Radiology Business Journal January February 2012

February/March 2012

Price Disparity +Price Transparency =

Imaging-market Turmoil Mostashari and Park: The Nation’s HIT Chiefs Speak page 12 Data, SOA, and KPIs: From Dashboard to Discovery page 31 Inside an Imaging IT Incubator: The Penn Radiology Department page 38

www.imagingBiz.com

February/March 2012

Price Disparity +Price Transparency =

Imaging-market Turmoil Mostashari and Park: The Nation’s HIT Chiefs Speak page 12 Data, SOA, and KPIs: From Dashboard to Discovery page 31 Inside an Imaging IT Incubator: The Penn Radiology Department page 38

www.imagingBiz.com

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CONTENTS

February/March 2012 | Volume 5, Number 1

22

Features

22

Price Disparity + Price Transparency = Imaging-market Turmoil

By George Wiley Five years of outpatient reimbursement cuts and widespread price disparity have left the imaging marketplace in disarray, with insurers enlisting patients in cost-containment efforts by encouraging them to price shop.

31

Dashboards: From Data to Discovery

By Kris Kyes Manual data collection is both more costly and less effective than a well-built performance dashboard.

38

University of Pennsylvania Health System: Inside an Imaging-informatics Incubator

By Woojin Kim, MD, and Tessa S. Cook, MD, PhD Penn Radiology is developing a new generation of imaging informaticists, charged with reinventing the way radiologists work.

48 Best Practices: How the RBMs Score

By Christie James, MS; Larry Buchwalter, JD; Michael Mabry; Ron Howrigon; and the RBMA’s Payor Relations Committee Surveyed providers say that five RBMs differ only 2%— but are 20% less compliant with guidelines than they claim to be.

4 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

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CONTENTS

February/March 2012 | Volume 5, Number 1 Publisher Curtis Kauffman-Pickelle · ckp@imagingbiz.com

Departments

8

AdView

EDitor Cheryl Proval · cproval@imagingbiz.com Art Director Patrick R. Walling · pwalling@imagingbiz.com Technical Editor Kris Kyes

Rehabilitating the E Word

By Cheryl Proval

10

Associate Editor Cat Vasko · cvasko@imagingbiz.com

The Bottom Line

Online Editor Lena Kauffman · lkauffman@imagingbiz.com

Commodity Practice or Experience Monopoly?

Online News Editor David Rosenfeld · drosenfeld@imagingbiz.com

By Mark F. Weiss, JD

12

Contributing Writers Larry Buchwalter, JD; Tessa S. Cook, MD, PhD; Ron Howrigon; Christie James, MS; Woojin Kim, MD; Michael Mabry; RBMA Payor relations Committee; Greg Thompson; Mark F. Weiss, JD; George Wiley

Priors 12 Health IT | A Conversation With the Nation’s Health IT Chiefs 16 Research | Is It Worth It?

Radiology and Comparative-effectiveness Research

17 Imaging Informatics | Following the Sound and the Fury:

Meaningful-use Attestation

By Greg Thompson

56

Advertiser Index

58

Final Read

Sales & Marketing Director Sharon Fitzgerald · sfitzgerald@imagingbiz.com Production Coordinator Jean Lavich · jlavich@imagingbiz.com Special Projects Coordinator Emily Kawka · ekawka@imagingbiz.com Webmaster Robert Elmquist · relmquist@imagingbiz.com

Cracking the Code

By Curtis Kauffman-Pickelle

31

38

Corporate Office imagingBiz 17291 Irvine Blvd., Suite 105 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, 17291 Irvine Blvd., Suite 105, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. February/March 2012, Vol 5, No 1 © 2012 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, 17291 Irvine Blvd., Suite 105, 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 Jean Lavich at jlavich@imagingbiz.com.

6 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

AdView

Rehabilitating the E Word In his first major speech since leaving Washington, DC, Donald M. Berwick, MD, turned a taboo into a clarion call

T

he upside to Berwick being shown the door in Washington is the pleasure to be had in reading his first major talk1 since leaving the office of CMS administrator on December 2, 2011. The occasion was the 23rd Annual National Forum on Quality Improvement in Health Care of the Institute for Healthcare Improvement, held in Orlando, Florida. Berwick was given the Picker Award for Excellence® by the Picker Institute, named for the son of the founder of a venerable imaging company that got its start producing portable radiography laboratories that were airdropped onto battlefields during World War II. In his December 7 acceptance speech, “The Moral Test,” Berwick had nothing to lose and no politics to play. Afterward, he would answer to no one but himself. Though he did take a few shots at those who had hurled the death-panel epithet, Berwick took the more important opportunity to rehabilitate the word efficiency in health care and to appeal directly to the only people capable of reforming it: the collective you.

In what marketers call the money part of the speech (worth the price of admission), Berwick wove together the thesis of a 2004 article by Pacala and Sokolow2 on carbon emissions with something that he heard when visiting Jönköping County, Sweden, while observing the headway made there in total–health-system improvement.

Pacala and Sokolow came to the conclusion that no single thing would solve the carbon-emissions problem; Göran Henrik, the county’s chief executive of learning and innovation, explained to Berwick that Jönköping county had come to the same conclusion, saying, “Here’s the secret: We do everything.”

Quality Dimension of Our Time Berwick reminded his audience of our stark choice: chop—and radiology has a

visceral understanding of that approach— or improve. Whether we choose to spend the 17% of the gross domestic product that we are spending now or something closer to the 12% being spent in Europe, the rate of increase in health-care costs is unsustainable.

Berwick acknowledges that efficiency is not his favorite dimension of quality improvement (with others being safety, effectiveness, patient-centered care, timeliness, and equity), but he refuses to apologize for using the word and emphasizes that value improvement is not enough.

“It will take cost reduction to capture the flag,” Berwick says. “Efficiency is the quality dimension of our time.”

Citing the quality gurus Noriaki Kano, James Womack, Taiichi Ohno (1912–1990), and W. Edwards Deming (1900–1993), Berwick adds, “The great leverage in cost reduction comes directly—powerfully— exactly from focusing on meeting the needs of the person you serve. Waste is actually just a word that means not helpful.”

Berwick identifies six of what Pacala and Sokolow call wedges, or forms of waste, whose removal from the system would improve patient health and reduce costs: • overtreatment (rooted in outmoded habits, supply-driven behaviors, and ignoring science); • failures of coordination (when people fall between the slats); • failures of reliability (poor execution); • administrative complexity (meaningless charting rituals and nonsensical, complex billing procedures); • pricing failures (prices beyond cost and fair profit); and • fraud and abuse (when thieves steal, resulting in blunt inspection and regulation).

Berwick estimates that $1 trillion in costs—possibly a third of the total cost of production—could be removed from the system if these wedges were worked.

Urging all providers to take up this challenge, Berwick suggests these five

8 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

guiding principles: Put the patient first; among patients, put the disadvantaged (the young, the poor, and the elderly) first; start at scale (meaning large scale, as there is no time to waste); return the money (hardest of all) by letting those who pay see their bills fall; and act locally (every state, community, organization, and profession must engage).

Getting in the Game Health-care providers are being required to let go of their disdain for efficiency and embrace the need to manage resources, and this issue of Radiology Business Journal is replete with examples of providers taking up this challenge: Informatics is a key enabling tool. In cooperation with the Society for Imaging Informatics in Medicine (SIIM), RBJ has launched a competition to name the Top Five Medical Imaging Informatics Projects of 2012. The winners will receive an invitation to present their work at the SIIM meeting in Orlando, Florida, on June 7, and a scholarship to help underwrite the trip (see advertisement on page 55).

We hope to see entries from every radiology department and private practice in the country. As Berwick says, it’s time to flood the triple-aim zone: improve quality, reduce cost, and widen access. I am sorry to see Berwick go, but he might now be in a place where he can be more effective.

Washington can’t make this happen, but you can.

Cheryl Proval cproval@imagingbiz.com References 1. Berwick DM. The moral test. http:// pickerinstitute.org/wp-content/ uploads/2011/12/Dr.-Don-Berwick-TheMoral-Test1.pdf. Published December 7, 2011. Accessed February 8, 2012.

2. Pacala S, Socolow R. Stabilization wedges: solving the climate problem for the next 50 years with current technologies. Science.

2004;305(5686):968-972.

The Bottom Line

Commodity Practice or

Experience Monopoly?

All of health care stands at what the author calls the great junction: the decision to become either a commodity provider or one differentiated by a high level of service

I

magine that your practice has been barreling down the health-care highway for years. Now, though, there’s a T intersection straight ahead, with one route leading to completely commoditized health care and the other (the road far less traveled) leading to high-touch, high-quality care—to an experience monopoly. This is a monopoly in terms of the experience that the group provides to its customers: hospitals, referring physicians, and patients.

There is no straight-ahead choice, other than running into a wall or being rear-ended by the mass headed into commoditization. That wall—that no man’s land where it’s not safe to park— is the mired-in-mediocrity zone, where many radiology groups will attempt to wait, continuing their level of business as usual until, one day, they’re surprised to learn that the hospital has decided to issue a request for proposal (RFP) for what had been the group’s services.

This is the context in which more and more hospitals are issuing RFPs. Having dealt with hospital RFPs for over four decades, I’ve classified them into three distinct categories.

The Three RFPs True RFPs: These are actual searches for the best-quality provider with a favorable quality/cost ratio. They are commonly seen in situations in which the current group (or, sometimes, the very recently former group) has blown up and can no longer provide coverage, as well as in situations in which the current group has completely lost the facility’s trust.

Fictitious RFPs: These RFPs belie the fact that the hospital’s administration is not interested in the merits of any response. It has already decided to whom it will award the contract, yet it’s decided to issue a phony RFP to project a patina of fairness to the medical staff, to the

hospital’s own board, to some third party— or, perhaps, to you.

Fulcrum RFPs: These are the increasingly common type of weaponized RFP. Fulcrum RFPs are designed to create leverage. The facility intends to renew with the present group, but uses the RFP as a tool to dictate terms by fiat and to pressure the group into negotiating against its own best interests.

Unfortunately, an RFP doesn’t come with a cover page announcing its category. One thing is certain: If the hospital issues an RFP, and you didn’t begin preparing for it years before it was announced, it might be too late.

Just as the future for radiology groups is at the great junction, so, too, is health care in general: Your hospital has decided, or is about to decide, which route it will take. If your hospital takes the commodity route, and if you cannot knock it off course, the only way that your group can become successful at that facility is to become a commodity-level provider.

The national groups are geniuses at adopting a business structure suited to the RFP environment. They bid; if they win, that’s great, but if they lose, so what? There other deals. The average commodity-level radiology group, on the other hand, faces a different set of options: If it wins the RFP, it continues to exist; if it loses the RFP, it no longer exists.

The problem inherent in the commodity route is that commodities are fungible. You are no longer a group of physicians; you are, despite any and all talk about health-care collaboration, a simple vendor, just like the laundry service. The solution, then, for those groups truly interested in their futures, their incomes, and their survivability, is to make a decision as to which way to turn at the great junction.

The Experience Monopoly If you take the experience-monopoly approach, a long-term strategy is required.

It includes laying groundwork to divert your

10 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

By Mark F. Weiss, JD

hospital from issuing an RFP, expanding your group’s focus from one facility to multiple facilities, and developing and enforcing the actual delivery of a high-touch, high-quality experience.

If, on the other hand, you take the commodity route (which is the default route), much of that same action is required because your group must still branch out from providing services solely at one facility.

Success, as a commodity provider, requires that you take the vendor approach, which means that you must have the ability to withstand any single commodity buyer’s decision to use another vendor.

If you don’t have that ability, then your only choice is to undercut your own expectations in your response to the RFP, which begins a self-reinforcing loop leading to decreasing reimbursement and an increasing level of service. This results, eventually, in the inability to perform— death by a thousand cuts, as opposed to the swift chop of immediate replacement by another group.

One last thing: You might think that it is easier to become a commodity group than to create a true experience monopoly—but if you go the commodity route, you will have more competition, including that from wellheeled national groups willing to buy market share. My belief is that the preferable route, in terms of protecting your group’s future, is to take the road far less traveled—the route leading to an experience monopoly—and to ignore market share and focus on profit instead.

Mark F. Weiss, JD, specializes in business and legal issues affecting physicians and physician groups nationwide. He is clinical assistant professor of anesthesiology at the Keck School of Medicine of the University of Southern California, and he practices with Advisory Law Group (Los Angeles and Santa Barbara, California); markweiss@ advisorylawgroup.com.

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A Conversation With the Nation’s Health IT Chiefs

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ttestation for stage 1 meaningful use is underway in radiology, and expectations are rising about the ability of IT to reduce cost and increase quality in health care.

In separate interviews with Radiology Business Journal, Farzad Mostashari, MD, ScM, national coordinator for health IT, and Todd Park, CTO for the US DHHS, clarify their perspectives and positions as the nation’s most influential health IT appointees.

Framing National Health IT Policy Farzad Mostashari, MD, ScM, joined the DHHS Office of the National Coordinator (ONC) for Health IT as national coordinator in July 2009.

RBJ: What are the obstacles to having a national health-care identifier issued at birth to help in aggregating each person’s health information?

Mostashari: The one obstacle to that is that Congress has been quite clear that it’s not something it wishes to see any money spent on, and that’s been consistent over several years.

RBJ: What’s your opinion about how valuable it would be?

Mostashari: I think we should probably leave it at that. I’ll say this: A lot of people assume that if we had a single patient national identifier, it would solve all problems having to do with patient identifiers, patient matching, and records being misattributed. I think there’s a little bit of magical thinking around that.

I’ve suggested we move on and think about how we can find better ways within the world we live in, where we don’t have a national health identifier at birth,

where we can do a better job at having identity validation as a service (whether it’s commercial based or state based) and work on improving our workflow around data collection and data quality.

That may end up doing a lot more for the issue than I think people assume a national patient identifier would.

RBJ: What about interoperability? What can/ should government do to encourage vendors to make it easier for health information systems to communicate?

Mostashari: We see the government playing a critical and limited role.

There are three areas where we are active: first, simply Farzad convening people Mostashari, MD, ScM to come up with shared solutions to common problems— bringing people together with a sense of urgency. It’s about providing a place where competitors can come together and work on common solutions around the standards.

The second area is curating the collection of the standards and implementation specifications that can be used and reused to solve certain problems, so we don’t end up reinventing the wheel for every problem people have. If you dealt with medication codes for medication ordering in one system, you should reuse that, if we’re talking about quality measures and it involves a medication.

The third area is enforcement through certification of electronic medical records (EMRs) and testing tools as part of that process. It really starts first with convening industry, academics, provider groups, and others around the standards and interoperability.

12 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

RBJ: Are we unlikely to see a top-down approach to setting a national standard?

Mostashari: It’s both bottom up and top down. The development of the standards is done from the bottom up in the sense that we’re not going to pay a contract to someone to come up with what the standards are going to be. It really has to come from the people who are going to have to live with it. The top-down approaches are the convening and the enforcement. I actually think the bottom-up approach is more important than the top-down approach.

RBJ: Many specialties complain that the generic set of meaningful-use criteria forces them to invest in meaningless IT capabilities or in duplicative work. How are you addressing these complaints?

Mostashari: It is a challenge. It’s a national program. Eligible professionals come in many different specialties. To have a common platform and a common set of measures that all specialties are going to feel are equally relevant to them is a real challenge.

It becomes particularly difficult when we’re talking about some specialists, like radiologists, who often don’t have direct patient contact and opportunities to do some of the things you would want to have as meaningful use for the large majority of physicians whose job (in large part) is patient contact. It is a challenge, and we and our CMS colleagues have tried to provide accommodations and exclusions where something is not part of the scope of practice.

The ACR® has been quite helpful and constructive in its comments and suggestions about how we can make meaningful use even more relevant to radiologists. We thank the ACR for that, and we are going to strive to make it ever more relevant.

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Integrated Medical Partners is a fully integrated suite of medical business services enveloping the spectrum of diagnostic imagingâ&#x20AC;&#x2122;s needs. Through revenue cycle management, analytics and decision support, managed imaging workflow, and strategic positioning and consulting, we comprehensively support your business through both challenging and prosperous times, offering the expertise you need to evolve and thrive.

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Journals like yours can help people understand what the accommodations and exclusions really are, and whether they are something that makes sense for their practice. If virtually all of their work is done in the hospital setting, they really are not eligible professionals. They are really hospital-based physicians, and the hospital would be embarking on meaningful use as an entity.

