorelik N, Hanagandi P, Del Carpio-O’donovan R, Torres C, Chankowsky J. CT technologist and radiologist thresholds for repeat series examinations for CTs of the head. Paper presented at: RSNA Annual Meeting; November 28, 2012; Chicago, IL. 2. Mosen DM, Schmittdiel J, Hibbard J, Sobel D, Remmers C, Bellows J. Is patient activation associated with outcomes of care for adults with chronic conditions?

J Ambul Care Manage. 2007;30(1):21-29.

3. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients’ ‘scores.’ Health Aff (Millwood). 2013;32(2):216-222.

4. Goldstein JA, Chinnaiyan KM, Abidov A, et al. The CT-STAT (coronary computed tomographic angiography for systematic triage of acute chest pain patients to treatment) trial. J Am Coll Cardiol. 2011;58(14):1414-1422.

5. Litt HI, Gatsonis C, Snyder B, et al. CT angiography for safe discharge of patients with possible acute coronary syndromes.

N Engl J Med. 2012;366(15):1393-1403.

6. Poon M, Cortegiano M, Abramowicz AJ, et al. Associations between routine coronary computed tomographic angiography and reduced unnecessary hospital admissions, length of stay, recidivism rates, and invasive coronary angiography in the emergency department triage of chest pain. J Am Coll Cardiol. 2013;62(6):543-552.

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Mount Sinai Medical Center | Decision Suport for Radiology

Mount Sinai Medical Center:

Implementation of Decision Support for Radiology Orders

A planned and methodical phase-in process has enabled this institution to prepare for the new era of health-care delivery without disrupting service

By Galen Kilroy; Paul Francaviglia; Aditi Vakil; and David S. Mendelson, MD, FACR

T

he rapid deployment of EMRs— in parallel with the extensive penetration of digital systems into radiology—has produced an environment that will enable many new technologies, including clinical decision support, to be introduced into the healthcare system. There has long been interest in clinical decision support, especially at the time of order entry, but a lack of systems (and credentialed guidelines) has limited clinical use.

In the realm of imaging, it is hoped that the implementation of radiology decision support will have an impact on inappropriate utilization and will thereby increase the quality (and diminish the cost) of imaging within the overall health-care system. Such solutions are now moving into commercially available systems. While we might expect growing pains, we simultaneously should look for enhancements in the quality of care that we can deliver to our patients. New opportunities have arrived; we need to take our new tools and put them to use.

At MSMC, our first efforts to implement a radiology decision-support system made us early adopters of commercial offerings.

MSMC encompasses both the Mount Sinai Hospital and the Mount Sinai School of Medicine. The Mount Sinai Hospital, founded in 1852, is a 1,171-bed tertiaryand quaternary-care teaching facility and is one of the nation’s oldest, largest, and most respected voluntary hospitals.

Nearly 60,000 people were treated at MSMC as inpatients in 2011, and approximately a million outpatient visits

Preload: Preview v Following a two-year search, Mount Sinai Medical Center (MSMC), New York, New York, began implementation of decision-support software for radiology order entry, delivered through its electronic medical record (EMR). v Integration of the solution into the EMR required minimal effort on the part of MSMC’s IT team, calling for about 40 hours of work.

v A phased implementation was planned: The baseline data-collection phase (in which scores were not provided) was followed by a limited rollout to the emergency department. v Initially, the EMR vendor provided two options for indications (one long list and one short list), but greater flexibility in presentation and order of indications is provided in the vendor’s latest version.

The authors (from left): Galen Kilroy; Paul Francaviglia; Aditi Vakil; and David S. Mendelson, MD, FACR.

took place. Due to MSMC’s location on the Upper East Side of New York City, the hospital is at the intersection of some of the wealthiest and poorest zip codes in the United States; it has the responsibility of meeting the unique medical needs of both patients from affluent backgrounds and those requiring indigent care.

MSMC’s focus is on seamless care coordination across all ambulatory, inpatient, and emergency-department settings—as well as on providing access

42 Radiology Business Journal | December 2013 | www.imagingbiz.com

to patients’ records to their clinicians.

This is being supported using a wellknown, broadly deployed integrated EMR at MSMC. In addition, MSMC is also implementing a wide array of advanced clinical processes that are made possible by the EMR. The primary drivers are quality, safety, and efficiency.

We spent approximately two years exploring potential decision-support solutions for radiology. In parallel, the ACR® had made a decision to make

its well-known ACR Appropriateness Criteria® available (in a format that can easily be consumed by downstream systems) via ACR Select—the Webservice version of the appropriateness criteria and exclusive distributor of the guidelines.

