Radiology Business Journal | October/November 2012

October/November 2012

Rolling Out the Red Carpet:

Increasing Patient Convenience page 18

Featured in this issue

Hospital–Physician Relations: Value-added Radiology page 14 Trends in Medicare Imaging Volumes: 2003–2010 page 27 ICD-10: Ensuring an Optimal Transition page 43 www.imagingBiz.com

October/November 2012

Rolling Out the Red Carpet:

Increasing Patient Convenience page 18

Featured in this issue

Hospital–Physician Relations: Value-added Radiology page 14 Trends in Medicare Imaging Volumes: 2003–2010 page 27 ICD-10: Ensuring an Optimal Transition page 43 www.imagingBiz.com

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CONTENTS

October/November 2012 | Volume 5, Number 5

18

Features

18

Meeting Radiology’s Consumer Mandate: Increasing Patient Convenience

As imaging providers work to ensure patient satisfaction, heightening convenience is a good place to begin.

27

Trends in Medicare Part B Imaging Volumes, 2003–2010

Imaging volumes in the Medicare population have shown three years of precipitous decline.

34

From Bad to Great: How One Radiology Department Made the Transition

Whenever a goal seems too hard to achieve, remember Advocate Condell Medical Center’s stunning transformation from laggard to leader in customer satisfaction.

43

ICD-10 Is Coming: How to Ensure an Optimal Transition

Radiologists must finally address the long-standing problem of inadequate referring-clinician documentation.

By Robin Brand

By Cheryl Proval

By Julie Ritzer Ross

By Melody W. Mulaik, MSHS, CPC, CPC-H, RCC

4 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

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CONTENTS

October/November 2012 | Volume 5, Number 5 Publisher Curtis Kauffman-Pickelle · ckp@imagingbiz.com

8

EDitor Cheryl Proval · cproval@imagingbiz.com

Departments

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

AdView

Who Crowned the Patient King?

10

The Bottom Line

By Cheryl Proval

Associate Editor Cat Vasko · cvasko@imagingbiz.com Online Editor Lena Kauffman · lkauffman@imagingbiz.com

The Culture Ultimatum

12

Priors 12 Health-care Reform | Preparing for Payment Reform 14 Hospital–Radiologist Relations | Value-added

Technical Editor Kris Kyes

News Editor Thanh Le · tle@imagingbiz.com

By Cheri L. Canon, MD, FACR

Contributing Writers Robin Brand; Cheri L. Canon, MD, FACR; Melody W. Mulaik, MSHS, CPC, CPC-H, RCC; Julie Ritzer Ross

Radiology, Defined

48

Advertiser Index

50

Final Read

Associate Publisher Sharon Fitzgerald · sfitzgerald@imagingbiz.com Production Coordinator Jean Lavich · jlavich@imagingbiz.com Webmaster Robert Elmquist · relmquist@imagingbiz.com

Monopoly Money

By Curtis Kauffman-Pickelle

34

43

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

Radiology Business Journal is published bimonthly by imagingBiz, 210 W. Main St., Suite 101, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. October/November 2012, Vol 5, No 5 © 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, 210 W. Main St., Suite 101, Tustin, CA 92780. While the publishers have made every effort to ensure the accuracy of the materials presented in Radiology Business Journal, they are not responsible for the correctness of the information and/or opinions expressed.

Please address all subscription questions to Jean Lavich at jlavich@imagingbiz.com.

6 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

AdView

Who Crowned the Patient King?

Will patient-centered care move the dial when it comes to improving patients’ health?

I

suspect that physicians and other health-care providers who have dedicated their lives to health care find the whole patient-centered movement inherently irksome. Let’s face it: The movement implies that patients previously were not central enough to the work of caregivers. In fact, a case could be made that the exact opposite is true. Today, caregivers not only have to give the care that they gave in the past, but also must document it, footnote it, and serve it up on a silver platter, leaving less time for care delivery.