RBJ: The free exchange of images among disparate health-care providers could help reduce health-care costs by preventing duplicate studies. How do you think healthcare policy and regulations could promote this?

Mostashari: It’s a cost issue. It’s also a patient-safety issue. Unnecessary radiation doses have a cost to human health, as well as a financial cost. There certainly is a rationale for including interoperability of images. Our Health IT Policy Committee and Health IT Standards Committee did not include these as part of their latest recommendations for stage 2 of meaningful use.

RBJ: Why was that?

Mostashari: I’m not sure whey they didn’t.

In the past, there was some concern about the distinction between EMR systems and RIS/PACS (and the appropriate line to draw there), whether we are talking about being able to view images or being able to include radiology systems as a whole as part of certified electronic health record technologies.

There were still some questions about the standards, in terms of the different flavors of DICOM that are currently implemented among different proprietary systems. That being said, we have heard from the ACR and other specialty groups about imaging being a low-hanging fruit—maybe more low-hanging than our federal advisory committee had considered—and we’re looking at those comments very carefully.

Cracking Open the National Health Data Vault Before joining the DHHS as CTO in August 2009, Todd Park had already cofounded athenahealth® (Watertown, Massachusetts) in 1997; over the following decade, he helped lead its development into one of the most innovative, socially oriented, and successful health IT companies in the industry. His Todd Park charge is to help DHHS leaders harness the power of data, technology, and innovation to improve the health and welfare of the nation.

RBJ: You’ve compared the DHHS, with its mountains of data that are not being used, to the US National Oceanic and Atmospheric Administration (NOAA) in its past state.

What is the practical potential of all those data in achieving the triple aim: improved access and quality at reduced cost?

Park: The DHHS has been engaged, for almost two years, in the Health Data Initiative. It’s an effort to open up access to (and improve the usability of) vast amounts of data and information that are sitting in the vaults of the DHHS, including CMS, the National Institutes of Health, the FDA, and the Centers for Disease Control and Prevention.

It includes everything from hospital quality data to the latest and greatest medical knowledge in the National Library of Medicine and FDA recall data.

We’ve created a new website, healthdata. gov, that’s a one-stop shop for all the data we’re making freely available and downloadable—by anybody, without intellectual-property constraint.

We are promoting the existence of these data to innovators across the country, who are using them as fuel for applications and services to help consumers take control of their health care, to help physicians provide better care, to help employers promote health and wellness, and to help local policymakers make better decisions.

The whole effort is modeled on what the government previously did with NOAA weather data and GPS data.

14 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

The government, for many years, has made weather data collected by NOAA’s National Weather Service openly available and machine readable, downloadable by anybody for free, without intellectualproperty constraint. That has powered a whole host of innovations in the private sector: weather newscasts, weather news sites, weather mobile apps, and other services that have created huge value for the people of the United States.

The government did something similar in the 1980s, when it liberated GPS data, which now fuel everything from foursquare™ to your iPhone to supertanker navigation systems and everything in between. Health Data Initiative is running the same open-data and open-innovation play, but this time, with health-related and health-care– related information that’s been sitting in the vaults of the DHHS and sister agencies.

RBJ: You’re basically putting the data into a format that others can take and use; are you doing much analysis yourselves?

Park: There’s a famous law we like to quote that’s really an underlying principle behind the Health Data Initiative. It’s called Joy’s Law, attributed to William (Bill) Joy, the cofounder of Sun Microsystems. He is believed to have said that no matter who you are, most of the smartest people work for someone else.

Our corollary to that law is that if you want to maximize national social return on DHHS data, don’t just have the smart DHHS people turn the data into tools that can help people. Have all the other smart people in the world—who vastly outnumber us—access and use the data and turn them into tools that can help people.

RBJ: What interesting solutions to problems have come out of that program?

Park: There’s an extraordinary array of new or upgraded tools and services that people have built. In the category of tools that help consumers, there are applications that help you find the best health-care provider for you and your family.

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There are applications that help you find the right clinical trial that might be of interest to you, as a patient. There are search engines that The Ries ingest large amounts Development of data from the Principles1 government and other sources to s Start with small, help you search interdisciplinary for information, teams. especially on the s Include Internet, where strategic, it’s much more operational, and reliable, accurate, technical expertise. and targeted than it is normally. s Plan to engage with your There are tools customers as that help you, as a soon as humanly consumer, get the possible. latest and greatest patient-education s Begin with minimal viable information from product, and let the National Library your customers be of Medicine—at your guide. your fingertips, exactly when you need it. There are tools that help you find affordable, healthy food, and other resources that may not be healthcare services, strictly speaking, but that definitely can help you take control of (and improve) your health.

For health-care providers, there are tools and services that help you deliver better and safer care; that help you actually make the transition into becoming a medical home, an accountable-care organization, or a bundled-care team; and that help you coordinate care and practically manage the health of your patients by leveraging the power of data and technology. There are tools that help you make a referral to the best possible provider and tools that help you deliver the latest and greatest educational material to your patients. What we’re seeing really does prove Joy’s Law. We’re taking data that we have and pushing them into the public domain.

Innovators across the country (with all of their talent, capital, developers, existing platforms, and audiences) are leveraging the data and their platforms, capabilities, and capital to do amazing things at incredible speeds.

RBJ: As health-care superusers, older people tend to be more interested in health-care

issues than the young and invincible are; how are you engaging more tech-savvy young people in the effort to improve the quality and cost of health care?

Park: As part of the work to educate developers and innovators across the country about the availability of these data, we have been in partnership with other organizations, such as Health 2.0 (San Francisco, California), on a whole series of challenges and open public competitions that anyone can enter to build the best application or product that, for example, helps consumers find the best health-care providers. We’re seeing a lot of new innovators join the healthcare–innovation ecosystem through these challenges and Code-a-Thons.

RBJ: What have you learned, through your work at athenahealth and your other endeavors, that has been useful in your current position? What IT solutions from business has health care been slow to adopt?

Park: One of the most interesting lessons that has been transferable from my experience as a private entrepreneur to my experience here at the DHHS has been the use of lean startup techniques to drive challenge. Lean startup is a whole philosophy that has been articulated by Eric Ries.1 It’s a set of principles (see box)

that entrepreneurs can follow to maximize the probability their startups will work.

The whole notion of rapid interdevelopment is that you don’t have development cycles that are nine months long. Have them be nine days long. It’s about working closely with customers to maximize how quickly and how effectively you learn about what your customers’ real issues are and how you can really help them. That actually describes pretty nicely what I learned the hard way to be key factors in building a successful project at startup.

As it turns out, those are the same principles that apply if you really want to drive maximum success and maximum speed for major-change problems in the government.

RBJ: Information exchange and general transparency efforts have been generally slow to be adopted. What is the rate of recent progress?

Park: I think we’re in a moment of enormous positive change on both of those fronts. I think the genie is out of the bottle, and there is a lot of progress that’s being made that’s very exciting.

—David Rosenfeld Reference 1. Ries E. The Lean Startup. New York, NY: Crown Publishing; 2011.

research

Is It Worth It? Radiology and Comparative-effectiveness Research

I

maging is increasingly pervasive in modern medicine; according to a 2011 study1 published in Radiology, the use of CT scans in emergencydepartment visits has risen 16% per year since 1995, and the report estimated that the modality could have been used in 20% of emergency-department visits in 2011. Remarkably little research has been performed to validate certain applications of advanced imaging, however.

“There’s a real lack of evidence for diagnostics, especially as to whether they are comparatively effective,” according to Larry Kessler, MD, professor and chair of the department of health services at the

16 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

University of Washington School of Public Health. Kessler presented “Communitybased Comparative Effectiveness Study of Advanced Imaging in Breast Cancer” as one of four parts of “Comparative Effectiveness Research for Radiology: Reports From the Field” on November 28, 2011, at the annual meeting of the RSNA in Chicago, Illinois. “When new imaging methods come out every month, the question is, ‘Do they change patient management or outcomes?’ There’s next to no information about that,” he says.

Kessler and his team are currently conducting two comparative-effectiveness research projects centered on imaging

and cancer: one on breast-cancer diagnosis and one on lung-cancer staging. The threeyear projects launched in fall 2009 and will Larry Kessler, MD conclude in fall 2012. Kessler explains that both studies began with an analysis of the available research.

“If you look at the literature, you’ll discover a number of studies suggesting that there’s really no evidence for the way MRI is currently being used in the diagnosis of breast cancer,” he says.

“With lung cancer, people who have a pathologically confirmed diagnosis are being imaged like crazy, and our stakeholders say this imaging is really biting them in the pocketbook, so we’re looking at whether that’s justified.”

Working with these stakeholders, including the providers and the payors, is critical to the success of comparativeeffectiveness research, Kessler says.

“The payors are very interested in this information. We asked them to generate data that would help us begin to examine this, and their involvement has been critical,” he says.

Both projects have leveraged payor data from every beneficiary of the local medical plans who was diagnosed with either lung or breast cancer from 2002 through 2009. “We use their claims records to create the datasets and perform analysis on the trends in imaging and whether they are affecting the patients, in terms of outcomes,” Kessler says.

Show Me the Funding Though results of both studies will be unavailable until the end of the study period, both projects are progressing well, thanks to stakeholder engagement and adequate funding from the National Institutes of Health. As Constantine Gatsonis, PhD, chair of the department of biostatistics at Brown University, reported in “The State of the Art in Comparative Effectiveness Research for Diagnostic Imaging: An Introduction” during the same four-part RSNA presentation, funding for radiology comparativeeffectiveness research became available

in 2009 following an Institute of Medicine report that named “the effectiveness of diagnostic imaging performed by Constantine radiologists and Gatsonis, PhD nonradiologists” 2 as one of 100 priorities in comparativeeffectiveness research.

Gatsonis notes that this report influenced the focus on patient-centered care and outcomes seen in health-reform legislation, suggesting that comparativeeffectiveness research will be a vital component of health-care policymaking in the years to come. Kessler concurs.

Comparative-effectiveness research “is a natural opportunity for those of us who are interested in health policy,” he says.

“It’s critical to figure out whether the addition of resources is justified and to add to the evidence base.”

That might sound like bad news for radiology, which is already under siege from Medicare and private payors when it comes to appropriateness of imaging and to reimbursement. Kessler and Gatsonis both emphasize, however, that the use of comparative-effectiveness research

can lead to powerful justifications of imaging’s value.

Comparative-effectiveness research “calls for illuminating the path between diagnoses and outcomes,” Gatsonis says; as an example, he cites the National Oncologic PET Registry, which led to the CMS decision to cover FDG-PET for nearly all cancer patients. For this reason, Gatsonis and other presenters urge radiologists to embrace the potential of comparative-effectiveness research.

“We want to know whether it is worth exposing patients to imaging and to the procedures that go along with it,” Kessler says. “What would be very desirable is to see that we are actually getting better patient outcomes with imaging.”

—Cat Vasko References 1. Larson DB, Johnson LW, Schnell BM, Goske MJ, Salisbury SR, Forman HP. Rising use of CT in child visits to the emergency department in the United States, 1995– 2008. Radiology. 2011;259:793-801.

2. Institute of Medicine. Initial National Priorities for Comparative Effectiveness Research. http://books.nap.edu/openbook. php?record_id=12648. Published June 30, 2009. Accessed February 3, 2012.

i m ag i n g i n f o r m at i c s

Following the Sound and the Fury: Meaningful-use Attestation By Greg Thompson

A

fter government officials revised the Health Information Technology for Economic and Clinical Health (HITECH) Act to include hospital-based physicians practicing in outpatient settings, radiology practices began scrambling to determine what it will mean to them. IT adjustments take time and money, and practices waiting for stage 2 meaningful-use requirements are keen to start preparing.

Alberto Goldszal, PhD, MBA, is one CIO who decided to dive in early. On November 3, 2011, Goldszal presented “Implementation Experiences” as part of the broader “Meaningful Use” session that began the ACR® Imaging Informatics Summit in Washington, DC. Sharing part of his ongoing odyssey, Goldszal reports

that the carrot-and-stick scenario is still firmly in place—with government holding the stick. For imaging providers, the now well-known carrot is the opportunity to receive $44,000 per physician for achieving meaningful use prior to 2015, when penalties (in the form of Medicare reimbursement reductions) begin.

At University Radiology (East Brunswick, New Jersey), where Goldszal is CIO, about a million procedures per year are handled by more than 90 radiologists, and this adds up to potential meaningful-use incentives that are too large to ignore. The partners read images generated at 10 imaging centers and six hospitals, and all of these arrangements now comfortably fall under the HITECH Act. “The purpose of the legislation is to

www.imagingbiz.com | February/March 2012 | Radiology Business Journal 17

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Imaging Market File

CT and MRI: Regional Variations in Utilization and Reimbursement Introduction: Imaging operations need to understand current utilization rates and patterns in their local markets to determine their relative rates of exam capture and to plan for future needs. This issue of Imaging Market File looks at national utilization rates (per 1,000 people) for outpatient CT and MRI procedures, according to Thomson Reuters (New York, New York) by age and by region (Table 1) as defined by AHRA: The Association for Medical Imaging Management. Reimbursement rates were based on Medicare outpatient rates from the Medicare Physician Fee Schedule (MPFS) of 2010, 2011, and 2012, and were calculated by averaging regional CPT® code mixes.

Growth stalls: Considering that the US population grew at an annual rate of 0.71% between 2010 and 2011 (Table 2), according to Thomson Reuters, and that the first members of the baby-boom generation—which the US Census Bureau estimates to represent a quarter of the population—turned 65 in 2011, factors other than demographics appear to have stunted growth in medical imaging (Tables 3 and 4).

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CT utilization rates are down: The area demonstrating the highest utilization rate for CT is the East South Central region, at 176.78 exams per 1,000 people, with a growth rate of 0.75%—just slightly above national average population growth (Table 5). This region also experienced the largest drop in reimbursement, resulting in an annual decline of 4.56% from 2010 to 2012 (Figure 1). In contrast, the Pacific region comes in with the lowest utilization rate, at 131.96 exams per 1,000 people, and had growth of 0.79% (less than that region’s population growth of 1.04%). The West South Central region demonstrates the lowest percentage of utilization change for CT, at 0.58%, while also enjoying the least change as a percentage of reimbursement, at 1.77%

Table 1. AHRA Regions

East North Central

IL, IN, MI, OH, and WI

East South Central

AL, KY, MS, and TN

Middle Atlantic

NJ, NY, and PA

Mountain

AZ, CO, ID, MT, NM, NV, UT, and WY

New England

CT, MA, ME, NH, RI, and VT

Pacific

AK, CA, HI, OR, and WA

South Atlantic

DC, DE, FL, GA, MD, NC, SC, VA, and WV

West North Central

IA, KS, MN, MO, ND, NE, and SD

West South Central

AR, LA, OK, and TX

Table 2. Population, by Region

Region East North Central East South Central Middle Atlantic Mountain New England Pacific South Atlantic West North Central West South Central Total

2010

2011

Growth

46,424,906 18,429,448 40,888,867 22,067,856 14,451,285 49,659,137 59,678,796 20,500,377 36,269,898 308,370,570

46,476,373 18,524,111 40,944,782 22,372,587 14,479,399 50,190,740 60,309,806 20,576,757 36,672,347 310,546,902

0.11% 0.51% 0.14% 1.38% 0.19% 1.07% 1.06% 0.37 1.11% 0.71%

2010

2011

Growth

168.69 175.47 172.14 140.92 172.64 130.92 166.13 157.92 139.36 157.01

169.86 176.78 173.31 142.3 173.77 131.96 167.64 158.83 140.49 158.17

0.69% 0.75% 0.68% 0.98% 0.66% 0.79% 0.91% 0.58% 0.81% 0.74%

Table 3. CT Exams per 1,000 People

Region East North Central East South Central Middle Atlantic Mountain New England Pacific South Atlantic West North Central West South Central Total 300 250 200 150 100 50 0

l l tic tra tra an en en Atl hC hC e t t l r u o o dd Mi st N st S Ea Ea

2010 2011 2012 n tai un Mo

d lan ng wE Ne

c cifi Pa

al tic al ntr an ntr Ce Atl Ce h h h t t t u u o or So st S st N We We

Figure 1. Average reimbursement per CT scan hit a high-water mark in 2011 in all US regions. Overall, reimbursement declined 3.07% per year between 2010 and 2012.