We were positioned to purchase a solution concurrent with the release of the ACR Select product; simultaneously,

vendor with lists of indications. The EMR then needs to orchestrate the presentation of these indications. In this first version, there was little flexibility regarding the structure and presentation of these indication lists. The lists were provided as groups, and one could combine these groups to build a list that would be presented to the ordering provider at the time of order entry. In essence, a site had

In the realm of imaging, it is hoped that the implementation of radiology decision support will have an impact on inappropriate utilization and will thereby increase the quality (and diminish the cost) of imaging within the overall health-care system. our EMR vendor adopted the approach of establishing a transparent means of importing and integrating credentialed rule sets for clinical decision support for radiology. These two converging strategies have facilitated our current approach. The ACR provides an authoritative source of clinical decisionsupport rules, meant to be consumed as a Web service by multiple EMRs, so the solution is vendor agnostic. In fact, this approach makes initial implementation fairly straightforward, requiring little technical effort (on the order of 40 hours of work).

This implementation represents a first version and an early effort of the EMR vendor to integrate the ACR Select rule set, and as such, it had many constraints.

The ACR Select product provides the

a choice of providing long lists—quite inclusive of every possible indication for an exam—versus short lists of common indications (excluding rarer indications).

As an academic institution with many specialty providers, we initially elected to provide the long, granular lists of indications. We had a small group of radiologists and clinicians review the lists and decide which to include and which to exclude. Our local EMR team then did the work to integrate these indications with our EMR. The Data-collection Phase Phase 1 of radiology decision support was implemented in March 2013. This was intended as a baseline data-collection www.imagingbiz.com | December 2013 | Radiology Business Journal 43

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Mount Sinai Medical Center | Decision Suport for Radiology

This phase is intended for data collection, validation, and initial analysis. Active decision support was not included in this phase; that is, the scores were not presented to the ordering provider, but were kept in a database in background. phase. When exam indications are selected, they are sent to ACR Select servers for the return of a decisionsupport score to the EMR via Webservices interface.

The scores can range from 1 to 9. A score of 7 to 9 indicates that the order is deemed highly appropriate. Scores in the range of 1 to 3 suggest that the indication for the exam does not meet the standard recommendations of the ACR Appropriateness Criteria; scores of 4 to 6 suggest an intermediate level of compliance with the guidelines. This does not necessarily mean that it is wrong to order the exam, but the indication should undergo further scrutiny to determine why the specific exam would be justified.

All agree that there will be fully justified outliers.

This phase is intended for data collection, validation, and initial analysis.

Active decision support was not included in this phase; that is, the scores were not presented to the ordering provider, but were kept in a database in background. An analysis of these data will be employed to

sit with these providers, review their personalized data, and try to understand the anomalous ordering pattern. If the provider cannot justify the deviation from standard practice, education will be provided.

When this step is completed, we intend to turn on the feedback mechanism. At that time, scores below 7 will be shown to ordering providers using a pop-up screen. They will be given the opportunity to change their orders and/or provide additional information. Recommendations for other imaging exams that match the provided indication better are listed on this screen.

It is important to note that we will not prevent the provider from moving forward with the original order. Our staff will be informed that this is an ongoing quality-assurance activity, and the data will continually undergo review.

Initial Response Radiology decision support is currently in use in our emergency-department and inpatient settings. Shortly before

Compliance with selecting a discrete indication of use for CT and MRI orders has been approximately 65% to 70%, with particular challenges seen in the emergency-department setting. help guide phase 2 of the project, in which active decision support will be rolled out to ambulatory and inpatient settings.

We will use these data to improve our understanding of the patterns of ordering at our institution. The data will be used as quality-assessment and education tools.

We are looking for providers who consistently obtain low scores (1 to 3) for the exams that they order. Senior clinical and radiology staff will privately

going live, we made several broadcast announcements to reach the various providers who order imaging exams; they include physicians, nurse practitioners, and physician assistants. In addition, within the EMR, we provided instructions regarding the new appearance of the indication screens and how to respond to them. ACR Select currently covers CT and MRI. Our local analytics group developed reports that we run weekly;

46 Radiology Business Journal | December 2013 | www.imagingbiz.com

they enable us to assess utilization and radiology decision-support scores by ordering provider, attending physician, and location.

Compliance with selecting a discrete indication of use for CT and MRI orders has been approximately 65% to 70%, with particular challenges seen in the emergency-department setting. Without a discrete indication being chosen, no decision-support score is returned, which prevents meaningful data gathering (and informed reporting). It is important to note that our implementation permits a workaround (typed-in free text) that bypasses the ACR Select scoring system.

There is an alternative available that would provide a hard stop if the user chose no ACR Select indication.

We deliberately have chosen not to implement that hard-stop alternative.

Initial feedback has indicated that clinicians have not always appreciated (or understood) that we would prefer the discrete indication to the free-text information, despite the education that we provided one to two weeks before the systemâ&#x20AC;&#x2122;s implementation. We would

Mount Sinai Medical Center | Decision Suport for Radiology

like to avoid making this introduction confrontational, so we have elected to extend the educational campaign. We have started to attend departmental grand rounds, to contact department chairs, and to extend these educational efforts.

Initial reporting has focused on score distribution (appropriateness of orders) and on the volume of radiology orders.

Although the clinicians are not receiving

Second, there is no ability to search the list of indications, nor are they grouped in a meaningful clinical manner.