Is this hyperbole? A few weeks after new payment rates based on the 27-question Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey went into effect, an article1 in the Wall Street Journal documented what the movement has meant to Grady Memorial Hospital (Atlanta, Georgia), a level I trauma center: wild-caught salmon on the menu and ESPN in the rooms. The facility had turned a $55 million deficit in 2007 into an anticipated $1 million surplus this year—only to be dinged for lower-thanaverage HCAHPS scores.

When did patients become king?

That role previously was reserved for the physician, but now Grady Memorial Hospital is counseling physicians not to interrupt patients and to get down to eye level when communicating with them.

With nearly $1 billion in payments based on the HCAHPS survey at risk this year, hospital administrators are not thinking about evidence-based medicine, upgrading old technology, or other clinical matters.

They are focused on how to get their patientsatisfaction scores high enough to prevent revenue losses: Grady Memorial Hospital’s CEO expects it to lose $230,000 in federal payments this year due to its lower-thanaverage patient-satisfaction scores. This is pay for performance, but the performance is more show business than health care.

Patient Experience and Pay Patient experience is one of four types of pay-for-performance measures identified in a new policy brief2 from Health Affairs and the Robert Wood Johnson Foundation.

The three other measures are process (for example, in radiology, steps taken to prevent nephrogenic systemic fibrosis when imaging calls for the use of contrast media); outcomes (such as recall rates for screening mammography or complications following interventional-radiology procedures); and structure (such as the facilities, personnel, or technology used).

The patient became king when the patient became a customer.

The brief states that despite mixed results for pay for performance through the past decade, we are likely to see even more of this approach, in the near future, because health policy experts look on it fondly—and the Patient Protection and Affordable Care Act expands the use of these techniques. Another factor in play might be even more powerful than policydriven pay for performance: Patients are playing an increasing role in the financing of health care. The patient became king when the patient became a customer.

This is something that outpatient radiology has understood for some time— and that hospitals are now discovering, through the HCAHPS experience. This issue’s cover story (page 18) dips into the subject of what patients are seeking from a radiology provider, which is currently rather basic: convenience.

Another feature in this issue (page 34) tells the fairy-tale story of how one hospital transformed bottom-quartile scores (from Press Ganey) for customer satisfaction with outpatient imaging into scores that place it in the top 10% of all hospitals. It will resonate with great leaders everywhere

8 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

because it is about the power of team dynamics and a triumph of cultural change.

Something to It The patient-centricity movement is rooted in some well-documented shortcomings of our health-care system. Over the past 15 years, evidence has mounted to indicate that in the United States, our past approach to health care is riddled with error, is uncoordinated, and (in comparison with the systems of other nations) is less effective and more expensive. Looping patients into the process not only is a good idea, but is impossible to avoid, now that patients are footing more of the bill.

Besides that, when you think about what a meal costs in a hospital, the food really should taste like food—and as Rhonda Scott, PhD, chief nursing officer at Grady Memorial Hospital, told the Wall Street Journal, “requests for pain medications go down during the afternoon football games.”1 Nonetheless, I think we need to ensure that patient-centered radiology doesn’t tilt too far in the direction of pampering the patient. Patient-centered care is not enough. In the rush to give patients their due, government and health-policy experts have glossed over one important element: patient responsibility. In order to get closer to the goal, we need to move the goalposts and transition to a more positive approach to consumerism in health care: patient engagement.

Cheryl Proval cproval@imagingbiz.com References 1. Adamy J. U.S. ties hospital payments to making patients happy. Wall Street Journal.

October 15, 2012:A1.

2. James J. Health policy brief: Pay-forperformance. Health Affairs and the Robert Wood Johnson Foundation. http://www. healthaffairs.org/healthpolicybriefs/brief. php?brief_id=78. Published October 11, 2012. Accessed October 17, 2012.

The Bottom Line

The Culture Ultimatum Radiology must overhaul a private-practice culture that fails to embrace leadership and practice-development activities

I

t is time for radiology-group culture to change. We need to counter our negative stereotype. More than once, television dramas have portrayed radiologists as pseudophysicians or weird technicians sitting in dark rooms drinking coffee, an upside-down chest radiograph in the background.