February/March 2012

Imaging Market File MRI utilization rates: With a 0.41% increase in utilization between 2010 and 2011, the 2.7% annual increase in MRI reimbursement between 2010 and 2012 belies the fact that MRI reimbursement in all regions declined in 2012 (Figure 2).

The high-water mark for CT and MRI reimbursement appears in 2011, when rates for both modalities were highest. The region with the smallest population growth, North Central, had the lowest utilization rate for MRI and the third-lowest MPFS reimbursement.

New England displayed the lowest increase in MRI utilization, at 0.19%.

Regional utilization (by age): The Mountain region’s utilization-rate growth from 2010 to 2011 exceeded that of all other regions, in every age group, with a total change of 0.96% while the population grew at a rate above the national average, at 1.38% (Table 6). MRI utilization in the Mountain states demonstrated the largest increase from 2010 to 2011 (0.64%) and the biggest three-year annual growth rate (3.37%).

Reimbursement rates for 2012 are lower than for 2011, but higher than for 2010.

When each region’s utilization growth is compared with its population growth, the data indicate that utilization growth, overall, is being outpaced by population growth.

Table 4. MRI Exams per 1,000 People

Region

2010

2011

Growth

East North Central East South Central Middle Atlantic Mountain New England Pacific South Atlantic West North Central West South Central Total

77.21 82.93 93.73 86.73 79.24 89.99 94.19 78.21 80.53 86.32

77.47 83.21 93.95 87.29 79.39 90.32 94.67 78.43 80.93 86.67

0.33% 0.34% 0.23% 0.64% 0.19% 0.37% 0.51% 0.28% 0.49% 0.41%

600 500 400 300 200 100 0

2010 2011 2012

c al al nti ntr ntr tla Ce Ce th le A rth u d o o d i M st N st S Ea Ea

n tai un Mo

d lan ng wE Ne

c cifi Pa

al tic al ntr an ntr Ce Atl Ce uth rth uth o o o S st S st N We We

Figure 2. MRI utilization increased 0.41% between 2010 and 2011, and reimbursement increased 2.7% between 2010 and 2012. Between 2011 and 2012, however, MRI reimbursement in all regions declined.

Table 5. CT Exams per 1,000 People, by Region and Age

Table 6. MRI Exams per 1,000 People, by Region and Age

Region

Age

2010

2011

Change

East North Central

East South Central

Middle Atlantic

Mountain

New England

Pacific

South Atlantic

West North Central

West South Central

< 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64

85.18 202.3 476.6 83.22 225.31 490.24 78.81 216.18 473.19 65.52 182.49 454.99 89.72 202.52 451.81 62.82 171.78 411 76.2 203.56 481.71 79.13 191.02 439.86 67.12 188.78 446.96

85.04 203.12 475.88 83.07 226.19 490.27 78.53 216.86 472.36 65.58 183.73 455.89 89.38 203.04 450.97 62.68 172.59 410.42 76.07 204.57 482.24 78.96 191.94 439.51 67.06 189.66 447.52

–0.16% 0.4% –0.15% –0.18% 0.39% 0.01% –0.35% 0.32% –0.17% 0.09% 0.68% 0.2% –0.38% 0.26% –0.19% –0.22% 0.47% –0.14% –0.17% 0.45% 0.11% –0.22% 0.48% –0.08% –0.09% 0.47% 0.12%

Region

Age

2010

2011

Change

East North Central

East South Central

Middle Atlantic

Mountain

New England

Pacific

South Atlantic

West North Central

West South Central

< 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64 < 45 45–64 > 64

45.65 116.03 141.09 47.25 128.41 153.81 54.32 142.86 162.25 50.93 137.55 172 47.55 116.23 134.45 54.36 141.58 171.2 52.78 142.46 181.37 45.76 117.42 144.84 46.42 131.91 165.87

45.53 116.36 140.92 47.14 128.71 153.76 54.01 143.1 162.01 50.99 138.34 172.45 47.24 116.33 134.19 54.19 142.03 170.87 52.66 142.94 181.54 45.64 117.85 144.81 46.37 132.41 166.07

–0.26% 0.28% –0.12% –0.23% 0.23% –0.03% –0.57% 0.17% –0.15% 0.13% 0.58% 0.26% –0.65% 0.08% –0.2% –0.3% 0.32% –0.2% –0.23% 0.34% 0.09% –0.27% 0.36% –0.02% –0.1% 0.37% 0.12%

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priors

Preparing for Meaningful-Use Attestation s Consult all stakeholders—including front-desk personnel, technologists, radiologists, legal counsel, and administrators—and gain their participation in changes driven by meaningful use. s Establish a core group to handle problems, develop documents answering frequently asked questions, review progress, and provide corrective action, where needed. s Create a meaningful-use policy, document your rationale for all discretionary decisions, and document your results. s Remember your grant could be audited to ensure compliance and results; assume that you will be audited.

lower health care costs, reduce medical errors, and improve care,” Goldszal says, “but the devil is in the details, and it does not come free.”

Despite the lack of stage 2 guidelines (still pending), Goldszal outlines three development stages to help administrators get started. Stage 1 focuses on electronically capturing health information in a coded format, tracking key clinical conditions, communicating health information for coordination of care, implementing decision-support systems for disease and medication management, and reporting clinical quality measures and publichealth information.

Stage 2 will expand on stage 1, but also includes health information exchanges and electronic orders and results. Stage 3 will expand on quality, safety, and efficiency; decision-support systems; and patient access to self-management tools.

Prior to partnering with a reliable vendor, Goldszal and University Radiology’s administrators made sure they had what he calls an invitation to the party, which essentially entailed a thorough eligibility check. Specifically, a physician is eligible if he or she provides more than 10% of his or her interpretations for outpatients, without regard to where the interpretations are rendered.

“While radiology is 85% of what we do, we also perform cardiovascular tests, apply radiation therapy, and perform interventional procedures,” Goldszal

explains. “Because of that, three years ago, when we decided to buy a new RIS, we determined that we needed something with lots of flexibility—more like an electronic health record (EHR) for radiology operations and related businesses.” This purchase gave University Radiology a head start in meeting stage 1 requirements.

Collect, Record, and Repeat Collecting data in a systematic and efficient way is crucial if radiology groups are to have the necessary data to demonstrate meaningful use. “For example, there are six to nine clinical quality measures out of a menu of 44, and they overlap with the Physician Quality Reporting System and HIPAA security measures,” Goldszal says. “We went back and measured who did what and the workload impact on the workforce (see figure).” Where the group could not find ways to use clinical data already being captured in the EHR or RIS to show meaningful use, front-desk staff and technologists bore the primary burdens of data collection.

Taken in isolation, it is easy to collect data for most measures, and it can even appear trivial. The complexity comes in trying to meet too many criteria at once without disturbing patients. “One measure that is foreign to radiology groups is the use of electronic prescribing,” Goldszal adds. “It is not common for radiologists to prescribe medication. If you do less than 100 prescriptions a year, then you are excluded.

Interventionalist groups prescribe more.”

Another easy-to-implement measure, usually managed at the front desk, is the collecting and reporting of extended demographic data. It is relatively simple to add a few more data points, and radiology groups must do that for more than 50% of patients. “An additional difficult one for radiology is to record vital signs because we usually don’t do that,” Goldszal says.

“You may think you meet the exclusion, but document your rationale.”

Reserve another dataset for an active medication list, also new to radiology, but now required for more than 80% of patients (with no exclusions). It’s not yet necessary to document dosage (which will be required in a later meaningful-use stage), but office personnel might want to develop this habit now.

Figure. Distribution of responsibility for collecting additional data needed to demonstrate meaningful use.

For many radiology groups, including University Radiology, the complexity lies in trying to achieve all objectives and measures at once. It’s a tall order, but it ultimately comes down to effective change management.

Whatever information you happen to be capturing, Goldszal says, any bonus payment from CMS carries the possibility of an audit. To that extent, Goldszal advises, “Radiology practices must develop policies and procedures documenting what needs to be accomplished by each different working group/department, which data points need to be recorded for each and every patient encounter, and which protocols need to be followed to achieve compliance on all meaningfuluse measures being tracked.”

He continues, “As one example, blood pressure may not be as relevant in the diagnosis of a hand fracture; however, your EMR should capture the dataset, or at least have the ability to get these data. Your RIS should have the ability to collect, display, analyze and exchange these data.”

Thanks to data collection via kiosks, handheld computers, and electronic tablets, collecting relevant information is easier than ever. The same technologies can be used to establish patient portals that conveniently maintain provider communications at an acceptable level.

The role of IT professionals seems to grow every year, and the risk-analysis elements of meaningful use ensure that this will only continue. “Get a hacker to break into your system,” Goldszal says. “Do not take this lightly, because this is where I have seen a lot of audits come from—HIPAA security breaches are taken seriously.”

Greg Thompson is a contributing writer for Radiology Business Journal.

www.imagingbiz.com | February/March 2012 | Radiology Business Journal 21

COVER | Price Disparity and Price Transparency

Price Disparity +Price Transparency =

Imaging-market Turmoil

Five years of outpatient reimbursement cuts and widespread price disparity have left the imaging marketplace in disarray, with insurers enlisting patients in cost-containment efforts by encouraging them to price shop By George Wiley

B

uy a banana, and it will cost you less than a dollar per pound— unless you’re in a hotel, where it might cost you twice the grocery-store price. The prices of many items readily obtainable by the consumer usually fall within a well-defined range, according to supply and demand. This is not so in health care (in general) and in medical imaging (specifically), particularly for advanced imaging such as MRI and CT exams.

According to Ana Perez, marketing director for American Imaging Management (AIM®), Deerfield, Illinois, the price variation in imaging can be so dramatic that an MRI exam that costs $300 from one provider might, from a different provider, cost as much as $3,000. This tenfold difference, Perez adds, is “for MRI facilities that are, by all claims, the same for quality.” AIM is a national radiology benefit management (RBM) company.

The disparity in pricing for CT, MRI, and other imaging studies shows itself everywhere. Susan Cox, CPA, is vice president of financial operations at Outpatient Imaging Affiliates (OIA), LLC (Nashville, Tennessee), which operates 23 joint-venture outpatient centers in eight states. Cox says that within her network, depending on location and other factors, the same MRI exam’s cost can vary from $300 to $800. “The people in the $800 market don’t know they’re paying $300 in the other market,” Cox says. “You can’t compare state to state or city to city.”

22 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

Rather than radiology being what you use as much as possible, now, you try to minimize imaging as much as possible.

[Some patients] may be encouraged to go elsewhere.

—Alexander M. Norbash, MD, MHCM

In a 2011 study1 on health-care costs, Martha Coakley, Massachusetts attorney general, found that not just radiology, but health care as a whole, was plagued by widespread pricing disparity. Insurers were paying some physician groups as much as 230% more than others for the same services, while same-service payments to hospitals varied by as much as 300%. Coakley termed the healthcare market dysfunctional, later adding that costs were not based on factors such as quality or value, but instead on the leverage of providers.

The Leverage Tool Leverage is at the heart of pricing in health care, and radiology is not excepted.

Many imaging providers will charge what they can; many others will try to get by on the lower fees that circumstances force them to accept. The situation in Massachusetts isn’t much different than it is in other states, but single cities also exhibit the pricing disparity. In Boston, for instance, the leverage-based disparity has been well documented.

Alexander M. Norbash, MD, MHCM, says, “Partners HealthCare (Boston) charges high rates for imaging because it has brand recognition.” The provider group was founded by Brigham and Women’s Hospital and Massachusetts General Hospital (MGH), both of Boston.

Norbash adds, “It will make demands on insurance companies, and the patients want that brand. That puts Partners HealthCare in a strong negotiating position.”

Norbash is chair of radiology and assistant dean for diversity at Boston Medical Center (BMC), a 508-bed innercity hospital affiliated with the Boston University School of Medicine, where he

is also a professor. He says that for highprofile hospitals with brand recognition, radiology departments are often operated as profit centers, and their income helps shore up less profitable departments.

At BMC, Norbash says, the situation is just the opposite. “At the other end of the spectrum, we charge half what MGH charges. Our brand recognition may be seen as inferior. We can’t jack up our rates to hit the standard,” he says. “We are frozen in time, with maybe a gain of 2% to 3% from inflation, but we’re not making any money. At my hospital, we have to be underwritten.”

Radiology has to be subsidized at BMC through the revenue streams from other departments. “We only have 25% of our patients underwritten by insurance,” Norbash says. “The others are free care, Medicare, and Medicaid. Medicare is fantastic; Medicaid, not so much; and free care is a problem.”

The lack of revenue has a big impact on radiology at BMC. “Rather than radiology being what you use as much as possible, now, you try to minimize imaging as much as possible,” Norbash says. Some patients, such as sports-medicine patients who have access to suburban care, “may be encouraged to go elsewhere,” Norbash adds.

The fact that imaging at BMC has to be subsidized also decreases support for the radiology department from other clinical departments at the hospital. “At MGH, there is a tremendous amount of money coming from imaging,” Norbash says. “That same potential is not the case here, and so there’s not the same level of support from the other clinical services.”

He continues, “If the profits are not there, then the loyalty is not clearly bound.

The consequence is that obtaining new

equipment gets to be more challenging.

It’s a different set of concerns. We go from department to department and try to get them to support radiology.”

Norbash says that so far, he hasn’t had radiologists leave, although he’s let some positions expire through attrition.

“Expense reduction is not enjoyable,” he says. “Creating new lines of business is enjoyable, and hiring faculty is fun, but we have to be realistic.”

BMC is caught in an inner-city trap that even lowering prices won’t cure, Norbash says. Patients who don’t have to do so won’t struggle with parking problems and other inconveniences. They go elsewhere.

“We are the lowest priced in the market, but we don’t attract business because we’re all in one location,” Norbash says.

While leverage works against hospitals (such as BMC) that face high-profile competitors, it works in favor of those that are able to exert leverage. Of the 23 imaging centers operated by OIA, some are run in partnership with high-profile providers, while others are ordinary urban or rural stand-alone centers, Cox says. The prices charged at each site vary widely, despite the fact that they are all part of the OIA network.

“I may be at six times the Medicare fee at one center, but at a center I own, I may E xe cutive Briefing

v Price disparity in health-care services is common within markets and is the subject of a report from the Massachusetts attorney general.

v Outpatient imaging centers are collapsing under price pressure or selling to hospitals that bill under preferred hospital rates.

v Maryland’s all-payor system reportedly has helped equalize hospital and nonhospital reimbursement for technical fees.

v Employer self-insurance trends and high-deductible plans are encouraging patients to price shop.

v Patients are getting an assist from RBMs and blue-book–style pricing services.

www.imagingbiz.com | February/March 2012 | Radiology Business Journal 23

COVER | Price Disparity and Price Transparency

A lot of times, we have bought imaging centers where it looked like everybody just walked out. I have an infrastructure and know how to run them more efficiently than a single imaging center can be run.

—Susan Cox, CPA Outpatient Imaging Affiliates, LLC

be at two times Medicare,” Cox notes. She points out, however, that listed prices are not what end up getting collected. Some providers will give discounts, even to self-paying (uninsured) patients, but the patients have to ask. “If my hospital gives a 15% discount, I will do the same,” Cox says.

“You really care about net global payment,” she says. “That’s a combination of what we negotiate in contracts, Medicare rates, and self-pay rates. All that goes into the calculation, and that varies significantly. Is my partner dominant in the market and somebody who will go to bat for the imaging center? If so, I have higher rates there.”

Pricing Pressures Several factors other than leverage also are at work in determining imaging charges. One universal factor that often results in lower prices is the decreased reimbursement for imaging exams imposed by Medicare and by payors that follow Medicare’s lead. “From where we sit, the imaging-center rates have been cut, cut, and cut,” Cox says.

Imaging centers still have the option of billing more than they know they will be paid for an exam, but that doesn’t look good on financial records. “You don’t want to charge $9,000 and write off $7,000; that sends the wrong message,” Cox says.

Many imaging centers have suffered such high losses of income because of the cascade of recent cuts in reimbursement that they can’t survive. Some imagingcenter owners abandon ship. “A lot of times, we have bought imaging centers where it looked like everybody just walked out,” Cox says. “I have an

infrastructure and know how to run them more efficiently than a single imaging center can be run.”