The list of indications is alphabetized; however, indications are not always intuitively named. For example, loss of consciousness (as a synonym for syncope) is listed not under L, for loss, but rather, under E, for episode of loss of consciousness. Some of the indications

On a weekly basis, 8% to 10% of orders are falling into the category indicating that they are inappropriate. decision-support feedback, we have seen certain trends consistently emerge. On a weekly basis, 8% to 10% of orders are falling into the category indicating that they are inappropriate.

While many providers sporadically receive such a score, there are a few who have a significant percentage of their orders in this category each week.

This group represents a target for this initiative to improve care and diminish inappropriate utilization. Once active decision support is in place, these reports can be used to monitor overall volume and behavioral changes (for example, how many orders are started, but are not placed—or are changed to more appropriate orders).

Challenges and Feedback We have had no unsolicited negative reactions to our introduction of radiology decision support. The use of free text by a significant number of providers, however, might (in part) have represented such a reaction. When we reviewed our data, it became clear that a large volume of the free-text entries arose in our emergency department—a fast-paced care setting and a high-volume user of radiology exams.

A focus session with members of the emergency-department staff identified three main challenges. First, the long list of indications—with more than 100 possible selections, in some cases— caused many providers to use the free-text option instead of scrolling through the list. Having too many choices available when ordering some tests discourages users (especially occasional users) from perusing the lists.

are so similar as to seem to be duplicates, and this contributes to the length of the lists.

Third, there are interface limitations.

Indications are often truncated, so the cursor must be made to hover over them before the user can see the full text.

Many of these observations were confirmed in other focus sessions and discussions. We also learned that despite our efforts, many providers remained unaware of the overall program and its goals.

Next Steps We quickly decided to address the first issue, long lists, by confining our system to using the shorter lists (most common indications). Orders with a high volume of noncompliance are being updated with truncated lists of indications, within the constraints of the EMR system. We did

48 Radiology Business Journal | December 2013 | www.imagingbiz.com

this first for exams of the central nervous system, and we achieved an improvement in compliance of as much as 10% for these exams.

We are in the process of providing shortened lists for all other studies that have long indication lists. These will be monitored to determine the effectiveness of the changes. In addition, radiology reached out to specific department leaders, requesting increased compliance with the initiative. Process instructions within the EMR also were updated; the new wording asks users to select a discrete indication for the ordered exam.

Our EMR vendor is aware of many of the current limitations of the current implementation. It has done significant development work concerning the indications-of-use section in its 2014 release, and we have requested an update/patch to the existing release.

These functionality changes to the EMR would not require a change in indication mapping or in the Web-services interface.

Despite the growing pains that we are experiencing, we believe that our current efforts are valuable. They have not been disruptive, and they have provided an early experience that will contribute to our ability to thrive in a new era of healthcare delivery. We have already collected data indicating that there are providers who can improve their practices with clinical decision support and education.

We would like to collect four to six months’ data in the background before turning on decision-support feedback for viewing by clinicians. The efficient, cost-effective delivery of care—with a concomitant commitment to raising the quality of care—requires us to implement (and evolve) the new tools that are available.

Galen Kilroy is application manager for computerized provider order entry at the Mount Sinai Medical Center (MSMC), New York, New York. Paul Francaviglia is associate director of reporting and analytics at MSMC. Aditi Vakil is director of IT at MSMC. David S. Mendelson, MD, FACR, is director of radiology information systems for the department of radiology and senior associate in clinical informatics at MSMC.

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Massachusetts | Radiology’s Value Proposition

Radiology’s Value Proposition:

The Massachusetts Experience

Panelists representing a payor, an outpatient imaging-center chain, and the radiology department of a luminary site provide insight into the specialty’s shifting value proposition under health-care reform

By Kris Kyes

O

n September 9, 2013, Cheryl Proval, editor, Radiology Business Journal, moderated “The Boston Experience: Radiology’s Value Proposition in the New Health-care Paradigm,” a panel discussion held in Boston, Massachusetts, at the RBMA Fall Educational Conference. The meeting location offered a unique opportunity to explore radiology’s changing value proposition under health-care reform with a panel that represents hospitalbased radiology, outpatient radiology, and the payor community.

Steven E. Seltzer, MD, FACR, has been chair of the department of radiology at Brigham and Women’s Hospital (Boston, Massachusetts) and Philip H. Cook professor of radiology at Harvard Medical School since 1997.

Michael Sherman, MD, MBA, is senior vice president and CMO of Harvard Pilgrim Health Care (Wellesley, Massachusetts), a full-service healthbenefits company. He serves on the advisory board of the Institute for Clinical and Economic Review and on the board of directors of Massachusetts Health Quality Partners.

Patricia Whelan-Downey, MHA, is CIO of Shields Health Care Group (Quincy, Massachusetts), a leading provider of outpatient diagnostic imaging for 25 years, and is senior partner of Shields Consulting.