We are partially to blame for this portrayal (but not the upside-down radiograph). We have not been uniformly engaged with our physician colleagues, the hospitals, or (sometimes) even our patients. Changes in the health-care arena now demand that we leave our dim reading rooms, join our hospital administrators, embrace a culture of service, and actively pursue leadership roles in our medical communities.

In addition, we should make extra efforts to interact with all of our patients—not just those undergoing invasive procedures or fluoroscopy.

This more engaged approach might run counter to the philosophies of some radiology groups because practicedevelopment activities can be viewed as a threat to productivity. Instead, these activities should be viewed as a necessary investment for a viable practice.

From the late 1990s to the mid-tolate 2000s, radiologists saw tremendous growth in their business. Not only were more exams being ordered, but there was an exponential increase in more complex (and, therefore, labor-intensive) crosssectional imaging.

Then, when the DRA came into effect in 2006, imaging volume plateaued and reimbursement dropped, driving more efficiency as groups faced an uncertain future. CMS Multiple Procedure Payment Reductions continued, further decreasing incentives to perform any activity not producing a clear RVU. Imaging is an expensive (but important) investment for hospitals. It is key to disease diagnosis and management, and for many hospitals, outpatient imaging provides important revenue. Like radiology groups, hospital administrators face threats of increasing costs coupled with decreasing reimbursement. These,

in turn, are compounded by challenges of quality-based reimbursement, increasing accreditation requirements, and myriad contractor audits.

The Radiologist–Administrator Relationship

For both hospitals and physician groups to be successful, medical-staff members—including radiologists— must be productively engaged with their administrators to ensure that goals are aligned. If the radiologists and hospital administrators are unwilling to work together, patient care will suffer.

Consider the issue of patient satisfaction.

Many hospitals have worked for years to improve patient satisfaction, relying on various survey tools and indicators to provide input and, they hope, to improve the patient experience. In contrast, only relatively recently has this become a discussion priority for some radiology groups.

Many patients are unable to tell technologists and nurses from radiologists, and customer surveys measure the total experience in radiology, not just encounters with the staff. It’s no wonder, then, that—in the past—hospitals were unsuccessful in improving patient encounters; they often implemented changes without including the radiologists.

These improvements have to be determined and implemented by the hospital and the radiologists in lockstep. A process for open review of data is a necessary driver, aligning the patient-satisfaction goals of the hospital and the radiology practice to ensure success for both.

Closely related to patient satisfaction is customer service. What is the radiologist’s role in customer service? Who are our customers? A customer is defined as someone who buys a product or pays for a service.

Of course, patients are our customers, but that means that referring clinicians are also our customers. We must provide them with prompt and accurate service, and it is important for us to be readily available.

The latter factor is key in the battle against commoditization, which is a significant threat to the viability of radiology.

10 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

by Cheri L. Canon, MD, FACR

Let’s not forget our other customers: third-party providers pay us for a service, too. Many people also consider the hospital a customer of radiology groups. While that is strictly true, I would argue that the hospital should be considered a partner rather than a customer.

The radiologist is a consultant: an expert who provides accurate and timely reports that are directive, not merely descriptive. The radiologist should actively participate in the hospital capital process, providing necessary technical input but also understanding the hospital’s financial constraints.

In turn, hospital administrators must be candid about capital-budget expectations. To become a part of the process, radiologists must actively pursue leadership opportunities within the hospital structure and must take the steps necessary to acquire the skills needed to be effective.

The current health-care climate is complex and rapidly changing. We must understand the environment and be able to maneuver nimbly. If we don’t make the important decisions for our profession, those decisions will be made without us. In radiology, leadership training should not be focused only on the practice leaders and department chairs; it should be implemented throughout radiology, beginning in residency. It is time for radiologists to become leadership savvy, step up, and engage their hospital associates.