A different tactic—much better than walking away—is for imaging-center owners (particularly radiologists) to sell to, or establish joint ventures with, hospitals where the radiologists also interpret studies. In many cases, these reconfigured imaging centers, now operating under a hospital’s banner, can then bill for the technical component of Medicare reimbursement at higher hospital rates. This can be the difference between being profitable or unsustainable, for imaging-center operation. The trouble with this is that it forces higher hospital rates onto insurers—and the insurers are fighting this strategy.

The difference in technical-component reimbursements between hospital-based and freestanding settings can be large.

These more lucrative hospital payments have also been adopted by private insurers that follow Medicare in setting reimbursement levels. As a result of these more lucrative fees, hospitals have been buying or partnering with radiology practices at a rapid (and, some would say, alarming) rate. Why wouldn’t they, when attaching a hospital imprimatur to an exam means gaining more revenue?

“At the 2011 annual meeting of the RBMA,” Cox says, “half the people I talked to had sold out to a hospital within the past year.” In Houston, Texas, she reports, the shifting of eight centers to hospital-based billing tripled insurance claims from those centers overnight.

The reason that claims tripled was that insurers were suddenly being billed the higher hospital-based technical fees. Thus, a move ostensibly begun by Medicare to

24 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

guide business to hospitals (which were assumed to have a broader accountablecare motive) has actually increased the reimbursements that insurers must make for advanced imaging at outpatient centers now affiliated with hospitals.

Insurers don’t want to waste money, so there are continuing attempts to rectify this. As Cox puts it, “Insurers can’t survive at hospital rates.” What they do, Cox says, is cut nonhospital outpatient reimbursements to balance the increases in hospital outpatient rates. This leaves OIA scrambling after every dime. “Every dollar matters; you have to collect everything. Nothing can be left on the table,” Cox says.

Recently, she says, OIA installed software that guides the front-desk employees in its centers in explaining to incoming patients exactly what their imaging exams will cost. There is then an attempt to collect the payment before the procedure. “The front desk is a paradigm shift,” Cox says. “If you go to the dentist, they’re great at that. Hospitals are now doing this more often, and we finally just said, ‘We’re going to have to do it, too.’”

One reason getting paid has become more complicated is that in the past few years, the playing field for patients has become increasingly uneven, in terms of the resources that they must expend.

Uninsured patients typically face the highest charges, but they also account for the highest portion of uncollected bills. Many patients who once didn’t worry about copayments or deductibles (because their health plans minimized them) are now facing higher charges because employers have cut back on coverage.

“The patients are never prepared to think that the bills are going to them,” Cox says, “and they’re not paying the high deductibles. You can’t get them to pay. We try to collect up front so we don’t have to chase them down on the back end—or so, at least, they know what the charges will be.”

Maryland’s All-payor System Jonathan S. Lewin, MD, FACR, is radiologist-in-chief at the Johns Hopkins Hospital (Baltimore, Maryland). He is also a professor and chair of the radiology

In radiology, the technical rates for certain specific tests are higher than Medicare rates, and for certain tests, they’re lower—but in aggregate, they are less expensive than standard Medicare.

—Jonathan S. Lewin, MD

department at the Johns Hopkins University School of Medicine. Lewin reports that Maryland is the only state in the nation that currently uses a system requiring all insurers to pay the same rate for a given hospital service, including hospital technical fees for imaging exams.

The rates that insurers pay are determined by a state commission and can vary from hospital to hospital, but at every location, insurers pay the same rate for the same service. The all-payor system is an attempt by Maryland to stabilize health-care costs by preventing insurance companies from competitively bidding prices up or down, Lewin says.

“The good news, from the insurance perspective, is that nobody has to worry about someone else cutting a special deal with a hospital, causing some payors to subsidize others. That can’t happen.

The insurance companies know there is a level playing field,” Lewin says.

Maryland, he adds, is also the only state to operate under a waiver of Medicare reimbursement rates from CMS. “We’re not paid based on the Medicare rates for hospital-based imaging,” Lewin explains. “Medicare pays the state a lump sum, and we have to show to Medicare that the lump sum (what they disperse) is less, in aggregate, than what Medicare would pay under its rate structure. In radiology, the technical rates for certain specific tests are higher than Medicare rates, and for certain tests, they’re lower— but in aggregate, they are less expensive than standard Medicare.”

He says that the plus, for Johns Hopkins, from the all-payor system is that many insurance companies have stopped leaving hospital-based outpatient imaging out of contracts because they could find cheaper providers elsewhere. “That has

fully reversed, as we’ve been able to show that our costs are not that different from the outpatient ambulatory world’s costs,” Lewin says.

It hasn’t hurt, either, that there is strong demand from patients for service from the well-known hospital, or that many referring physicians complained when Johns Hopkins was not a contracted provider for their patients’ health plans.

Referrers were unhappy when patients couldn’t go to Johns Hopkins because quality is high there, Lewin says.

Low-quality CT or MRI exams equal higher expenses in the long run, he says, because tests must be repeated and treatments can be delayed or pursued in error. “It doesn’t take many unnecessary surgeries to make up for a whole lot of CT scans,” Lewin says. “That might be a message for other academic centers that see steerage away from them.”

Lewin is careful to point out that the all-payor system, with regard to radiology, applies only to technical fees. On the professional-fee side, the payments that radiologists get for interpreting exams is still negotiable, and this still is an area where insurance companies compete, Lewin says.

“On the professional side,” he says, “Maryland tends to be lower priced. We have to work to make sure we get rates that are competitive—high enough to pay salaries and low enough that the insurers want to contract with us.” Overall, the allpayor system, even though it has been controversial, has saved money for payors, Lewin says. “Maryland has beat the rest of the country in cost containment,” he notes.

Consumer As King The continuing push to bring prices down for imaging services finally has

looped the consumer into health care’s economic calculations. Because higher deductibles and higher copayments are now common, there is an effort to encourage consumers to shop around for the least expensive MRI or CT provider in their area.

This is easier said than done, as Cox notes, because consumers referred for a CT or MRI exam are likely to be more worried about their health than about seeking the lowest-cost option for getting the exam. They also might not want to challenge their physicians by going to imaging sites other than those to which their physicians have referred them.

Nonetheless, empowering the consumer to price shop for advanced imaging tests is a large wave that is building, even if it is not cresting. Mark S. Grossman is COO of ProScan Imaging (Cincinnati, Ohio). ProScan Imaging operates 24 outpatient centers in seven states, as well as a teleradiology business, all under the leadership of radiologist Stephen J. Pomeranz, MD. Its primary outpatient-imaging offering is MRI, although some locations provide CT, radiography, ultrasound, and women’s imaging services, Grossman says. It has about 20 radiologists in its network and performs and reads about 100,000 MRI exams per year, Grossman adds. Part of ProScan Imaging’s marketing effort is to work in tandem with Anthem BlueCross BlueShield of Ohio in what the insurance company calls its Radiology Imaging Shopper program.

When a patient’s MRI exam has been scheduled and preauthorized, Grossman says, a representative from Anthem might call that patient and point out that he or she could reduce out-of-pocket expenses by scheduling the exam at another approved imaging site, such as ProScan Imaging, instead of at the higher-cost hospitalaffiliated imaging provider to which the patient was originally referred. If the patient is willing to switch, Anthem will then—often, at that very moment—call the lower-cost provider and reschedule, Grossman says.

“Many times, Anthem’s representative will ask the patient to stay on the line and conduct a three-way call with our patient-concierge team to reschedule the

www.imagingbiz.com | February/March 2012 | Radiology Business Journal 25

COVER | Price Disparity and Price Transparency

For a CT exam of the abdomen and pelvis with and without contrast, the hospital charge range is $1,557 to $2,098; the ProScan Imaging price is $413.

—Mark S. Grossman ProScan Imaging

Many patients have no idea what they are paying and what sort of rates they can get. As the prevalence of highdeductible plans has spread, that information has been critical.

—Randy Hutchinson American Imaging Management

exam immediately at ProScan Imaging,” Grossman says. “We will then help the patient navigate obtaining the exam order from the referring physician and any prior relevant exam reports, to make the transition as seamless and easy as possible.”

The savings in rescheduling can be considerable, Grossman adds. He uses examples of costs for self-pay patients to illustrate the differences. “For an MRI exam of the lumbar spine without contrast, the self-pay charge at hospitalaffiliated Cincinnati facilities can range from $962 to $1,559, including the technical and professional components.

The ProScan Imaging combined price is $565,” Grossman says. “The average saved is $782, making the scan 58% less expensive. For a CT exam of the abdomen and pelvis with and without contrast, the hospital charge range is $1,557 to $2,098; the ProScan Imaging price is $413.”

Grossman acknowledges that patients are often hesitant to consider options other than where their referring physicians suggest that they undergo their exams, but he says that Anthem has expressed willingness to talk to referring physicians about the patient’s right to choose a provider. He calls the Anthem

program a triple win: The patient’s employer wins because health-care costs are held down, the patient wins because he or she pays less out of pocket, and the insurance company wins because its reimbursement is less.

“What’s causing the focus on prices, right now, is that employers are choosing to self-insure and going to consumerdirected high-deductible health plans that are forcing subscribers—the employees— to become involved in the health-care decisions that are being made,” Grossman says. “We need to educate consumers proactively so that when they’re put in the position of needing an advanced imaging test, they understand they have high-quality, lower-cost options.”

Steerage for Less The irony, for insurance companies, is that by mirroring the CMS reimbursement cuts to imaging, they might have encouraged outpatient-imaging providers to join forces with hospitals, where higher technical rates continue to be paid. A further irony is that these same insurers are now paying RBMs to direct patients away from the higher-cost hospital outpatient setting and back to those low-cost outpatient providers that have

26 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

managed to survive the rate cuts.

Randy Hutchinson is senior vice president for strategic development and client management for AIM, a subsidiary of WellPoint—by its own description, one of the nation’s largest health-benefit companies, with 66 million participants served through its networks and health plans. WellPoint is the licensee for numerous Blue Cross Blue Shield plans—including those in Ohio, where the Radiology Imaging Shopper patientrouting program is being run.

AIM is the actual entity running the Radiology Imaging Shopper program and is now expanding it, Hutchinson says. AIM provides RBM services not only to WellPoint entities, but to other insurers as well. “We provide RBM services to 32 million members,” Hutchinson says. “WellPoint is a little under half of that.” He says that the Radiology Imaging Shopper rollout now encompasses about 1.5 million insured members.

Hutchinson says that AIM initially tried to steer patients to low-cost imaging providers through OptiNet, its Internet portal for referring physicians, where referrers were encouraged to schedule patients at low-cost imaging centers. The referring physicians mostly ignored this, however, and continued to refer patients to sites where they had involvement or preference, Hutchinson says.

“The reality is that a fair number of referring physicians are in large, integrated delivery systems geared to keeping those systems intact. Breaking that up is a less-than-compelling reason for them to switch,” Hutchinson says. Thus, for a fee, AIM has become proactive in actually telephoning patients once their advanced imaging exams have been preauthorized, pointing out to the patients that they can pay less elsewhere.

“Many patients have no idea what they are paying and what sort of rates they can get,” Hutchinson says. “As the prevalence of high-deductible plans has spread, that information has been critical.”

Perez says that when AIM representatives call patients, the patients are told where they can get their imaging done at a much lower cost. They are also told that if they want to switch, AIM will

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COVER | Price Disparity and Price Transparency

When we work with employers, we’re looking at 4% to 12% savings through consumerism. The average yearly expenditure per employee, for them, is now $10,000, so it’s a percentage of that.

—Jeffrey J. Rice, MD, JD

make the new appointment for them.

“We have found, through membersatisfaction surveys, that this program has been really agreeable,” Perez says.

She says that AIM screens its low-cost imaging providers for quality and directs patients only to high-quality sites.

Hutchinson says that about 15% to 18% of patients contacted have switched to the recommended low-cost providers— enough to create a healthy return on investment for the program.

“We’ve measured approximately 40 cents per member, per month, in savings,” Hutchinson says. “We cost about five cents to do that. Those savings opportunities are higher in the more populated areas.

You can’t do that in Missoula, Montana, but in St. Louis, Missouri, it’s a sizable chunk of money.” Hutchinson adds that the speed with which patients are called and advised that they can switch imaging providers is often of the essence.

“We are often placing calls within five minutes of preapproval and catching patients in the parking lot, before they leave the referrer’s office,” he says. “It sounds like an exaggeration, but it happens quickly. A key component to this is the degree to which the member wants to engage. If the patient declines, that doesn’t kill the preauthorization. It all processes as if he or she didn’t get the phone call.”

Blue Book Variation in imaging prices is responsible for another notable trend.

Internet entrepreneurs are designing websites to show patients how much they should pay—not only for imaging tests, but for surgeries, chronic-condition treatment, and general care. One of these websites is Healthcare Blue Book (www.

healthcarebluebook.com).

Healthcare Blue Book was founded and is operated by Jeffrey J. Rice, MD, JD, its CEO. Rice says that he started the company—modeled on the Kelley Blue Book, the vehicle price guide—after his son needed foot surgery.

Told at the outset that surgery would cost $37,000 at a hospital, Rice says that he asked for a discount and was given a price of $15,000 to $25,000. He says that he kept investigating until he found an ambulatory-surgery center that would perform the procedure (with equal quality) for $1,500. “Things like that happen every day,” Rice says.

Healthcare Blue Book sets prices for health-care procedures for every zip code in the country, Rice says. He uses his own staff of analysts to do so. For imaging, the technical and professional fees are bundled into a single recommended price, with a note to consumers that they ought to expect, at times, to receive a split bill from providers. “Our prices are based on what commercial insurers pay,” Rice says. “It’s midlevel pricing. We try to be fair.”

For a CT exam of the abdomen and pelvis without contrast performed in Central Florida, the recommended price is $411. For Portland, Oregon, it’s $380; for the Bronx, New York, New York, it’s $489; and for Twin Falls, Idaho, it’s $371.

“Imaging is pretty straightforward,” Rice says. “Relative to everything else in health care, imaging is pretty amenable to the patient understanding the services.”

Rice says that Healthcare Blue Book sells advertising space to support its services and also works with self-insured employers directly to find optimal pricing.

“When we work with employers, we’re looking at 4% to 12% savings through

28 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

consumerism,” Rice says. “The average yearly expenditure per employee, for them, is now $10,000, so it’s a percentage of that.”

He continues, “This has been a really good year for this whole transparency issue. Patients and employers are starting to understand pricing. That helps get providers on board.” Efforts to level the price playing field are a long way from finished, however. Imaging providers that must deal with wide swings in pricing remain wary. Cox says, “I have no idea where the whole system is going, but it can’t last like this.”

George Wiley is a contributing writer for Radiology Business Journal.

Reference 1. Office of Attorney General Martha Coakley. Examination of Health Care Cost Trends and Cost Drivers Pursuant to G.L. c. 118G, §6 1/2(b): Report for Annual Public Hearing. www.mass.gov/ago/docs/ healthcare/2011-hcctd.pdf.

Published June 22, 2011. Accessed February 2, 2012.

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Dashboards | Data, SOA, and KPIs

Dashboards:

From Data to Discovery Manual data collection is both more costly and less effective than a well-built performance dashboard By Kris Kyes

P

aul J. Chang, MD, FSIIM, says, “Because of the external expectations that we will all do more in radiology with less time and fewer resources, we are now entering a maturation phase that I call image management. The emphasis, now, is on understanding what we do to help the value proposition. The key is now measurable improvement in efficiency, productivity, or whatever key performance indicators create value for your institution.”

Chang, an abdominal radiologist, is professor and vice chair of radiology informatics and medical director of pathology informatics at the University of Chicago School of Medicine and is medical director of enterprise imaging and of service-oriented architecture at the University of Chicago Hospitals in Illinois. He presented “Technical Aspects: Developing and Deploying a Dashboard” as part of the multisession course “Quality Improvement: Quality and Productivity Dashboards” on November 29, 2011, at the annual meeting of the RSNA in Chicago.

The PACS, RIS, and electronic medical record (EMR) were originally designed to let radiology departments do their work, not assess their work, and that is still their primary function. For this reason, Chang says, there will usually need to be a separate business-intelligence entity (Figure 1), deployed on a service-oriented architecture and constructed to bring together the information that a dashboard will then show.