The panel (from left): Steven E. Seltzer, MD, FACR; Michael Sherman, MD, MBA; and Patricia Whelan-Downey, MHA.

Proval: Massachusetts is the birthplace not only of the American Revolution, but also of the revolution in US health care.

The state went live, in 2007, with its brand of health-care reform, widely seen as the model for the federal Patient Protection and Affordable Care Act. How did health-care reform affect what Harvard Pilgrim was looking for from radiology?

Sherman: In Massachusetts, we were first—ahead of the curve—in universal access. I think we are getting a lot of scrutiny to answer these questions: What happens after you do that, and what happens to cost? The good news is that virtually all of our citizens in Massachusetts have coverage.

We are number one in many things, however, and unfortunately, one of those things is per-capita cost (among the 50 states) in what we spend on health care for our population. Part of it is that we have world-class providers, and some of them are expensive. It’s an expensive part of the country, too.

We also have a state that likes mandates. We have mandates that many other states do not have concerning autism, infertility, and other conditions.

50 Radiology Business Journal | December 2013 | www.imagingbiz.com

These are not inherently good or bad, but when you put those in place, they do raise costs.

Jump ahead from the onset of universal access to today: We’re in an expensive market, and there’s concern about our ability to pay for care. Massachusetts Chapter 224 passed last year; that is a law that says, OK, good job getting access: Now, we need to think about value.

One of its implications is that the state has decided that health-care costs should not grow any faster than 3.6% per year (which policymakers estimated as the probable equivalent of growth in the state’s version of the gross domestic product). This has payors and providers thinking, together, about how to work toward a 3.6% goal.

It’s having an impact on how we contract—and on how we look at coverage policies (in terms of products, narrow networks, lower price points, and other types of innovative products that we have. It has to do with how we are looking at our informatics capabilities and how we are partnering with the physician community, which presumably would have some enforcement mandate.

That’s important stuff, but ultimately,

we’re not quite sure what happens if we don’t keep cost increases at less than 3.6%. It’s been suggested that you’ll be taken before the state attorney general’s office.

We did partner with a radiology benefit management (RBM) company, and that’s helped keep our trend to 3.6% for radiology, over the past five years. It was higher, before that.

Proval: What did Brigham and Women’s Hospital want from you?

to happen on the federal level. The state government began seeing utilization creep up a little bit in all fields, including radiology also, and it saw increasing expenditures to make sure that everyone had insurance.

Now, we shift to phase two, which we sometimes call payment reform: how our insurers and our providers are responding to a climate where reducing costs and improving value are now imperative. We’ve got the coverage part; now, we have to work on the cost side.

Seltzer: We are in the sixth year of what we jokingly call RomneyCare (though it was disavowed by the presidential candidate), and 99% of adults and 99.5% of children in the Commonwealth of Massachusetts have health insurance.

The initial impact of universal coverage on a provider radiology department such as ours was not that significant.

We had always had a core value of being a payor-agnostic department and would cover patients with or without health insurance. We saw a little bit of an uptick in demand, but not a tremendous difference.

Predictably, the costs borne by the state government went up—because one of the ways that we got the uninsured insured was to take everyone who was eligible for Medicaid and make sure that they were actually in Medicaid. Those who were earning up to 300% of the poverty level got state-government subsidies for their health-insurance premiums.

This is very similar to what’s going

Whelan-Downey: Coming from the forprofit market (with Shields Health Care Group), we have not seen huge upticks, in terms of volume. We have chosen to focus on a very simple concept: How much is it? A lot of our focus has been on reaching out to consumers and really helping them understand what it is that they’re going to pay for, how they’re going to pay for it, and for which part they pay (versus for which part the insurer pays).

That is actually contributing to increased volume because many other plans, as you know, are high-deductible plans. When patients are reaching into their pockets to pay for services, they want to know how much those services will cost.

We’ve been doing a lot of direct-toconsumer outreach programs through our website (and through other mechanisms), but we’re starting to see, from the IT perspective, multiple online tools becoming available to consumers.

These tools try to enable them to

participate in the conversation about cost (but contribute to cost containment) by understanding that if I make this choice—to go see this provider, versus that one—our total health-care cost, with my employment group, will be affected.

We still have an employment-based health-care system; employees have some control over how they’re contributing to the cost of the overall health-care marketplace, but they are also considering their individual out-of-pocket costs.

Reaching out specifically to the consumer has really been our focus.

Proval: As a pioneer in the development and use of clinical decision support for radiology orders, is your department eliminating unnecessary imaging?

Seltzer: Clearly this is one element (though not the only element) of reducing total medical spending on imaging services. The decision-support system that we use was largely developed by one of our own faculty members (Ramin Khorasani, MD, MPH), who was granted a US patent on this more than two years ago. We’ve licensed the intellectual properties to a company in which our institution is an equity owner; I want to be sure that you know about that economic conflict before I comment.