To address these challenges, the ACR® launched the Radiology Leadership Institute™, an innovative, multilevel leadership academy designed specifically for the field of radiology. This program equips radiology professionals—in both private practice and academia—with the leadership skills required to navigate the complex business of medicine successfully. To learn more, visit www.radiologyleaders.org.

Cheri L. Canon, MD, FACR, is professor and chair of radiology at the University of Alabama at Birmingham School of Medicine.

She serves on the board of the Radiology Leadership Institute.

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{priors} h e a l t h-c a r e r e f o r m

Preparing for Payment Reform

W

ith mounting pressure to curb the cost of health care, large medical groups need to prepare themselves for oncoming payment reform. Policymakers have been experimenting with different models, resulting in the CMS Pioneer Accountable Care Organization (ACO) Model and the Medicare Shared Savings Program (MSSP). Providers are now being asked to maintain tight budgets, deliver high-quality care, and manage risk under these new models.

In the 1990s, many medical groups signed risk-based contracts for global capitation arrangements under which they received fixed per-member, permonth payments. Many of them were unable to manage the risk and suffered heavy losses. In the 2000s, these groups shed their capitation contracts and returned to fee-for-service arrangements, leaving them inexperienced in managing cost and quality under risk-based contracts similar to those of ACOs and the MSSP. Mechanic and Zinner1 surveyed 21 large multispecialty groups to assess their preparedness for assuming risk and published the results in a recent issue of Health Affairs. Nearly twothirds of the groups surveyed employed

more than 440 physicians, representing about 16% of the country’s large medical groups and spanning 14 states and 19 metropolitan regions. Survey participants were divided into two categories, based on their payment arrangements: riskbased contracts and fee-for-service reimbursement. Mechanic and Zinner defined risk-based contracts as payment based on full or partial capitation, as well as shared-risk and shared-savings methods.

Payment Mix On average, 57% of 2010 patient revenue for surveyed groups came from commercial insurers; 32%, from Medicare; 7%, from Medicaid; and 4%, from other sources. Fee-for-service payments represented about 65% of that revenue, global and partial capitation accounted for roughly 30%, and shared risk and savings accounted for less than 5%. Fee for service was the dominant form of payment, but more than half of the groups received 45% or more of their revenue from some form of risk-sharing model.

While fee-for-service arrangements remain popular, government initiatives have slowly pushed groups toward risk-based arrangements. The surveyed

Table. Payment Mix for Survey Participants, 20101

Fee for service

53.9%

Global capitation

24.6%

Fee for service from affiliated health plans

7.8%

Partial capitation

5.2%

Fee for service with pay for performance

3.2%

Shared risk

3%

Shared savings

1.7%

Other revenue

0.6%

12 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

groups predicted that their fee-for-service revenues would decline—a loss for which they would be compensated by increased revenue from shared-savings programs, pay-for-performance contracts, and global capitation.

Executives interviewed for the survey expected the market to move away from fee-for-service payment, and they predicted that the largest immediate change would be an expansion of sharedsavings arrangements, reflecting the influence of the MSSP and the growing prevalence of private payors offering such arrangements.

Groups for which fee-for service payment is dominant largely based physician compensation on productivity.

Risk-based groups were divided in their compensation models. Five of the risk-based groups paid 80% or more of physician compensation as salary, and the other five groups paid 80% or more of compensation based on productivity.

According to Mechanic and Zinner, limited steps were taken to compensate physicians based on objective measures of quality, patient satisfaction, or efficiency.

Over half of all groups, including 75% of fee-for-service groups, predicted that they would make changes to physicians’ compensation within the next two years to align incentives with these new contracts.

Information Management All of the risk-based groups reported full implementation of systemwide electronic data warehouses and analytics software for performance measurement, and two-thirds of them had developed patient registries. In comparison, only 10% of fee-for-service groups had fully developed these capabilities.