The adoption of standards for information systems can only be seen as a huge improvement over the proprietary protocols that came before them (and

made communication between systems profoundly difficult, absurdly expensive, or simply impossible). There are still communication problems among information system today, however— along with far better ways of overcoming them.

Watching the Battle The hospital information system (HIS) typically uses the HL7 communication standard, for instance, while the PACS is likely to support at least one form of the DICOM standard. Once the EMR, billing/ financial systems, any relevant standalone pathology and laboratory systems, and the RIS are added—as they must be, to obtain a comprehensive picture of the department’s operations—it is easy to see why manual data aggregation became the norm in many organizations, if they tried to bring together their data at all. Even today, guessing (whether educated or less so) based on the output of the RIS alone is not an uncommon management method in radiology.

Of course, manual data-aggregation methods produced information of relatively low utility (at high cost), and never in real time. Business-intelligence systems replace manual aggregation by pulling relevant data from all available sources in the organization. “The critical, absolutely essential tool for us to have to navigate through this environment is business intelligence/analytics,” Chang says. “Health care is about 10 years behind every other industry in IT, but it’s closer to 15 years behind in business intelligence.”

Chang adds, “It is useful to distinguish dashboards from scorecards,” despite the fact that the two are the forms of business

intelligence/analytics most likely to be seen in health-care settings. Although both scorecards and dashboards can be built using similar data from the organization’s information systems, E xe cutive Briefing

v

Radiology has entered a maturation phase that demands greater productivity with fewer resources, requiring tools that allow leaders to assess performance.

v Data must be aggregated from multiple information systems, normalized for reliability, and displayed for easy access using a businessintelligence informatics layer best achieved through a service-oriented architecture.

v Determine what matters most to the organization, and these key performance indicators will provide a subfloor for the dashboard, which should have the flexibility to display information in a way that makes sense to each user.

v Objective data lead to objective thinking and objective discussions.

Chang explains, “The dashboard is a performance-monitoring tool similar to a pilot’s heads-up display: It’s a tactical, realtime, operational tool typically achieved using graphics, charts, and gauges.”

The dashboard, he adds, provides tactical situational awareness. It tells users whether they are winning the battle; scorecards (or report cards), in contrast, are strategic, rather than tactical. They tell

www.imagingbiz.com | February/March 2012 | Radiology Business Journal 31

Dashboards | Data, SOA, and KPIs

Normalize the data so that you can unambiguously use and trust the information.

—Paul J. Chang, MD, FSIIM

users whether they are winning the war.

The business-intelligence layer is necessary because it is dangerous, Chang explains, to consume naked data.

Without integration and analysis, data sourced from a single information system might not be relevant because it is not comparable to data acquired, handled, defined, changed, or retrieved (according Patient’s record

RIS

HL7

M CO DI

Dictation reporting

Pathology

Winning the War The data normalization performed using business-intelligence systems makes large tables into smaller entities in

Pathology

RIS 7 HL

to different criteria) from another system. The solutions to this problem of comparability and compatibility are data standardization and normalization.

PACS

PACS

DICOM M CO DI

Modality

Electronic medical record

RIS

PACS

Business-logic layer

Figure 1. Moving away from human-integrated workflow (top) by using HL7 and DICOM protocols to integrate RIS and PACS (middle) and by deploying service-oriented achitecture throughout the enterprise (bottom); image adapted with permission of Paul J. Chang, MD. 32 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

which an added, changed, or deleted field is less likely to affect other areas adversely and is more likely to maintain its actual meaning as it propagates through the information system.

Relationships among various kinds of data are also more tightly defined than they would be in a single information system before normalization. “Normalize the data so that you can unambiguously use and trust the information,” Chang says.

The development and implementation of a useful dashboard in radiology should not focus on the final appearance of the dashboard itself, Chang says, although that is the misguided emphasis of many dashboard projects and their developers.

The appearance of the tool is far less important than the reliability of the underlying data and the agility of the architecture supporting the dashboard.

As Chang puts it, garbage in, garbage out is still a sequence that imperils information systems. This is true even (or perhaps especially) when the risk is one of garbage in, pretty garbage out, as it is for dashboards. An attractive dashboard with a user-friendly interface might still have only a tenuous relationship with the reality of the radiology department if the methods used to generate that dashboard are unsound.

Bringing together all of the available information in a reliable way, however, constitutes leverage for the radiology department in exactly the same way that making full use of equipment and staff expertise does. Make the most of what you already have by using it as well as you can.

Chang notes, however, that in using what you have as well as you can, time is a factor. It is important to favor today’s action over tomorrow’s possible perfection. He says, “The biggest risk you have right now is delay—saying ‘We have to do an analysis’ or ‘Let’s think about this.’ Leverage your local resources, as well as external resources (as necessary).”

The real risk in business intelligence/ analytics, he says, is not having it at all.

Choosing Performance Indicators C. Daniel Johnson, MD, is chair of the department of radiology and professor of

Be as specific as you can with all these measures because the more specific you are, the more directly they will translate into improvement.

—C. Daniel Johnson, MD

care was not measured very well.” To manage the quality of work, he adds, departments need measurements that are at least as rigorous as those used for financial attributes.

“Begin by defining some key process measures for quality. Safety is probably the easiest one to begin with; efficiency is always something that people are interested in because it reflects dollars saved. Satisfaction isn’t too hard, but professional outcomes are the most difficult to measure well,” Johnson says.

The definition of quality is not static, and it needs to reflect the characteristics of the department—as well as those of its customers and its broader environment, both now and as those characteristics change, Johnson notes. Quality and safety can be seen, in a sense, as the points where care providers meet patients; the Mayo Clinic approach to imaging’s interaction

with the patient pathway (Figure 2), as it affects safety and the quality of care, was first illustrated and described by Swensen and Johnson1 in 2005.

Among many other possibilities, some of the main measures outside the financial arena that Johnson names as examples of helpful indicators are exam access and finalization times (in the efficiency category); waiting times and survey results (in the customer-satisfaction category); and interpretation accuracy, complication rates, and order appropriateness (in the professional-outcomes category).

The safety category is likely to be among the largest shown on a dashboard, with common indicators including harmful falls, medication errors, sentinel events, critical tests/results, adherence to universal precautions, infection rates, hand hygiene, contrast-induced nephropathy incidence, and mislabeling

Radiology Department

Physician

Patient

Radiologist

radiology in the College of Medicine at the Mayo Clinic Arizona in Scottsdale. In addition to moderating the three-session course, he presented the second section, “Key Performance Indicators That Drive Quality.”

Dashboards are built from the bottom up, so the key performance indicators on which they stand must be both relevant to the department’s operation and feasible to construct using data available from existing information systems (the RIS, PACS, HIS, EMR, departmental, and billing/financial systems).

For those reasons, Johnson says, the possible key performance indicators used in dashboards should be narrowed down to those that are most likely to be useful in practice; what it’s nice to know is not the same as what it’s necessary to know.

“We really don’t have standardized ways of defining quality,” he says. “In fact, the very best quality measures are probably customized.”

Established performance measures in health care can serve as a starting point in the creation of dashboards, however— although they will need to be fleshed out in ways that reflect the actual situation of the organization. These measures are used to predict future performance, but they are also the basis for tracking daily activities (and whether those activities represent progress toward the long-term objectives of the organization).

Because the administrative/financial areas of many institutions have been using analytical methods longer than most clinical departments have used them, it might seem easier to begin with billing/financial indicators in setting up business intelligence for radiology.

According to Johnson, however, those indicators should certainly not be given priority when the importance of various measures is assessed; in fact, a separate financial dashboard is used at the Mayo Clinic to keep quality and finances apart.

Johnson says, “We underwent an analysis by the Baldridge Performance Excellence Program in the radiology department at Mayo Clinic Rochester in Minnesota several years ago. We were astonished to learn that the best metrics we had were financial, and what was really important in creating great patient

Global Outcome

Patient exam Appropriateness Orders test

Answer clinical question/ positive patient outcome Reviews finding/ treats patient Finalization times

Access times

Exam performed

Schedules

Complications

Waiting times Standard protocol (%) Protocol selection

Interpretations Outcomes Finalization

Figure 2. The Mayo Clinic approach to safety and quality assesses critical points (red) where imaging interacts with the patient pathway via referring physicians, radiology departments, and radiologists; image adapted with permission of C. Daniel Johnson, MD. www.imagingbiz.com | February/March 2012 | Radiology Business Journal 33

Dashboards | Data, SOA, and KPIs

Most departments do not have robust business-intelligence tools.

They will not come from the HIS, the RIS, or the PACS. They will only come from the construction or adoption of freestanding programs.

—James M. Thrall, MD

of images. Johnson says, “Be as specific as you can with all these measures because the more specific you are, the more directly they will translate into improvement.”

In determining patient satisfaction, Johnson says, it is especially important to understand that patients’ needs and expectations will very widely. The survey responses of oncology patients can be expected to differ from those of breast-imaging patients or the parents of pediatric patients, so survey data will have more meaning if the individual respondent is first asked to define what is important in his or her choice of an imaging facility. Then, that person can be surveyed as to whether those personally important criteria are being met—not on unrelated matters, Johnson reports.

Another type of customer, he continues, is the referring physician. No matter what preferences this physician might have concerning consultation, interpretation accuracy, or report-turnaround times, it is easy to assess whether those need are being met with just one question. That question, Johnson says, is “How likely are you to refer a family member or close friend to our institution for radiologic care?” While the answer picks up none of what might be relevant detail, it captures the core of any definition of referrer satisfaction.

It will not, however, automatically become part of the business-intelligence database. Johnson says, “If you don’t have access to world-class IT support, this process certainly requires a lot of manual work.”

Many types of data used in the Mayo Clinic scorecard/dashboard are still entered manually because they are not routinely collected by the RIS, PACS, HIS, or EMR and cannot be integrated

automatically by a business-intelligence system. Survey results, Johnson says, are an example of measurements calling for manual data entry. Other manually compiled indicators might come from external databases (such as national disease registries) for which electronic access is available, but from which information is not always distributed electronically.

In constructing a scorecard/dashboard, it is important to remember, Johnson says, “Metrics are only one piece of the puzzle. A high-performing radiology department has to think about all areas and aspects of good business practice, of course, but metrics should allow us to do the most important thing better and more efficiently. That most important thing is taking care of patients.”

Roll Up and Drill Down James M. Thrall, MD, is radiologistin-chief at the Massachusetts General Hospital in Boston and is Juan M. Taveras professor of radiology at Harvard Medical School. In “Using a Dashboard to Manage a Radiology Department,” his section of the three-part presentation, he emphasizes that access to business intelligence is vital to the sound management of today’s radiology departments.

Without that layer to integrate data from the RIS, PACS, HIS, and billing/financial systems, the radiology department remains data rich and information poor, Thrall says. If a radiology department is trying to base its everyday operational decisions (not to mention its longer-term strategies) on information compiled manually from disparate databases, it is more than inefficient; it is probably ineffective as well—because it is underinformed.

Hospitals (and radiology departments),

34 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

Thrall says, not only have access to mountains of data through their HIS, RIS, PACS, and billing/financial information systems, but expend considerable time and effort collecting these facts.

Nonetheless, the resulting collections have not been particularly helpful in the management of radiology departments or their parent institutions because it has been difficult (ranging from cumbersome to impossible) to organize the available data into useful formats.

The RIS and PACS, in particular, do not usually have the report-construction abilities that a radiology department needs in order to keep track of its performance and its day-to-day status. These systems were not designed for reporting purposes, and they cannot readily perform the cross-referencing outside their own databases that is called for in constructing useful analytical material for radiology departments.

Thrall says, “Most departments do not have robust business-intelligence tools. They will not come from the HIS, the RIS, or the PACS. They will only come from the construction or adoption of freestanding programs.” This is why business intelligence, including access to scorecards and dashboards, has become so necessary, he adds. By integrating data that are already being collected, businessintelligence systems can turn disparate fact collections into relevant dashboard categories that provide accurate, up-todate information.

Thrall calls manual data compilation the swivel-chair method, since someone must retrieve and print data from one of the organization’s information systems and then turn to another system to enter those data into it before any useful analysis can take place. “We know the benefits of adopting data warehousing and data normalization. If that’s done, then a lot more can be extracted electronically. If that’s not done, then it’s back to printing out data on one system and manually entering data in another,” Thrall says.

The first step in moving beyond the swivel-chair method is to determine what matters most in operating a radiology department. Those key performance indicators, once chosen, then form the level below the dashboard—the

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Dashboards | Data, SOA, and KPIs

foundation of dozens of variables upon which it is built and to which the dashboard’s approximately 20 categories give access when greater detail is desired.

Key performance indicators form the level of information that the dashboard user can view by drilling down; the bigger picture, containing four to six overarching topics, is accessed by rolling up from the dashboard (Figure 3).

Key performance indicators are the measurements and parameters that tell radiology departments where they stand in terms of financial performance, quality of care, efficiency, and satisfaction (of patients, referring physicians, and other stakeholders within and outside the institution).

Thrall says, “We define the key performance indicator, we define the term, and we define who is accountable for it.” Units, metrics, and targets for the indicator are then determined. These are not shown directly on a well-constructed dashboard because they are too numerous (Thrall’s department, for example, began with 155 key performance indicators).

Instead, the dashboard aggregates the key performance indicators in ways that make sense to users and allow them to drill down or roll up quickly, as needed, to the information that they require to support the decisions that they must

make. “The value of dashboards comes from the accessibility of the data. How many clicks does it take to get the desired data? If it’s more than a couple of clicks, it’s too many,” Thrall says.

For example, he adds, a service-line manager would be interested in a level of detail that would not normally require the attention of the department chair. From the same dashboard gauge, therefore, the manager could drill down for access to the key performance indicators, and the department chair could roll up to determine how the current status shown by the gauge affects (and is affected by) the other dashboard categories in the same broad strategic area.

Different dashboard users who are viewing referral patterns, for example, might be interested in levels of detail ranging from the overall geographical distribution of patients’ home addresses to the particular communities where patients live to the specific physicians who referred them for imaging exams (or the imaging modalities and diagnoses noted for those referrals).

Thrall stresses, however, that a properly constructed dashboard is useful to the department (and the organization) as a whole, not just to department managers and administrators. Medical personnel tend to respect data-driven,

Dashboard-level indicators (< 20)

wn do ill Dr

Ro ll u p

Strategic categories (four to six)

Key performance indicators (dozens) Figure 3. Hierarchy of business intelligence; image adapted with permission of James M. Thrall, MD. 36 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

objective approaches to management, and staff members might be more likely to respond positively to change when it is supported by clear and relevant data.

“The reason that it’s so powerful is that objective data lead to objective discussions and objective thinking.

Without objectivity, many people cannot distinguish between being busy and being productive,” he says. “Everyone thinks that he or she is busy, and a lot of people feel that they are overworked, but when you actually have objective data for them to look at, it changes their attitudes.”

Start Now Thrall reassures the analytically timid that it is not necessary to reinvent the wheel in building a dashboard, and Johnson emphasizes that customization is not the same as starting from scratch.

Both report that the work already done (some of which has been published or presented) by other institutions can be a source of key performance indicators that can then be made specific to one’s own radiology department.

“Both,” Chang concludes, is the best answer to the build-or-buy question.

Make full use of the organization’s interface/integration team and of your data sources, as well as of the staff or outsourced service that now creates your management reports. Take advantage of the services of good business-intelligence/ analytics consultants if your in-house expertise is incomplete.

When it’s time for the last step in building a dashboard—creating the user interface—look at the packages and services available from the dashboard companies already active in the radiology field, Chang adds. External and existing IT resources can be blended to obtain the ideal business-intelligence system—and the dashboard that makes it useful every day.

Kris Kyes is technical editor of Radiology Business Journal.

Reference 1. Swensen SJ, Johnson CD. Radiologic quality and safety: mapping value into radiology. J Am Coll Radiol.

2005;2(12):992-1000.

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Penn Radiology | Informatics Incubator

University of Pennsylvania Health System:

Inside an Imaging-informatics Incubator Penn Radiology is developing a new generation of imaging informaticists, charged with reinventing the way radiologists work

B

y observing the quantity and quality of informatics innovation emerging from a radiology department, it is possible to identify those institutions that are nurturing the next wave of informaticists in radiology. One beacon is the University of Pennsylvania Health System (UPHS) in Philadelphia, where R. Nick Bryan, MD, PhD, is chair of radiology.