The system is designed to work with an electronic health record and computerized provider order entry (CPOE) to provide advice to referring physicians at the time that they order radiology studies. The advice can be as

www.imagingbiz.com | December 2013 | Radiology Business Journal 51

Massachusetts | Radiology’s Value Proposition

Have we eliminated unnecessary imaging?

I’m sure that the answer is no—because that’s a very tall order.

—Steven E. Seltzer, MD, FACR

simple as, “Great idea, let’s do it.” It can be as simple as, “Did you know that this patient had that exam last week? Are you sure you want to do it again?” It can be as simple as, “The indication was leftarm pain, and you ordered a right-arm radiograph; is something wrong with that?”

It also can be as sophisticated as, “Considering that in the last 1,000 women (aged 35 to 45) who presented with headache and no focal neurologic findings, the yield of MRI in the emergency department was next to nothing, think twice before you do this exam.” We allow physicians to override the advice that’s given, but we find that generally, they do follow the advice and the decision.

Have we eliminated unnecessary imaging? I’m sure that the answer is no—because that is a very tall order.

I wish I could tell you this is a panacea for eliminating unnecessary utilization, but I’m sure I can’t do that. In targeted situations, though, it does seem to help us look at reducing the intensity of utilization and increasing the positive yield of studies.

Clinical decision support through software is necessary—but not sufficient, we found, in managing radiology utilization. That has to be multidimensional.

In addition to clinical decision support, which we apply hundreds of thousands of times a year, we also have a peer-to-peer consultation program to get radiologists more active, more out of the shadows, and more involved in clinical decision making. Sometimes, when an order is entered into the CPOE system, the input is so unusual that we say, “We can’t even give you decision support; you’d better call Dr Khorasani or Dr

Seltzer, talk to one of them, and figure out what it is that you really want to do.”

We also construct profiles of physicians’ test ordering, as a lot of insurers do. We provide educational opportunities to help them order the proper tests, and we team up with our physician organization to give them financial incentives (under the pay-for-performance systems that our insurance colleagues have developed— where typically, one of the measures is intensity of radiology utilization).

In our own organization, we’ve not put radiologists at financial risk for this because we feel that radiologists don’t order the tests. In fact, we feel as though we’re part of the solution, not part of the problem. We do try to help referring physicians earn their withholds back, however, so it’s a multidimensional program. The computer basis is amazing—and it is necessary, but not sufficient. You need other solutions as well, in our experience.

Proval: Has your imaging spending increased or decreased since health-care reform came into effect? What impact will the mandate to control cost have on your strategy?

52 Radiology Business Journal | December 2013 | www.imagingbiz.com

Sherman: Imaging spending was going up to the high single-digit and low double-digit range—and again, it’s not about the radiologists. Patients don’t get up and decide to go get imaging studies; radiology is subject to demand created by others. The RBM helped to bring the trend down to about 3% a year, which is consistent with Chapter 224; our objective in this area was to ensure that referring/ordering physicians are using accepted evidence-based clinical guidelines in deciding whether to order advanced imaging studies.

We actually have exempted Partners HealthCare (which includes Brigham and Women’s Hospital and Massachusetts General Hospital) from our utilizationmanagement program, but it’s not really about the radiologists. They know what to do. There are some other tactics that we’re using to try to keep our focus on high-value radiology procedures.

On the member side, we do have a transparency tool coming out that will provide information about the cost in different imaging facilities; we’re intending to present some quality information as well. I would suggest that if you want to be successful, either be a lowcost provider of service—or think about imaging studies not as isolated services, but as part of the larger ecosystem and as part of how you contribute to value.

Proval: There is a greater price sensitivity in today’s broader market; what role is IT playing in response?

Whelan-Downey: I find it simply astounding that patients can’t find out how much services cost. The students who are now covered, along with postgraduate students and recently graduated college students, cannot believe the lack of available information.

I employ a small group of programmers. We have a lot of think-tank discussions about how we should handle this and how we could do better. One of the things we’ve talked about doing (but haven’t done yet) is creating something like a cost-savings locator.

Maybe, if there were an app (or a site) where you could see all of the

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Massachusetts | Radiology’s Value Proposition

area’s providers of the relevant services, in order by distance from the patient’s home (as well as by any other factors that interest the patient), people would find that useful. I see the number of online

Partners provider can have that image on his or her electronic desktop with a couple of clicks.

All this happens within the electronic medical record of the Partners system,

I find it simply astounding that patients can’t find out how much services cost. The students who are now covered, along with postgraduate students and recently graduated college students, cannot believe the lack of available information.

—Patricia Whelan-Downey, MHA Shields Health Care Group

tools increasing. I see the IT departments collaborating, between the insurers and the providers—more than ever before.

Proval: What’s your strategy for maintaining market share, with aggressive new for-profit organizations coming in—and how have your communications changed with the marketplace?

and in addition, we are now beginning to do consultation to support the care continuum. Price-based competition is bad for us, and we’re biased against it, for obvious reasons. We feel as though that also creates commoditization of our services.