The biggest concern for risk-based groups is the expansion of their analytics and evaluation procedures. Risk-based

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priors

groups implemented more informationmanagement solutions, compared with fee-for-service groups, because of the greater difficulty of managing risk-based contracts.

According to Mechanic and Zinner, many groups with limited riskcontracting experience lack the data/ analytics infrastructure necessary to manage these contracts effectively. Some health plans are developing collaborative tools to help providers succeed under such contracts, but it is not a widespread effort. Performance measures will be an invaluable tool, moving forward, and cooperation between providers and payors is necessary to make these models work.

All but two groups in the survey employed formal methods of operational management, such as lean production or Six Sigma™. Most groups had taken

measures to reduce avoidable hospital admissions and readmissions, but a much higher percentage of risk-based groups than fee-for-service groups reported efforts to reduce network leakage (referrals outside the network).

Risk-based groups were more likely than fee-for-service groups to hold preferred relationships with reliable specialists and hospitals because of accountability concerns. According to the survey, risk-based groups had also implemented management programs for high-risk patients at nearly double the rate of fee-for-service groups. Both groups reported little progress in patientengagement initiatives.

Conclusion The research suggests that there are three key components of success with new payment models: information systems

that track performance and provide steady support, physician-compensation incentives that align with organizational goals, and an organizational commitment to improving performance. Payment reform alone will not bring about this change.

Mechanic and Zinner conclude that policymakers, payors, and providers need to work together to establish accountable care. It can only happen with sound leadership, reliable information, and targeted investments in performanceimprovement infrastructure.

—Thanh Le Reference 1. Mechanic R, Zinner DE. Many large medical groups will need to acquire new skills and tools to be ready for payment reform. Health Aff (Millwood).

2012;31(9):1984-1992.

h o s p i ta l–r a d i o lo g i s t r e l at i o n s

Value-added Radiology, Defined

I

f on-site radiologists want to distinguish themselves from other image-reading specialists or teleradiologists, they must be more than image readers, according to Vijay Rao, MD, David C. Levin professor and radiology chair at Jefferson University Hospitals (Philadelphia, Pennsylvania).

On December 1, 2011, she presented “Value-added Services of Hospital-based Radiology Groups” in Chicago, Illinois, at the annual meeting of the RSNA. Rao outlines the reasons that might tempt a hospital to replace an on-site radiology group with a teleradiology group and then counters them with a list of on-site radiology’s value-added services.

“Hospitals may be attracted to a teleradiology company or tempted to give away privileges because they didn’t really understand the value that we have— or we haven’t educated them enough,” Rao says. “Sometimes, maybe we aren’t adding the value we should be adding.”

Perhaps the group does not provide the subspecialty expertise that clinicians are asking for, or maybe the service level is poor in the areas of turnaround times

and willingness to sit on hospital committees. “It is possible that the radiologists own an imaging center that competes with the hospital,” Rao Vijay Rao, MD says. The hospital might wish to give turf to specialties that make image interpretation a condition for referring patients to the hospital (economic credentialing); might desire more control over physicians in support of quality and cost-containment initiatives; and might want a share of the radiology professional component.

“The hospital may want to bill globally (and have the radiologist on a salary) so it can benefit from the professional component,” Rao suggests. Not only must hospital-based radiologists deliver the entire continuum of services to the institution, but they also must market their value-added services to the administration. Rao divides radiology’s value-added services into six categories.

Patient safety: Imaging patients face

14 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

potential risks from exposure to radiation, magnetic fields, and contrast media.

Vigilance by well-trained physicians is needed to minimize those risks, Rao says, and radiologists are the only physicians who get formal training in radiation biology, radiation safety, and how to treat contrast reactions. Radiologists are on-site in the department and available to deal with these issues when problems arise.

Exam quality: Quality is increasingly important in this era of pay for performance. Rao has been a strong proponent of an overarching quality/ safety committee that would oversee all interventional procedures. Radiologists receive formal training in the physics and technical aspects of imaging equipment and also are able to ensure that the patient gets the right exam done. “Urologists at your institution may have privileges for CT, but they are not in the best position to determine whether MRI would be the more appropriate exam because they only look at stones,” she says. “They are not trained in MRI. We know all of the modalities and can advise” referrers and patients.