Bryan is quick to attribute the department’s success in this arena both to his predecessors and to others in the department, beginning with former chair Ronald Arenson, MD, (instrumental in the development of the first RIS, in the 1980s) and including Steven Horii, MD; Reuben Mezrich, MD, (during his time at UPHS); and, most recently, Curtis Langlotz, MD, PhD, vice chair for informatics.

Bryan reports that focus, organization, and culture have made imaging informatics a hallmark of the radiology department at UPHS, and that immediate health-care exigencies are influencing current activities and priorities.

Reinforcing Tradition A continuous line of faculty with expertise and interest in informatics has made informatics an innate part of the department, Bryan says, attracting—in turn—a consistent flow of young people interested in the field. “Having people with those levels of skill and knowledge just reinforces informatics within a department,” he says. “They impress and attract young people who want to follow their path.”

To maintain the informatics edge, Bryan has had to dedicate appropriate resources, in the form of recruiting both clinical and nonclinical staff. “Informatics and health-services research, a near

neighbor, are viewed as one of a number of main academic fields of interest of the department,” Bryan explains.

A strong medical-informatics group, headed by Dan Morton, PhD, provides critical support for researchers. “That group has had strong intellectual leadership and good on-the-ground people to support the faculty,” Bryan says.

More recently, with the recognition of the need for increased efficiency, Bryan has strongly encouraged some of the younger staff members to invest their time in informatics. “Informatics is the key to

three senior faculty for whom informatics is the main focus. A combination of natural interest and encouragement by leaders has resulted in an increase in the number of trainees and junior faculty interested in this area. “We have three to four junior faculty members who are focusing on this area, and that is more than we have traditionally had,” Bryan notes.

The Hit Parade Among the recent activities of the department, Bryan highlights involvement in the CMS Medicare

Informatics is the key to gaining the efficiency we will need and, at the same time, the means to provide the quality of care and document it.

—R. Nick Bryan, MD, PhD

gaining the efficiency we will need and, at the same time, the means to provide the quality of care and document it,” he says.

He continues, “Staff members are rewarded on the basis of their presentations, publications, and patents— all of the incentives of the traditional academic environment. In some cases, they gain additionally if they link that to commercial activities, but most of them are doing this because it is what they like, this is what they are interested in, and that is the academic part of their career.”

Three years ago, Bryan formed a new committee on departmental efficiency and appointed Woojin Kim, MD, as the chair.

Under Bryan, the already sizable informatics group has grown 10% to 20%, he estimates.

Traditionally, the department has two or

38 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

Imaging Demonstration for electronic decision support as part of a consortium with Brigham and Women’s Hospital (Boston, Massachusetts); Geisinger Health System (Danville, Pennsylvania); and Weill Cornell Medical College/New York– Presbyterian Hospital (New York, New York). “Curtis Langlotz is leading the effort on our campus, and we actually have that turned on and running,” he reports.

He also cites the RADIANCE project of Tessa Cook, MD. “In terms of quality issues, I think Tessa’s RADIANCE is a very good example,” he says. “We now have an automatic system for retrieving our patients’ radiation exposures, and for documenting and reporting them in a variety of fashions, so that people can make use of them in their patient care.”

Business Intelligence Series: Pueblo Radiology FIRSt PROFILE In a SERIES OF SIx

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 Santa Barbara, 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.”

“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.

“It’s not 1982 anymore. You have to figure out how to modify your operations to survive in the new world.”

Zotec Partners. The total solution.

PROFILE The Challenge: 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 and increased bad debt.”

Zotec Partners. The total solution.

Additional information derived by Zotec on a monthly basis tracks nearly every aspect of operations, Baldwin says, ranging from physician productivity as measured by work RVUs to payor performance to referral patterns.

“Without Zotec’s data and the ability to track those metrics in near-real-time, we wouldn’t have an accurate picture of how we’re doing.”

“At the end of the day, Zotec’s data is a very valuable tool,” Baldwin says. “Without that data, and the ability to track those metrics in near-real-time, we wouldn’t have an accurate picture of how we’re doing.”

The Solution: Leveraging Business Intelligence Once Pueblo Radiology had leveraged business intelligence to identify 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

Bad Debt Percentage

Zotec client graphic displaying decrease in bad debt percentage over three years

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 interactions with patients regarding payment. “We needed to educate them about the issues they would face when asking for the money upfront, and how to prepare both themselves and the patients beforehand,” Baldwin says. “We have been diligent about preparing

“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 them so that they are confident and able to deal with those interactions, and are able to escalate it if there is a special issue or a question.”

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.”

PROFILE Zotec’s business intelligence not only enabled Pueblo Radiology to spot its bad debt issue, 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 used the data not only to identify the problem, but to measure our progress. Our results have been remarkable.”

“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.”

Looking Forward: 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 within 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.”

11460 N. Meridian St. Carmel, IN 46032

317.705.5050 sales@zotecpartners.com zotecpartners.com

A third project that Bryan cites is Presto, the UPHS name for the management tool developed by Kim; William Boonn, MD; and colleagues.

“It indexes data from multiple information systems and provides a very effective user interface to extract the data and create reports online that we use every day in the management of our department,” Bryan reports.

Moving forward, Bryan predicts that his informatics team will make further contributions in the areas of quality and efficiency that will resonate throughout the health system. “All large health systems are looking for programs and projects that increase efficiency, while maintaining the quality of patient care,” Bryan says.

“Our department has been looked at by the system as something of a leader in using informatics to deal with these issues. Decision support and electronic order entry are things the health system recognizes, from the regulatory and reimbursement perspectives, as critical for our institution, and we have a mission of providing leadership in that area.”

Bryan continues, “In general— given the unknowns in health-care delivery and (in particular) with

the possibility of more managed-care or population-accountability components of health care—having a very sophisticated informatics system is critical for being able to deliver care in that fashion.”

The Next Productivity Leap Informatics is an important strategic tool for Bryan, and he intends to use it to increase clinical efficiency by the 20% to 30% necessary just to counterbalance the decrease in clinical volume anticipated as a result of utilization control and reimbursement reductions. He estimates that electronic workflow and hard work by the faculty have allowed the department to increase productivity by 30% over the past 10 years. “We are looking for 20% on top of that,” he says, “and the sooner, the better.”

In retrospect, what RIS and PACS have done is keep radiologists busy, according to Bryan. “When we are on clinical assignment, we are working all the time,” he says. “There is always a study in front of us; there’s no downtime. We’ve gained efficiency by RIS and PACS allowing us to work harder at more or less the same thing that we used to do.”

While some aspects of electronic workflow (especially voice recognition) might have slowed radiologists, overall, electronic workflow has enabled

E xe cutive Briefing

v Informatics talent attracts talent to the University of Pennsylvania Health System radiology department.

v Informatics is deployed to achieve strategic goals, such as improved quality and clinical efficiency.

v An indexing tool provides Googlelike search capability of radiology and pathology reports, and issues alerts for radiologists when pathology reports are available.

v A dose-monitoriing application for CT exams that imports dose parameters is freely available as open-source software.

radiologists to increase productivity by working more quickly, Bryan says.

“We probably can’t pedal any faster,” he adds. “Now, we are going to have to get informatics to provide us with some intelligent tools that will actually make us more efficient—on an individual, case-by-case basis. That’s a big challenge, and that’s where we are really pushing informaticists right now.”

—Cheryl Proval

Google-like Access to Hospital Data

J

ust before joining the Hospital of the University of Pennsylvania—part of the University of Pennsylvania Health System in Philadelphia—as a full-time faculty member, I found myself asking why it was so difficult to find a case that I had dictated only several weeks ago.

Without knowing the patient’s name, medical-record number, or studyaccession number, looking for a case that I had dictated a while back was a very difficult task.

When searching for a case, one typically remembers the type of study and certain words or phrases used in the original report. For example, it was not an easy task to do a search

for all cases of Morton neuroma seen on MRI on which I had reported within the past five years—yet we are living in a world where we can find all kinds of information online instantaneously.

There are a number of reasons that radiologists would look for past cases.

They might want to find cases for retrospective research, case reports or series, lectures, quality-improvement projects, or teaching files. They might be looking at a case and want to refer to similar cases in the past for help with clinical decisions.

An attending physician might be reading a case with a resident, might come across a case of extraperitoneal bladder rupture, and might want to show similar cases to supplement the resident’s education. A resident might simply want

By Woojin Kim, MD

to find out how a particular attending physician likes to dictate reports and might look up prior reports by that attending physician. The possibilities are endless; in fact, naming them is like asking someone why and how he or she uses Google.

The reference to Google also applies to the design and functionality of the application that was created as a result of unmet case-finding needs. A purely Web-based search and data-mining tool was created to meet these needs, but the software application was designed, from the beginning, to go beyond searching just radiology reports. Pathology reports also were incorporated, and the tool was designed to combine different report databases on demand, to allow searching for cases with both radiology

www.imagingbiz.com | February/March 2012 | Radiology Business Journal 43

Penn Radiology | Informatics Incubator Figure 1. The search and data-mining system developed at the University of Pennsylvania can retrieve and analyze needed information in less than a second, offering both clinical and administrative staff the power of the search function through an intuitive user interface. It is a zero-download, browserbased application that makes searching and data mining possible from any computer or mobile device.

and pathology reports—all in a matter of seconds (instead of weeks or months).

Soon after the development of the search tool, an automated pathology follow-up module was created.

Radiologists often look at an image and wonder what the anomaly that they are seeing will turn out to be. Using an intelligent report-matching algorithm, the automated pathology follow-up module notifies the user of pathology reports pertinent to the radiology reports that he or she has previously dictated.

For example, a patient undergoes surgery to remove his renal cell carcinoma, and the pathology report becomes available today. The application then notifies the radiologist of that pathology result, based on the MRI exam that he or she read a month ago.

Features of this application were presented at national meetings, and after each presentation, many attendees expressed interest in having a similar tool installed at their institutions. This led to commercialization of the software application.

Software Enhancements Since that commercialization, additional uses of data mining have been developed. By mining the metadata (including exam code, exam type, modality, reporting physician, and ordering physician), we were able to create business-intelligence and analytics tools, allowing measurement of productivity and analysis of the referral base.

Intelligent automining of the reports allowed the creation of quality dashboards, automatically evaluating reports for critical test results, and finding cases with dictation errors (such as mistaking right for left body sides or male for female patients).

The Web’s search engines, such as Google or Bing, work by looking for information on Internet servers (crawling) and then indexing this information. The search engine quickly delivers results for a user’s query by examining its index.

Because the usefulness of the search engine largely depends on relevance of the results returned, much attention is paid to algorithms related to improving relevance.

Figure 2. The application provides multiple options for exploring search results, including this bird’s-eye view. It combines radiology and pathology search functions, enabling users to find pathologyproven cases easily.

Figure 3. The analytics package optimizes practice by providing tools for measuring key performance indicators.

Interactive tools display turnaround time and RVUs to help users tailor physicians’ schedules and optimize productivity.

Google bases some of its relevance ranking on the PageRank algorithm, for example. Our application functions in a similar fashion, with attention paid to the unique features of medicalreport databases and algorithms for understanding medical-report text.

The application has minimal hardware requirements for most practices’ study volumes, and it even runs in a virtualized environment. For extremely large operations, it can be horizontally scaled to distribute the load across a number of servers or virtual machines. It has the ability to crawl and index report

44 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

data residing in any RIS or hospital information system directly, and it accepts standard interchange formats such as HL7. A flexible architecture allows the application to index and search reports outside radiology, including those in cardiology and pathology systems.

Great attention has been paid to the overall user experience (Figures 1–3) to ensure the practical and efficient use of the application.

Being Web based, the application follows Web standards that ensure cross-browser compatibility, supporting all modern browsers, legacy versions of Internet Explorer, and even mobile browsers such

The Missing Piece in the Meaningful Use Puzzle.

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Penn Radiology | Informatics Incubator

as Android and Mobile Safari. A zerodownload application, it provides access from reading rooms, offices, VPN-attached home computers, and mobile devices such as iPhones and iPads.

As imaging services are targeted for cost cutting, radiology practices need timely business intelligence to survive.

Furthermore, there is growing interest in the improvement of health-care quality,

leading to increasing demand for quick access to timely and accurate healthcare data. Spending weeks working with a database analyst to produce a static report is no longer a tenable approach to business intelligence in health care.

With the ability to extend beyond the radiology-report database to include other specialties in medicine, such as pathology and cardiology, the possibilities

for enhanced knowledge discovery and improvement of health care are greatly increased.

Woojin Kim, MD, is interim chief of the division of musculoskeletal imaging at the Hospital of the University of Pennsylvania in Philadelphia and is cofounder of a health-care informatics solution; woojin@ montagehealthcare.com.

CT Dose Monitoring Using RADIANCE By Tessa S. Cook, MD, PhD

T

hough no medical procedure is without risk, medical imaging is generally considered safe, so when a number of instances of patient overexposure to imagingrelated radiation from CT exams came to light, the radiology and medicalphysics communities quickly responded.

The ACR® Dose Index Registry (DIR) is actively collecting CT dose parameters from facilities worldwide in order to develop a set of benchmarks and dosereference levels for diagnostic CT. For pediatric patients, the Society for Pediatric Radiology is sponsoring a similar effort on a smaller scale. In addition, the American Association of Physicists in Medicine has developed size-specific dose estimates that allow normalization of CT dose parameters (based on patient size) for children and small adults.

The biggest challenge in the CT dosemonitoring effort has historically been the way that the dose parameters are stored—as pixels on an image-based dose sheet, rather than as structured numeric data. More recently, the major CT-scanner vendors have adopted the DICOM standard for radiation-dose parameters: the Radiation Dose Structured Report (RDSR). Only newly or recently introduced scanner models support RDSR generation, however, leaving a vast repository of existing CT exams worldwide for which no effective means of dose monitoring previously existed.

To meet this need for a dose-monitoring solution, my colleagues and I at the Hospital of the University of Pennsylvania in Philadelphia, part of the University of Pennsylvania Health System (UPHS),

Figure 4. The automated RADIANCE pipeline, which can import dose parameters from either image-based CT dose sheets or the DICOM Radiation Dose Structured Report.

developed Radiation Dose Intelligent Analytics for CT Exams (RADIANCE).

RADIANCE is a freely available dosemonitoring application for CT exams that imports dose parameters from either the image-based dose sheet or the RDSR. Once configured, it can be scheduled to run as an automated pipeline that processes new dose sheets and updates the database without user input (Figure 4).

The pipeline can also be triggered manually, as needed. Imported dose parameters include the volumetric CT dose index and dose–length product, as well as other reported parameters that vary by scanner manufacturer. Additional information about the patient, the imaging facility, the type of study performed, and the scanner hardware used is extracted from the DICOM study header.

All data are stored in a relational database that resides behind the firewall of the imaging facility. If the facility participates in the DIR, it can elect to submit data to the registry using RADIANCE. Reporting tools built on the RADIANCE database schema can be used to facilitate

46 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

data analysis and dose reporting. A realtime dashboard provides a snapshot of the database that can be filtered by study type, scanner model, individual patient, or dose-estimate threshold (Figure 5).

Monthly scorecard reports are tailored to the role of the recipient: radiologist, technologist, or radiology administrator (section chief, medical physicist, and so forth). Radiologists and technologists receive a summary of dose estimates for studies interpreted or performed, respectively, during the immediately preceding month.

Administrators get a wider view of the data, with 12-month trend information, as well as access to individual radiologists’ or technologists’ scorecards (Figure 6).

Comparative data from preceding months for equivalent study types are provided, as are data from equivalent studies that were interpreted or performed by others in the department during the same month.

A subset of the highest-dose estimates for all patients, as well as for patients under the age of 50, is provided. Scorecard users within UPHS can access the final study interpretation, original study images,

Figure 5. The RADIANCE dashboard shows individual-study dose estimates for the specified time interval, as well as averagedose and maximum-dose estimates on different scanners within the facility.

or the original image-based dose sheet for the study. Any factors identified that could have contributed to a higher-thanexpected dose can be documented directly from the scorecard and attached to the study within the RADIANCE database.

Within UPHS, all three of our hospitals use RADIANCE for CT dose tracking.

The pipeline is automatically triggered when dose sheets are received by the RADIANCE computer from any of the three hospitals. Radiologists at our main hospital can launch a patient’s CT doseestimate profile directly from the PACS when viewing an existing CT exam for that patient.