Seltzer: This is a point of distinction between the ways that an academic medical center and a high-quality community provider approach trying to retain market share. Our attitude is more focused on the value part of the proposition. We like to talk with our referring physicians, but not so much with our patients.

If you work within our integrated delivery system and use our IT tools, you’ll get advice on test selection. You may be immune from preauthorization.

You can schedule the exam online at any of our facilities. You get a pretty good guarantee that the patient is going to be scanned with the most advanced imaging equipment possible.

We track radiation exposure for patients throughout our entire healthcare system. We promise subspecialty interpretations for all exams. We have automated abnormal-results–reporting mechanisms that make it quick to send back actionable clinical information to referring physicians. We have an anyimaging, anywhere, anytime approach to our PACS, so any referrer having a patient’s imaging study done at any

54 Radiology Business Journal | December 2013 | www.imagingbiz.com

We prefer to market on a value basis, so we don’t typically market directly to our patients. Our opinion is that it’s hard to understand completely the ambiguity and the obfuscation of what it really costs to get an exam. It is hard for a typical patient to make a value judgment, when there are so many factors in the value equation that he or she can’t possibly understand. For these reasons, our marketing communications are aimed directly at the physicians—in our network and outside it.

Proval: How are you demonstrating the value of your services to hospitals and payors?

Seltzer: The definition of adding value in radiology is still complicated. It’s very challenging to put a quantitative estimate on the value that a high-quality diagnostic-imaging exam provides to

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Massachusetts | Radiology’s Value Proposition

the patient. Once you’ve made a precise diagnosis that dictates what the treatment is going to be, savings can come from the reduced cost of therapy for a wellcharacterized disease.

We’re finding it harder to attribute costs and outcomes to radiology specifically, and we’re moving toward the model of making the right diagnosis

The question is not how much radiology is costing, but what the value of that episode is— and what radiology contributes.

—Michael Sherman, MD, MBA

and getting it exactly right—down to the genomic level. It’s interesting, it’s brand new for us, and it’s challenging.

Proval: Is Harvard Pilgrim using incentives to move radiology providers toward valuebased care?

Sherman: We’re trying to put together various bundles that pay a global amount for a spectrum of care. In these emerging models, we are paying a provider group for outcomes, not volume of services— which, in some cases, could actually mean that if something goes wrong, the group might not get paid additionally for the care required to address the complication.

In these models, the physicians and other providers should not be thinking about encounters, and they are free to get away from focusing on what activities will get them paid. In order to be successful in these models, they need to be thinking about what services and tests best deliver the desired outcomes, including which services create no value (such as repeating tests that they were unaware had been done previously).

The question is not how much radiology is costing, but what the value of that episode is—and what radiology contributes. If you have radiologists who are helping to guide referrers to the right studies (or helping to prevent the wrong studies from being done) and ensuring

that the information is used appropriately, that’s what I get excited about; that adds value.

Proval: How has heightened cost consciousness affected the Shields value proposition?

Whelan-Downey: Our value proposition has changed very little since the company was founded, in 1971: It’s to treat every patient as you would want your mother to be treated; be easy to do business with; and hire the best and most talented technologists and radiologists—and do it all at an affordable cost. If we do those things well, that’s how we are going to define survival ability.

We believe that there’s a place for a provider—whether it’s a for-profit organization or not—that has those kinds of values. That represents the goal: to get to a sustainable health system in which we all contribute to lowering the pooled cost.

Proval: How will Shields engage in care coordination and collaboration with other providers—and what role will IT play?

Whelan-Downey: An increasingly strategic one: All of IT and radiology, historically, has been somewhat inward.

The business itself needed to run. It was an operational IT role—but with health reform, market changes, and changes in demand, we’re starting to see IT departments become more strategically imperative. You need to connect in new ways with referring physicians, patients, and even other providers in hospitals and health systems.

The collaboration component of it has probably changed form about three times in the past 30 years. In the 1990s, it was about getting everything online. In the 2000s, it became about interfaces, point-to-point connections, and passing information to one another.

In the 2010s, it’s best described as (more or less) information sharing. It’s more of a platform-based approach that allows you to exchange information bidirectionally with other organizations.