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Other important image-quality services provided by radiologists include optimizing imaging protocols, supervising and providing education for technologists, and overseeing the process of gaining and maintaining accreditation.

“Do you think other physicians or teleradiologists can do this?” Rao asks.

“Only on-site radiologists do this.”

Interpretation quality: In training, radiologists spend a minimum of five years exclusively studying imaging, and they are commonly urged by professors

imaging close to their homes, and then they come into the tertiary-care facilities to see their clinicians,” Rao explains.

“The tertiary-care clinicians want their radiologists to look at the images. We are giving second interpretations on these cases, and we are not getting paid for that. That is a value-added service that we provide to the hospital so that its clinicians are satisfied.”

Meeting an increasing number of turnaround benchmarks and targets is another key aspect of service. Not

Meeting an increasing number of turnaround benchmarks and targets is another key aspect of service. Not incidentally, tracking those measures also can be in the interest of radiologists who want to maintain their business. to find the four corners of the image. “We can interpret the entire image, not just one organ,” Rao says. “The problem with cardiologists who want to do cardiac CT, for example, is that they may miss lesions in the lung, potentially the cause of the patient’s symptoms.”

Arriving at a diagnosis might entail integrating images from all modalities— something at which radiologists are adept. “When we are looking at a patient’s record, and we are on the MRI service, we are reading the MRI—but we are looking at CT, ultrasound, and plain films. The specialists are not going to do that. They are just going to look at their little piece of information and move on,” Rao explains.

In addition, many departments employ a peer-review process for interpretations. At Jefferson University Hospitals, that entails sending data to the ACR® for benchmarking against data from other practices. “Do you think the other specialists would do that?” Rao asks.

Patient/referrer service: A key service provided by on-site radiologists is the physician consultation. While PACS use means that fewer consultations happen in the department, more of them are occurring as overreading of outside images in multidisciplinary and tumor conferences.

“That piece of our work is actually growing because patients like to get their

incidentally, tracking these measures also can be in the interest of radiologists who want to maintain their share of business.

At Jefferson University Hospitals, vascular surgeons wanted privileges to read vascular studies and were given privileges three days a week (to radiology’s two), but only if the studies were read within 12 hours.

Rao says, “Guess what: Last year, vascular surgeons read very few cases because they were unable to hit those targets. We actually have grown the business, even though it looked like a turf issue, initially. It’s become a wonderful team. They would much rather be doing procedures.”

Because radiologists’ incomes depend on the number of patients seen in a day, radiologists are highly motivated to maximize department throughput, Rao says, with important dividends for institutions trying to decrease lengths of stay. Radiologists huddle with technologists every morning to prioritize the day’s cases. “Hospitals want to decrease their lengths of stay,” Rao says. “We clearly participate and help with that.” In addition, the department regularly conducts patientand physician-satisfaction surveys.

Cost containment: “What are the buzzwords for any hospital today?” Rao asks. “Patient safety and quality at lower cost: We are able to help contain costs by

maximizing patient throughput, keeping the unit cost down. We do head-to-toe imaging, not just a limited scope of practice.

If you have a CT scanner in cardiology, where they do only cardiac work, you can’t keep the CT scanner in full use.”

In addition to working with the administration to ascertain the optimal level of staffing for the department, radiologists can assist hospitals with technology assessment and imagingappropriateness initiatives, ensuring that imaging systems are available for necessary studies. “Have you ever witnessed vascular surgeons shopping for a vascular suite?”

Rao asks. “The vendor says it does this, this, and that, and the vascular surgeons want it all, even though they may not use half of it. We’ve experienced this. We value hospitals’ capital dollars like our money. That’s been our culture, and we don’t want that to be eroded.”