The dose profile summarizes individual dose estimates stored in RADIANCE for all CT exams undergone by a patient within our health system, with links to the reports for every exam. Dose estimates for an individual patient can be retrieved from the RADIANCE database during the study-protocol process so that an appropriate choice of modality and study protocol can be made for the patient’s next imaging study.

Using RADIANCE data, we have implemented dose-reduction measures for our thoracic and cardiovascular CT exams, as well as for CT urograms.

By tightening scan length, decreasing the number of imaging phases (when clinically appropriate), reducing tube current, and customizing protocols to the patient’s body-mass index, we have been able to reduce dose estimates for singlephase thoracic CT exams, pulmonaryembolism CT exams, and high-resolution

Figure 6.

The administrator’s view of the RADIANCE scorecard shows a 12-month trend for average-dose and maximum-dose estimates, in addition to comparative data and summary information for a subset of highest-dose estimates for a particular study type during the preceding month.

parenchymal chest CT exams by 38%, 30%, and 65%, respectively.

RADIANCE data have also been used to educate radiology trainees about CTrelated radiation and how alteration of CT protocols and parameters can reduce dose. Dose-monitoring and dosereduction efforts continue within our health system; they include education of referring physicians and nonradiology trainees about CT and dose, as well as assessment of the effect of dose-specific decision support on ordering patterns.

A successful dose-reduction initiative requires the ability to monitor and analyze dose estimates for specific study types, whether by using an internal dosemonitoring solution, by participating in a dose registry, or both. Combining the facility’s internal dose monitoring with participation in a registry provides the ability to monitor individual-study dose estimates regularly and to determine how well national or regional dose benchmarks are being met.

Once an opportunity for dose reduction is identified, a plan must be implemented. The plan might include specific protocol modifications, use of clinical decision-support tools, education of referring physicians regarding imagingrelated radiation, or some combination of these interventions. The success of the initiative depends on closing the loop after the plan is put in place and demonstrating a reduction in dose estimates, while ensuring continued dose monitoring via compliance with the systematic improvements.

As has been done within UPHS, RADIANCE can be used as the cornerstone of a successful dose-monitoring and dosereduction effort. For more information and to download RADIANCE, please visit http://www.radiancedose.com.

Tessa S. Cook, MD, PhD, is a fourthyear radiology resident at the Hospital of the University of Pennsylvania in Philadelphia.

www.imagingbiz.com | February/March 2012 | Radiology Business Journal 47

SPECIAL REport | RBM Practices

Best Practices:

How the RBMs Score Surveyed providers say that five RBMs differ only 2%— but are 20% less compliant with guidelines than they claim to be

By Christie James, MS; Larry Buchwalter, JD; Michael Mabry; Ron Howrigon; and the RBMA’s Payor Relations Committee

G

rowth in imaging utilization has led prior authorization (a 1980s health-plan strategy) to be applied to advanced imaging services. RBMs have developed increasingly complex programs to reduce imaging expenses through utilization management, credentialing, channeling to lower-cost providers, and network contracting.

Five competitors dominate this marketplace: American Imaging Management (AIM®), Inc (Deerfield, Illinois); CareCore National (Bluffton, South Carolina); HealthHelp® (Houston, Texas); MedSolutions (Franklin, Tennessee); and National Imaging Associates (NIA)/Magellan Health Services, Inc (Columbia, Maryland).

By 2009, these companies managed utilization for almost 100 million US covered lives.1 Today, they hope to expand into the Medicaid and Medicare programs.

RBMs have caused radiology to experience declines in volume and increases in administrative costs. In response, the ACR and the RBMA developed the best-practice clinical, administrative, and transparency guidelines for RBMs in 2009 and updated them in 2011.2 As much as 28% of savings attributed to RBMs could be shifted to providers,3 and the overall value of RBMs to imaging providers, referrers, and the medical community has been questioned (with speculation that RBMs could increase total health-care costs through denial of appropriate and necessary tests).

The intended purposes of the ACR–RBMA guidelines were to provide standards for RBMs and establish a benchmark with which RBMs could be compared. AIM was the first to recognize this potential and benchmark itself against these standards (in 2010).

The RBMA then determined that each RBM should have its compliance measured and scored. In order to minimize bias, the RBMA hired Fulcrum Strategies (Raleigh, North Carolina), an independent, thirdparty, physician-practice consulting company.

Methods The RBMA’s Payor Relations Committee (PRC) created a survey questionnaire that incorporated the ACR–RBMA guidelines and was divided into clinical, administrative, and transparency topic sections. Fulcrum Strategies and the PRC then developed a scoring system for the questionnaire, based on feedback from RBMA members and the RBMs. Points were awarded based on the assigned weight of each standard. The weighting was determined by collecting comments from the PRC and the RBMs about the perceived importance of each question (five to 15 points). This produced a scoring matrix with a maximum possible score of 300 points, with partial credit possible for each question.

Fulcrum Strategies was engaged to complete the evaluation process in order to avoid any specific provider bias, promote the objectivity of the process, and make sure that one person would be scoring each RBM (to ensure consistency).

Fulcrum Strategies sent the RBMs the questionnaire and scoring matrix, requesting that they score themselves. The RBMs were asked to provide additional relevant information, indicating which processes or policies were dictated by payors and what objective, verifiable information could be provided to support their responses.

Each RBM filled out the scoring grid and returned it to Fulcrum Strategies,

48 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

E xe cutive Summ ary The degree to which radiology benefit managers (RBMs) adhere to ACR® and RBMA best-practice guidelines was measured by a survey of five RBMs themselves and imaging providers. The RBM self-ratings of compliance ranged from 80% to 88%. Providers did not significantly differentiate among the RBMs (scored at 64% to 67% compliant).

While the overall rankings are quite similar, the degree of compliance with guidelines perceived by RBMs and providers varies significantly.

This suggests, at a minimum, an opportunity for RBMs to structure and communicate their policies better.

which then called to clarify any unclear responses, seek additional information, and obtain supplemental support. RBMs were awarded the total possible points for questions that fully met the standards and were awarded no points for questions that did not meet the standards at all.

For questions where an RBM partially met the standard, partial points were awarded; for example, if an RBM provided information showing that a standard was followed 90% of the time, it would receive 90% of the possible points for that question. Once the process was completed, Fulcrum Strategies assigned a score to each RBM. In order to obtain a balanced representation (given current business exigencies and the regulatory environment), the RBMA then sent the same survey to a broad cross-section of imaging providers, including hospital-

Take time to combine The joy of play and learning Return home refreshed – a haiku Plan to attend the 2012 Radiology Summit and combine business with pleasure. We have aligned our schedule to give you ample time to enjoy the surroundings.

While we have your attention however, you will have the opportunity to attend and participate in extraordinary general and concurrent sessions.

Take time to meet and network with colleagues and browse through a full exhibit hall offering the latest industry products and services.

Radiology Business Management Association info@rbma.org • 888.224.7262 Universal elements and all related indicia TM & © 2011 Universal Studios. © 2011 Universal Orlando. All rights reserved.

SPECIAL REport | RBM Practices Table. Radiology Benefit Managers’ Self- and Provider-scored Compliance With Best Practices Standard

Total points possible

Self/ Provider

HealthHelp

AIM

MedSolutions

NIA

CareCore

Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Variance Self Provider Variance Self Provider Variance

15 6.7 12 4.7 12 5.8 12 10.2 10 8 8 9.7 15 13 8 5.7 10 4.7 8 7.3 6 3 5 8.8 121 87.6 –33.4 87.7% 63.5% –24.2% 1st 2nd 4th

15 12.7 12 8.1 12 6.3 12 8.8 10 8.1 8 8.6 15 12.9 8 4.4 0 2.6 7.5 6.5 0 2.3 6 8 105.5 90.3 –15.2 76.4% 65.4% –11% 5th 1st 1st

7.5 4.9 11.5 6.9 12 5 10 9.9 8 8.2 8 8.6 15 11.9 8 5.2 11.5 6.1 8 7.9 6 3.7 8 8.4 113.5 86.7 –26.8 82.2% 62.8% –19.4% 2nd 3rd 3rd

15 8.4 12 6.2 12 4 12 9.7 10 8 8 9.1 15 13 8 5.3 0 3.3 8 6.9 6 3.7 5 7.9 111 85.5 –25.5 80.4% 62% –18.5% 3rd 4th 2nd

7.5 0 12 4.4 12 4.2 12 10.3 10 9 8 9.3 15 12 8 5.4 0 0 8 8.6 6 3 10 8.3 108.5 74.5 –34 78.6% 54% –24.6% 4th 5th 5th

Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Variance Self Provider Variance Self Provider Variance

12 8.5 8 9.3 12 9 7.5 4.2 8 6 12 8.5 8 6.7 10 8.2 5 3.3 8 9.3 8 5.8 10 7.4 108.5 86.2 (22.3) 88.9% 70.7% –18.3% 2nd 2nd 3rd (tie)

11 7.6 8 7.7 12 8.1 7.5 5 8 6.9 12 8 8 6.4 10 7.6 5 2.6 8 8.6 9.5 6 10 6 109 80.5 (28.5) 89.3% 66% –23.4% 1st 5th 5th

11.5 7.9 8 8.6 12 7.1 7.5 5.1 8 7 12 7.1 8 6.8 10 8.8 5 2.9 8 8.4 5 6.3 10 6.7 105 82.7 (22.3) 86.1% 67.8% –18.3% 3rd 3rd 3rd (tie)

12 8.6 8 8.4 12 7.3 7.5 5.8 8 7 12 6.8 8 6.8 10 7.7 5 3 8 8.9 0 6.9 10 5.1 100.5 82.3 (18.2) 82.4% 67.5% –14.9% 5th 4th 2nd

12 9 8 8.3 12 9.8 7.5 4.5 8 8 12 8 8 5.8 10 7.2 5 3.3 8 8 8 6.3 10 9.3 101 87.5 (13.5) 82.8% 71.7% –11.1% 4th 1st 1st

See Standards Scored (below) for expanded guideline descriptions

CLINICAL 1a. Uses code families 15

1b. Lets radiologists revise orders 12

2. Offers after-hours approvals 12

3a. Has evidence-based policies 12

3b. Gives public guideline access 10

4. Applies medical criteria consistently 10

5. Has clinically experienced personnel 15

6. Educates referrers on submissions 8

7a. Allows imagers to get approvals 12

7b. Enforces approval processes consistently 10

8. Discourages self-referred overutilization 12

9. Requires accreditation 10

Subtotals: 138 clinical-patient care guidleines

Compliance

Rank

ADMINISTRATIVE 10a. Doesn’t deny approvals later 12

10b. Applies processes consistently 10

11. Transfers claims to payors 12

12. Doesn’t withhold technical component 15

13. Waives preauthorization for emergencies 8

14a. Uses quick, low-burden processes 12

14b. Has 30–60 day approval validity 10

14c. Allows electronic submissions 10

14d. Provides referrers with guidelines 5

14e. Applies criteria uniformly 10

15. Doesn’t split mandatory/voluntary programs 10

16. Uses electronic ordering/approval 10

Subtotals: 122 administrative-process guidelines

Compliance

Rank

50 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

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Standard

Total points possible

Self/ Provider

HealthHelp

AIM

MedSolutions

NIA

CareCore

Self Provider Self Provider Self Provider Self Provider Self Provider Self Provider Variance Self Provider Variance Self Provider Variance

0 1.3 12 7.5 6 4.3 10 7.5 5 5 33 25.6 (7.4) 82.5% 64% –18.5% 3rd 4th 3rd

0 0.2 12 6.6 8 5 10 7.3 5 3.6 35 22.7 (12.3) 87.5% 56.8% –30.8% 1st (tie) 5th 5th

0 1.1 12 7.8 6 5.2 8 7.8 5 4 31 25.9 (5.1) 77.5% 64.8% –12.8% 4th 2nd 2nd

0 1.3 12 7.2 8 5.7 10 7.6 5 4 35 25.8 (9.2) 87.5% 64.5% –23% 1st (tie) 3rd 4th

0 0.5 12 11 8 7 10 8 0 4 30 30.5 0.5 75% 76.3% –1.3% 5th 1st 1st

Self Provider Variance Self Provider Variance Self Provider Variance

262.5 199.4 (63.1) 87.5% 66.5% –21% 1st 1st 5th

249.5 193.5 (56) 83.2% 64.5% –18.7% 2nd (tie) 3rd (tie) 4th

249.5 195.3 (54.2) 83.2% 65.1% –18.1% 2nd (tie) 2nd 3rd

246.5 193.6 (52.9) 82.2% 64.5% –17.6% 4th 3rd (tie) 2nd

239.5 192.5 (47) 79.8% 64.2% –15.7% 5th 5th 1st

See Standards Scored (below) for expanded guideline descriptions

TRANSPARENCY 17. Shares savings with referrers 5

18a. Collects data consistently 12

18b. Allows providers to review data 8

18c. Has an appeals process 10

19. Benchmarks itself publicly 5

Subtotals: 40 transparency guidleines

Compliance

Rank

OVERALL Totals: 300

Compliance

Overall rank

Standards Scored 1a. The prior-authorization process covers a family of codes, not a specific CPT® code.

1b. Radiologists providing clinical supervision of procedure are permitted to revise an order based on emergency clinical conditions and/or medical appropriateness or necessity.

2. There is a mechanism for approval of outpatient studies scheduled or needed after hours or on weekends, when the RBM might be closed.

3a. All prior-authorization policies conform to applicable state and federal law, are transparent, and are evidence based so that they follow medical best practices.

3b. All specialty-specific guidelines for utilization management and clinical literature are available to the public.

4. RBMs apply medical criteria for prior-authorization decisions consistently across similar clinical situations, geographic boundaries, and authorizing entities.

5. Physicians or nurses with detailed and extensive training on imaging modalities are the ones making the decisions at RBMs. 6. RBMs educate referring physicians about the clinical information that needs to be submitted in the prior-authorization request, and the required information is consistent across geographic boundaries and authorizing entities.

7a. RBMs and payors allow imaging providers to obtain prior authorizations on behalf of referring physicians, if the imaging provider elects to do so.

7b. RBMs and payors vigorously and consistently enforce the prior-authorization process to maintain market integrity.

8. RBMs and payors give consideration to the role of for-profit, self-referring imaging providers so that the RBM’s primary mission (avoiding economically motivated overutilization) is maintained.

9. Accreditation of imaging equipment, technologists,

professional coverage, and services is required.

10a. Imaging services that are approved through the accepted prior-authorization process are not having claims denied after the fact.

10b. Prior-authorization processes are applied and administered consistently across geographic boundaries and authorizing entities with respect to medical necessity, appropriateness, coverage, and adjudication policies.

11. Payors and their contracted RBMs make sure that all services preauthorized by the RBMs are properly and promptly transferred to the insurance company for accurate claims processing.

12. When the radiologist is not in control of the priorauthorization process and the procedure is not billed globally by the imaging provider, the professional component of the procedure will be paid for by the insurance company, even if the claim is denied for prior-authorization reasons.

13. Prior-authorization policies exclude all emergencydepartment procedures and all inpatient procedures performed in response to life-threatening situations.

14a. In most instances, the pre-authorization process is quick and places as little administrative burden on the referring physician’s staff as possible.

14b. Once preauthorization has been given, both the referring physician and the patient are notified; the authorization is valid for 30 to 60 days after it is first issued (not from the date of service), to avoid reapplication or payment denial; and the patient can schedule the exam for any time within the validation period.

14c. RBMs facilitate and allow electronic submission of requests to perform high-tech imaging studies.

14d. RBMs educate referring physicians in the use of online reference tools and provide them with a reference guide and explanation of the RBM’s priorauthorization requirements.

14e. RBMs apply the process and criteria for obtaining

preauthorization uniformly and consistently across geographic boundaries and approving entities.

15. Payors/RBMs do not apply a voluntary priorauthorization program for some product lines when they have a mandatory RBM program in place for other product lines under the same payor. The RBM and payor do not burden providers with the responsibility for determining whether the member is under a voluntary or mandatory priorauthorization program.

16. In order to improve compliance and ensure process consistency and quality across geographic boundaries and authorizing entities, payors/RBMs use online prior-authorization or imaging-requisition products; the ordering physician can enter the patient’s clinical information and requested study and receive nearly instantaneous approval (or guidance for a more appropriate study).