This has changed the role of IT in radiology. It’s brought CIOs to

56 Radiology Business Journal | December 2013 | www.imagingbiz.com

advertiser index Affiliated Professional Services (800) 841-5200 www.affilprof.net............................................. 11 CliftonLarsonAllen (612) 376-4500 www.cliftonlarsonallen.com/HealthCare......... 55 eRad (864) 234-7430 www.erad.com................................................ 15 Esaote (800) 428-4374 www.esaoteusa.com....................................... 39 Fujifilm Medical Systems (800) 431-1850 www.fujimed.com.................................. 5, 49, 57 Hitachi Medical Systems America (800) 800-3106 www.hitachimed.com........................................ 2 Integrated Medical Partners (877) 816-1467 www.integratedmp.com.................................. 19 Intelerad (514) 931-6222 www.intelerad.com.............................. 27–34, 60 Konica Minolta (800) 934-1034 www.medical.konicaminolta.us....................... 53 McKesson Enterprise Medical Imaging (800) 661-5885 www.mckesson.com/medicalimaging............ 13 Merge (877) 446-3742 www.merge.com............................................. 47 Optimal Radiology Partners (877) 833-2242 www.optimalradiology.com............................... 3 Philips (800) 229-6417 www.healthcare.philips.com/us_en/............... 37 Radiology Leadership Institute (703) 637-4381 www.radiologyleaders.org/enroll............... 44–45 RamSoft (888) 343-9146 option 2 www.ramsoft.com........................................... 59 Red Rock Diagnostics, LLC (877) 362-6077 www.redrockdiagnostics.com......................... 41 Sectra (203) 925-0899 www.sectra.com.............................................. 25 VMG Health (214) 369-4888 www.vmghealth.com......................................... 9 Zotec Partners (317) 705-5050 www.zotec.com..................................... 7, 22–23

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Fujifilm DR Is “a Step Above”

atients at University of Wisconsin Health Partners (UWHP) Watertown Regional Medical Center may not understand all of the technical nuances related to how Fujifilm’s AcSelerate digital radiography (DR) suite improves their care, but they routinely benefit from its pure speed. “About a month ago, I had a patient who was in a car accident and needed multiple x-rays,” Nate Schubert, RT(R) CT, a technologist at UWHP, says. “The patient was obviously in extreme discomfort, nervous, and scared that bones might be broken. Instead of the total exam taking an hour, it took about 25 minutes.”

Auto Positioning Ergonomics

AcSelerate’s innovative design and auto positioning system were engineered with a focus on staff ergonomics, in response to recent trends showing that repeatedly moving heavy x-ray equipment contributes to workplace injuries. According to OSHA, U.S. healthcare workers suffer more injuries on the job than any other U.S. occupation. In one U.S. study, 70% of surveyed radiologic technologists suffered from some form of work-related repetitive stress injuries (RSI).

For radiologic technologists like Schubert, AcSelerate’s automation adds up to vastly improved workflow complemented by ergonomics, which allows for better outcomes and improved patient (and technologist) satisfaction.

Advanced Applications

Schubert, his colleagues, and the clinical staff are making use of multiple advanced applications beyond the system’s timesaving capabilities, including dual-energy subtraction (DES). DES is an advanced imaging application that intelligently separates anatomical structures of high and low x-ray absorption, such as soft tissue and bone—subtracting one from the other, the better to visualize pathology hindered by underlying and/or overlying structures.

“In your standard x-ray of the chest, you get to see the lungs, but ribs are overlying the lungs, along with the sternum and other bones,” Schubert notes. “DES takes a standard chest x-ray and then almost instantly takes a second at half the dose.

Then it processes the two images, and by subtracting one from the other, it gives us three different images—your traditional chest x-ray, plus an image where the lung tissue is removed (so all you see is bone),” Sponsored by FUJIFILM Medical Systems USA, Inc

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and a third image that shows soft tissue only. The simple logic is that malignant/ cancerous tumors are not typically calcified, so if a suspect pathology is not evident in the soft-tissue image, then it’s likely benign and therefore needs no further, more doseintensive imaging.

Lowering Cumulative Dose

Like many facilities, UWHP used computed radiography (CR) for years, so when it made the transition to DR, its staff wanted to invest in the most advanced technology possible. “AcSelerate is a step above DR,” Schubert says. “It offers unique patented detector engineering designed to lower dose as much as 20%, compared

“AcSelerate is a step above DR.” — Nate Schubert, RT(R) CT with conventional DR detectors like it. These dose efficiencies are nicely coupled with advanced applications and automation that are becoming indispensable in radiography.”

Many of the AcSelerate’s advanced capabilities are especially promising when it comes to reducing patients’ cumulative radiation dose by cutting back on alternative CT utilization. “This is one advantage of the Tomosynthesis feature,” Muria Dorshorst, RT(R), a technologist at UWHP, explains. “Let’s take a patient who might have a fractured wrist. If a standard x-ray cannot show the fracture well enough for the surgeon, the next step is to take him or her into CT. It is more expensive than an x-ray, and a significant increase in radiation dose, but with the AcSelerate, you may be able to use Tomosynthesis to see that fracture—and reduce radiation dose and the cost.”

In addition to lowering the radiation dose for patients, lowering costs is a critical concern in today’s healthcare-reform environment. As hospitals and physicians assume greater financial responsibility for overall population-health management, it’s becoming increasingly vital that healthcare providers use just the right amount of technology to accomplish the clinical task at hand. By broadening the applications of low-cost, low-dose DR, AcSelerate can help hospitals and practices manage costs while providing advanced quality care.

Enhancing Patient Care

Fewer retakes and additional time with patients also can have a positive impact on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient-satisfaction scores. “If you can get the exam done with speed, accuracy, and automation, that can allow you to spend more time at the patient side,” Schubert explains. “We have more time to interact with the patients at a personal level. We can ask how their day is going because we know we can make up time on the back end with the speed and efficiency of the DR room.”