Business building: An engaged on-site radiology group can attract referrals from all specialty groups in the community. “In the hospital, you will not attract referrals from other cardiology groups if just your own cardiology group is doing the cardiac imaging—because they compete for the same patients. We are not a threat to any of the clinicians.”

An unrelated area of potential valueadded service is health IT. “We are leaders, we need to prove we are leaders, and we need to show we add value there,” Rao says. Radiologists also have proven to be excellent partners in joint-venture imaging centers. When Rao became chair 10 years ago, Jefferson University Hospitals opened one joint-venture imaging center with the radiologists; today, it has five.

“We’ve really grown that business in the outreach areas and given the hospital visibility there,” she notes. “We have become a port of entry. When we make a diagnosis, those patients may come to Jefferson University Hospitals for their care.”

Rao concludes, “We have to remain radiologists, not image readers. We can’t just talk about it; we have to stand behind our word and show added value. That is what is going to keep our specialty strong in the future.”

—Cheryl Proval

www.imagingbiz.com | October/November 2012 | Radiology Business Journal 17

COver | Patient Convenience

Meeting Radiology’s Consumer Mandate:

Increasing Patient Convenience As imaging providers work to ensure patient satisfaction, heightening convenience is a good place to begin By Robin Brand

I

ncreasingly, imaging leaders are observing changes in patients’ behavior. Schedulers are fielding questions about the cost of procedures, while front-office staff, technologists, and even radiologists are being called upon to deliver greater levels of service—spending more time with patients, alleviating concerns, and explaining procedures.

These changes point to the arrival of a trend that has been discussed periodically over the past 20 years or so: health-care consumerism. Outpatient imaging, in particular, is primed to feel the effects.

Procedures are nonurgent, allowing ample time to select from the multiple providers operating in many markets.

Significant price variation, especially between hospital-based and freestanding facilities, also makes outpatient imaging susceptible to the pressures of consumerism. A number of market forces have combined to bring about consumer behavior in patients; five of these forces are particularly important.

First, cost shifting: Heightened cost shifting has made patients increasingly price sensitive. Patients are now responsible for a larger portion of their health costs than they have been in years past. The percentage of US workers with high-deductible health-care plans tripled from 2006 to 2010,1 with 30% now responsible for at least the first $1,000 of costs (and up to almost $6,000, for family coverage).

Adding this cost shifting to the existence of about 50 million people who are uninsured in the United States makes it clear that patients have a strong interest in seeking care from the provider offering the greatest value. This has led many to shop around for health-care services.

Preload: Preview v A new era of health-care consumerism is underway, propelled by five key forces, and outpatient imaging is already feeling the effects. v Foremost among the forces driving this trend is cost shifting, which is heightening price sensitivity among consumers.

18 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

v Web services figure prominently in what consumers expect from imaging providers. v Research from the Advisory Board Co shows that IDTFs have a head start on hospitals in providing the services that consumers want from an imaging provider.

Table 1. Incentive Comparison

Compass SmartShopper

SaveOn

Insurer

Anthem Blue Cross Blue Shield

Harvard Pilgrim Health Care

Differentiating features

Offers toll-free phone number and website

Pays incentive for calling; phone line staffed by nurses

Incentives

$50 to $200

$25 to $75; $10 for calling

Geographic spread

NH, CT, and IN

NH and MA

Second, patient steering: Payors have long been aware of the huge price differences among imaging services, and they have recently intensified their efforts to steer patients toward lowercost imaging providers. These efforts don’t end with steering alone. Some insurers have begun to offer patients cash incentives (typically $50 to $200) when they select lower-cost providers for particular services.

Two large payors, Anthem Blue Cross Blue Shield and Harvard Pilgrim Health Care, have deployed these types of programs, encouraging patients to go online or call a toll-free number and compare prices for certain ambulatory procedures. In fact, Harvard Pilgrim Health Care’s SaveOn program even pays $10 to patients who simply make the call, not even requiring the patient to select the lower-cost provider (Table 1).