17. Payors/RBMs offset the additional costs associated with prior authorization incurred by the ordering physician by sharing a portion of the savings realized by the payors from the preauthorization process 18a. If the RBM/payor collects quality and/or cost data, it has fair, consistent, and accurate processes in place to ensure that the data are collected consistently across practices.

18b. All data applying to a particular practice are subject to review by that practice prior to release, and the RBM/payor allows for frequent and easy updating as information changes.

18c. There is an appeals process.

19. To provide the same degree of transparency currently asked of providers, improve process compliance, and ensure process consistency and quality across geographic boundaries and authorizing entities, RBMs benchmark themselves regularly against these guidelines and make the results available to the public.

www.imagingbiz.com | February/March 2012 | Radiology Business Journal 51

SPECIAL REport | RBM Practices

based or -owned imaging centers, radiologist-owned imaging centers, and IDTFs. Each provider surveyed operates multiple imaging locations, with a considerable volume of advanced imaging procedures (in a number of imaging modalities) being performed every year.

Providers were instructed to score only RBMs with which they had direct interaction. They were also instructed to score only those questions with which they had direct experience. Fulcrum Strategies collected the providers’

responses, analyzed them, and tabulated the results. The scoring for each RBM represents an average of a minimum of five provider responses.

Results The table presents the combined RBM self-reported scores and the average provider-reported scores, by RBM, for each of the guidelines. RBMs generally gave themselves higher marks, while providers awarded the RBMs significantly fewer points. RBMs might have provided

responses based on their policies (or what should happen), while the providers’ scores might represent reality (or what does happen): Sometimes, policies are not administered as planned.

The RBMs gave themselves full credit for 11 of the 19 criteria and partial credit for seven criteria. No RBM, however, gave itself any points for sharing savings with referrers or providers (to offset some of the administrative costs imposed by preauthorization requirements). This is a point of significant divergence between what RBMs are doing and what the ACR and the RBMA believe that the best practice should be.

Some RBMs explained that their processes did not put significant administrative burdens or costs on providers or referrers, but each RBM eventually admitted that its processes add at least some additional cost and burden (and stated that those are driven principally by individual payors’ requirements). No RBM is doing anything significant to offset the additional administrative costs and burdens that its programs impose.

Provider scoring shows interesting results, compared with RBMs’ selfreported scores, concerning whether imaging providers are allowed to obtain preauthorization. The RBMs indicating that this was allowed were not scored accordingly by providers, while those indicating that it was not allowed received points from the providers as if it were allowed. This could indicate confusion about which RBMs allow this practice (and in what situations). Concerning the role of RBMs in educating referring physicians, provider scoring was significantly below self-scoring, showing general dissatisfaction with RBMs’ performance.

Limitations and Conclusions Rating compliance through surveys and interviews is subjective. While the RBMA took steps to minimize this, the results probably reflect some variability.

Provider scores could also show variation caused by the specifications of payors.

Utilization-management programs that were initially much the same could have payor-defined customizations that affected provider scoring.

52 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

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SPECIAL REport | RBM Practices

The provider scores are the averages of five observations per RBM and might have changed if more observations had been collected, but the surveyed providers represented large numbers of facilities and procedures. The study did not address clinical decision support, widely considered a viable alternative to RBMs in making sure that advanced imaging is utilized correctly.

A major observation is the significant difference between how the RBMs score themselves and how providers score them. Every RBM scored about 20% lower on the provider survey than in its self-reported scores.

HealthHelp follows the guidelines most closely overall. MedSolutions, AIM, and NIA constitute a middle group, all having scores very close together. CareCore is the lowest-scoring RBM and the one that appears to be most at odds with the guidelines. Between the highest and lowest finishers, however, the difference in compliance is only 8% for self-scoring and 2% for provider scoring.

The survey results show that providers do not differentiate greatly among RBMs. This tight grouping of responses probably reflects the competitive RBM marketplace, which has little perceived product differentiation.

In general, the RBMs agree with most of the best practices developed by the ACR and the RBMA. Standards for consistency of program deployment, self-referral, and credentialing are widely accepted by the RBMs. The disparities seem to appear as a result of differing standards imposed by the payors employing the RBMs. Accordingly, this might be common ground where RBMs and radiology providers can work together to educate payors on these best practices and why they should be followed.

Christie James, MS, is chair of the RBMA Payor Relations Committee and is group practice management manager, radiology business services, for the Massachusetts General Physicians Organization in Boston. Larry Buchwalter, JD, is chair of the committee’s RBM ad hoc writing group and CEO of Stilwell Enterprises LLC, Ridgewood, New Jersey. Michael Mabry is executive director of the RBMA. Ron Howrigon is president of Fulcrum

Strategies, Raleigh, North Carolina. This article has been excerpted from Radiology Business Management Association Report on Radiology Benefit Management Companies and their Comparison to ACR and RBMA RBM Best Practices Guidelines, which was prepared by the committee and Fulcrum Strategies and was released on February 17, 2012.

References 1. Wiley G. RBMs: the debate heats up.

Radiology Business Journal. http://www. imagingbiz.com/articles/view/rbms-the-

debate-heats-up. Published July 1, 2009.

Accessed January 25, 2012.

2. ACR, RBMA. Best practices guidelines on radiology benefits management programs. http://www.acr.org/Hidden/ Economics/FeaturedCategories/ WhatsNew/Attachments/ACR-RBMARBM-Guidelines.aspx.

Published December 21, 2010. Accessed January 25, 2012.

3. Lee DW, Rawson JV, Wade SW. Radiology benefit managers: cost saving or cost shifting? J Am Coll Radiol.

2011;8(6):393-401.

The RBMs Respond At the request of the RBMA, Radiology Business Journal gave representatives from each RBM company assessed in the report the opportunity to respond (in fewer than 250 words). Their comments follow.

A

IM is the leading specialty benefit management company, working with 42 health plans to ensure clinically appropriate high-tech imaging is performed for 32 million members in 50 states. We manage a total of $8 billion in outpatient health-plan spending. Our clinical guidelines are applied consistently across health-plan clients; however, the administrative execution of the program can vary based on plan preferences and requirements.

AIM’s evidence-based clinical guidelines are frequently reviewed and updated by physicians across a number of specialties. In 2012, AIM is working with a leading meaningful-use company to enhance the structure and usability of our guidelines further and to make the ordering process and decisions rendered more transparent for providers.

AIM, in addition to clinical appropriateness review, is leveraging selfreported imaging-site capability data,

54 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

including accreditation, complemented with average unit cost to support informed decision making around imaging-site selection. Our transparency and engagement program proactively and consistently shares imaging-site information with ordering providers and members and supports high-value imaging-site choices.

AIM strives to make the review process convenient and responsive for ordering providers, while retaining clinical credibility. Our success is evident in our December 2011 Provider Survey results; 97% of 10,000 providers surveyed are satisfied with the AIM processes and tools.

As a pioneer in Web order entry, we are now receiving 60% of orders via our convenient 24/7 Web portal; for some health plans, this number has reached close to 80%.

We value the input from the RBMA and its providers and will continue to deliver a program that ensures appropriate, safe, and affordable imaging.

Brandon Cady President and CEO AIM

T

he report indicates that rendering radiology sites preferred coverage of a family of codes as opposed to specific codes. Evidence-based medicine, however, as applied to the physician ordering the imaging study, recommends the most appropriate procedure (or code) for a specific clinical problem. Evidencebased medicine does not recommend a family of procedures or codes unless they are all considered to be of equal value to the patient. It ranks procedures from most appropriate to least appropriate to inappropriate. CareCore National researches and establishes criteria for the most appropriate procedure (CPT速 code) for a given medical condition, when that distinction can be made.

Thus, our criteria may be different, by individual CPT code, within a family of codes. The current ACR appropriateness criteria also rank procedures or codes by

which one is the most appropriate and, for example, distinguish between contrast and noncontrast codes. We disagree with the standard that supports approval for a family of codes, as it is not always consistent with the recommendations of evidence-based medicine.

Our program does permit and encourage rendering radiology sites to change codes, if medically necessary. The program permits this change prior to imaging; during imaging (that is, while the patient is in the imaging facility); or after imaging has been completed.

We encourage radiologists to complete studies during the first patient visit and avoid recommendations to have the patient return for another study from the same family of codes on a different day.

If, however, a radiology provider requests a change of code, it must be consistent with the evidence-based medical criteria.

Shelley Nan Weiner, MD, FACR Executive Vice President CareCore National

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SPECIAL REport | RBM Practices

T

he HealthHelp team was so pleased to learn that the RBMA had granted our company the top spot in its first-ever best-practices benchmark report. Each day, we strive to meet the standards and bestpractice criteria created by the ACR and the RBMA, and having the highest scores in the overall ratings confirms that HealthHelp continues to lead the RBM industry and encourages us to think of the effect on our providers every day as we design and implement our workflows.

We also appreciate the report’s objective and detailed feedback on areas where we— and all RBM companies—can improve.

Striving to maintain HealthHelp’s solid relationship with the radiology industry on matters of policy and procedures will continue to be a top goal for 2012.

This year also will be one of growth for HealthHelp. Our established and effective programs in the areas of diagnostic imaging, oncology, cardiology, emergency medicine, and pain management/spine/ joint care will continue to ensure patients get the right tests and treatments at the right times, helping our provider clients to lower costs, improve care quality, and prevent illness. New areas and enhanced features will further expand our ability to assist clients and to have a positive effect on our country’s ever-changing health-care industry.

Cherrill Farnsworth President and CEO HealthHelp

A

s noted in the introduction to your report, the expanding array of imaging technologies has increased both cost and utilization dramatically.

That being the case, it is understandable that private insurers, and an increasing number of government payors such as Medicare and Medicaid, have partnered with RBMs to help ensure the appropriate, cost-effective use of imaging services. We applaud your efforts to measure best practices, and while this study is certainly a step in the right direction, we would like to comment on a few concerns that we have with your effort.

First, the practitioners surveyed for the study were primarily rendering providers rather than ordering physicians. Some RBMs, including NIA, concentrate their efforts on ordering or referring providers as a matter of policy, since they have a more complete understanding of the patient’s clinical status and history.

Second, the small number of providers sampled for this study (five provider groups) is a very small sample from which to obtain a reliable measure of how providers feel about RBMs. Our hope is that with future studies, the sample size will be larger and more diverse, therefore providing a more accurate reflection of provider interaction with RBMs that we can reliably use to adjust our processes.

Third, in the spirit of bilateral transparency, the custom in health care would be for such survey tools to be crafted, distributed, and compiled by parties whose independence is explicit and unquestioned.

At NIA, we share your interest in ensuring the affordability, efficiency, and (above all) quality of these services, and we look forward to working with you on these issues.

Thomas Dehn, MD, FACR Executive Vice President and CMO Michael Pentecost, MD, FACR Associate CMO NIA

advertiser index ACR (800) 770-0145 www.acr.org................................................................. 57 Affiliated Professional Services (800) 841-5200 www.affilprof.net.............................................. 29–30, 45 eRAD (864) 234-7430 www.erad.com............................................................ 15 Fujifilm Medical Systems (800) 431-1850 www.fujimed.com.......................................................... 5 Health Connect Partners (843) 689-9996 www.HLTHCP.com...................................................... 53 Hitachi Medical Systems America (800) 800-3106 www.hitachimed.com.................................................... 2 iCRCo Inc (310) 921-9559 www.icrcompany.com................................................. 37 Imaging On Call (888) 647-5979 www.imagingoncall.net............................................... 35 imagingBiz (714) 832-6400 www.imagingbiz.com.................................................. 55 Integrated Medical Partners (877) 816-1467 www.integratedmp.com.............................................. 13 Intelerad (514) 931-6222 www.intelerad.com...................................................... 60 McKesson (800) 661-5885 www.allaboutPACS.com................................... postcard Microsoft amalga@microsoft.com www.whatsnextinhealth.com/connectedimaging............. 3 MMP (800) 895-0002 www.cbizmmp.com....................................................... 7 ProScan Imaging (877) PROSCAN www.proscan.com...................................................... 52 RamSoft (888) 343-9146 option 2 www.ramsoft.com....................................................... 59 RBMA (888) 224-7262 info@rbma.org............................................................. 49 Regents Health Resources, Inc (800) 423-4935 www.regentshealth.com......................................... 18–20 Sectra (203) 925-0899 www.sectra.com.......................................................... 27 Virtual Radiologic (vRad) (800) 737-0610 www.virtualrad.com..................................................... 11 VMG Health (214) 369-4888 www.vmghealth.com..................................................... 9 Zotec Partners (317) 705-5050 www.zotec.com...................................................... 39–42

56 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

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FinalREAD

Cracking the Code Success in radiology will be increasingly dependent on teamwork By Curtis Kauffman-Pickelle

N

o matter what one thinks about healthcare reforms as they are currently being revealed in their entirety, implicit within any future integrated delivery system (accountable-care organization) is the understanding that turf lines will be blurred and that patient care will be much more of a team effort than one in which silos of specialists carve up the body—as well as the reimbursement dollar. A continuum of care with aligned incentives, seamless handoffs, and patient-first points of view will be a minimum expectation for those who want to practice in the redefined arena.

Business Teams: Cracking the Code for Standout Performance, is replete with case studies of some of the most successful leadership teams in the world—and what makes them tick. There are lessons to be learned from a peek inside some of those organizations that have succeeded, as well as some that have failed based on their lack of teamwork and leadership.

Guttman outlines high-performance team leaders as capable of creating a burning platform for fundamental change (a sense of urgency) and as being simultaneously visionaries and architects (with visions that can be operationalized). They know that they cannot do it alone (they need highly functional teams) and that they must build authentic relationships (build trust); model the behaviors that they expect from their teams (practice what is preached); and

The book, Great Business Teams: Cracking the Code for Standout Performance, is replete with case studies of some of the most successful leadership teams in the world—and what makes them tick.

How can anyone make this happen?

Now, more than ever, the development of aligned, cohesive, and optimized teams will be dependent upon a leader’s ability to articulate a vision clearly, to define the practice’s mission, and to deploy wellmanaged assets within a structure based on a core set of values reflecting quality and service.

To that end, I am always on the prowl for resources and educational materials to share with imaging executives. A part of my commitment to our readers is to continue to provide guidance and direction about the current wisdom on the topic of leadership and success. Over the past several years, I have passed along suggestions for interesting reading, and I have another suggestion that I think will be a good read for those interested in improving their management skills.

I have come across a book1 written in 2008 by Howard M. Guttman, principal of Guttman Development Strategies (Mount Arlington, New Jersey). The book, Great

redefine the fundamentals of leadership (decentralized power, responsibility, and accountability).

Guttman has an impressive track record as a leadership/executive coach for some very successful organizations, and much of what he has learned over the years is reflected in this well-written summary of how high-performing leaders are developed and nurtured.

Bringing It Home What can we learn from this treatise, and how can it be applied to the modern radiology practice? The bottom line is that effective communication—among team members, between teams, between team members and the leader, and at all points in between—will be essential for those who intend to thrive in the future health-care structure.

Breaking down the barriers between silos, threading common messaging throughout the entire organization, and clearly articulating the organization’s value proposition to customers and stakeholders: These are

58 Radiology Business Journal | February/March 2012 | www.imagingbiz.com

the primary tasks of the radiology leader in the new marketplace. It will take discipline, focus, superior communication skills, and a commitment to build trust and accountability into each and every relationship, encounter, and transaction.

It is expected, and has been for quite some time, that radiology will lead the way toward efficient utilization of diminishing resources, that the profession will play a meaningful role at the front end of the health-care encounter, and that radiologists will emerge as agents of change within a redefined system that is increasingly dependent on diagnostic certainty and on effective use of medical and IT technologies.

That being the case, it is incumbent upon imaging leaders to accept the responsibilities that accompany such expectations and to do what is necessary to prepare for such an important leadership role.

A great place to start is by reading everything one can about what makes a great leader and how high-performing teams are created. Add Guttman’s book to your library and commit to putting its wisdom into action in your practice, hospital, or imaging center.

Curtis Kauffman-Pickelle is publisher of ImagingBiz.com and Radiology Business Journal, and is a 25-year veteran of the medical-imaging industry.

Reference 1. Guttman HM. Great Business Teams: Cracking the Code for Standout Performance.

Hoboken, NJ: John Wiley & Sons; 2008.

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