The improved workflow creates happier patients, but it also creates happier employees, capable of increased productivity.

“With the improved efficiency, you may not need the same amount of resources that you would have five years ago,” Schubert says. “In the case of a new hospital being built, if you could cut one or two x-ray rooms out of the overall construction plans; that would pay for the AcSelerate rooms.”

“Not only does AcSelerate cut down on operational costs, but it almost doubles workflow.” — Muria Dorshorst, RT(R) “Not only does AcSelerate cut down on operational costs, but it almost doubles workflow,” Dorshorst adds. “Turnaround time is just about half of that of our preceding CR environment. When not using automated positioning, the system has an ultra-lightweight design that makes manual positioning really easy and fast, to help eliminate strain and work-related injuries on our x-ray techs. Patient satisfaction, speed, repeatable accuracy, lower radiation dose, and more detailed images add up to a powerful combination.”

Massachusetts | Radiology’s Value Proposition

We have to come out of the shadows and be consultants. The radiologist who has no exposure to referring physicians or patients is not going to fare well in a full-risk environment because he or she will be deemed irrelevant to patient care.

—Steven E. Seltzer, MD, FACR

boardrooms where they weren’t seen before; many joint-venture boards are starting to see vice presidents of IT included, at these strategic levels, because sharing of information is only going to grow, continue, and become more and more important. Organizations are continuing to make investments in business-intelligence solutions that are playing large roles in how they are moving forward with their various strategies.

We interface with absolutely every major hospital in the health system, in the markets in which we operate. We are passing our radiology reports/images into hospital information systems and PACS, and I think you’ll see that level of exchange increase, over time. It’s key to our survival: If we’re not providing results, in a timely way, to both the provider and the patient, that certainly wouldn’t be added value.

Proval: As more providers are pressed to assume risk, what are the implications for radiology?

Seltzer: As we move from fee-for-service payment to alternative payment methods based on risk, the implications are pretty profound for radiology. Many of the payors (as well as some providers) believe that as long as we’re in a fee-for-service environment, we will never be able to control health-care costs because we have a moral hazard: The more you do, the more you get paid.

When the Pioneer accountable-care organization (ACO) opportunity came about, five health-care systems in Eastern Massachusetts signed up to be Pioneer ACOs for Medicare. Partners is in risk contracts with all of the major private insurers in the state. Payors are moving us

inexorably from fee-for-service payment to full-risk capitation. We’re not there yet; we’re halfway between those two poles, and many of our products now involve pay for performance, bundled payments, or payment against a total medicalspending budget—which is a very uncomfortable place for the radiology department to be.

We are in this very awkward, inbetween situation. Let’s assume we go way over toward the risk side. What is the implication for radiology? An increasing proportion of our business is covered by risk contracts, so what would we do about it?

One answer is to continue what we’re doing, but with even more intensity: managing radiology utilization in collaboration with other providers. With our decision-support system and our other medical-management systems, we will add value to the health-care system— if we can aggressively manage radiology utilization.

A second strategy would be to keep care within the network. If patients leak out of the network, and we are fully at risk, all those technical and professional revenues that go to other providers do us no good.

How do we coordinate care with other providers? How do we team up radiologists with referring physicians in clinical service lines to decide on the appropriate algorithms for working up different clinical conditions? We have done that already. We have to do even more of that because we have to share risk with referring physicians.

We have to come out of the shadows and be consultants. The radiologist who has no exposure to referring physicians or patients is not going to fare well in a full-

58 Radiology Business Journal | December 2013 | www.imagingbiz.com

risk environment because he or she will be deemed irrelevant to patient care. We have to build consultative services, either in multidisciplinary clinics or by moving our reading rooms out into the clinical areas, as we are actually doing now, on an electronic leash that’s very loose.

We want to offer, in partnership with other diagnostic disciplines, the full suite of diagnostic services. If we’re getting a fixed payment, we’re going to get the diagnosis right (all the way down to the genomic level) and help the health system to save money.

Image-guided intervention is a huge opportunity for us. Here, we’re the low-cost providers, compared with surgeons—and we can provide outcomes that are just as good, with no hospital stay, less time off work, and a lower risk to the patient.

As image-guided interventionalists, we can do everything from imageguided surgery to image-guided focused ultrasound treatments for uterine fibroids. Particularly in an environment where we’re sharing a risk with our obstetrician/gynecologist friends, our incentives are, all of a sudden, aligned to get those fibroid patients treated at the lowest possible cost—because we’re in this together.

Don’t forget to push image-guided interventions as part of your solution to the problem of taking on more risk. Don’t forget that it’s just good for patient care, too. As you’re steered away from fee-forservice medicine and toward assuming more risk, remember that our ability to provide image-guided interventional services is another key capability for us.

That’s what we’re doing, as we’re learning to love payment reform.

Kris Kyes is technical editor of Radiology Business Journal.

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