Third, social media: Social-media platforms—Facebook, Twitter, and especially the consumer-review site Yelp—all allow patients to shop virtually for providers. Increasingly, these sites have become places where patients share information on health-care providers, writing reviews about experiences both positive and negative.

Survey2 data underscore the spread of this trend: a quarter of adults are using social media to post information about their health-care experiences, while 42% access these reviews (Figure 1).

These numbers show the importance of ensuring that every patient interaction is a positive one. Reviews are shared instantaneously with millions of people, affecting providers’ online reputations.

Fourth, patient-satisfaction scores: Beyond reputation, patients’ perceptions of their experiences with particular

providers are now tied to reimbursement.

While CMS started administering the Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) survey in 2006, on October 1, 2012, its results became part of the measures included in value-based purchasing, tying patient satisfaction directly to payment.

The 27-question HCAHPS survey is submitted to patients after discharge and asks about their experiences: How responsive was the staff? Would the patient recommend the hospital?

While these categories focus on the inpatient experience, ambulatory experiences are likely to become part of the system. Moreover, it also is probable that commercial insurers will follow the lead of CMS, introducing comparable pay-for-performance initiatives that encompass patient satisfaction.

Programs that focus now on improving the outpatient experience will be well prepared when reimbursement hinges on performance.

25%

Fifth, choice of provider: The patient’s choice of provider is staunchly protected within accountable-care organizations (ACOs), underscoring the importance of the patient experience. Many of these models of care delivery are not the traditional, restrictive HMOs of the past, which limited the patient’s choice of provider.

In fact, Medicare’s Shared Savings Program, rapidly taking hold across the country, allows individuals to choose their providers, placing the attributed ACO at financial risk for any services provided outside the network. By providing strong service, imaging programs can reduce the chance that patients will receive out-ofnetwork care.

Simplifying Patient Transactions Faced with all of these forces, many provider organizations have begun to take a hard look at current service delivery, scrutinizing operations and searching for ways to ensure that patients feel that they are getting the greatest

42%

Figure 1. US adults using social media to post (left) and access (right) health-care reviews.2 www.imagingbiz.com | October/November 2012 | Radiology Business Journal 19

COver | Patient Convenience

64%

58%

51%

21% 79%

Preregistration

Preappointment instructions

Payment

Figure 2. Nearly 80% of patients would select a provider with online services over one without those services.3

Figure 3. Online preregistration is the most sought-after service, followed by access to preappointment instructions and the ability to view and pay bills.3

value for their health-care dollars. While dramatic gestures can be effective, efforts will be futile if the basics aren’t mastered.

The first step, for every imaging program, should be to remove obstacles to patient convenience.

One aspect of convenience is selfservice; many patients prefer to handle the administrative tasks associated with health care online. In fact, one survey3 showed that almost 80% of patients are more likely to select a provider with online services over one without them. Specifically, patients would like to preregister for appointments, get preprocedure instructions, and have access to financial information (Figures 2 and 3).

Despite the evidence that patients would benefit from greater online access to services, health-care providers have lagged well behind other industries in supplying such access. In 2008, the Advisory Board Co’s Imaging Performance Partnership (IPP) conducted an audit of 100 member websites and tabulated the percentage that offered a number of key services. Though most programs had sites, they were frequently missing key functions.

Only 46% of programs actually provided directions to the imaging site, and 42% were providing exampreparation information—two very basic capabilities. Performance on a more advanced service, processing online

100% 82%

100% 82%

appointment requests, was worse, with only 9% of program websites providing that function.

To gauge progress since 2008, the IPP conducted the audit again, calculating the percentage of programs with websites that offered the services originally identified. While notable improvements have occurred—100% of programs have imaging websites that list services and contact information—many programs continue to lag.

Only 76% are providing directions to the imaging center. While a greater number of imaging programs are offering this service, websites without this information are missing a great service opportunity. Giving directions online

100%

Hospitals, 2008 Hospitals, 2012

76%

72% 46%

42%

30% 9%

Radiology website

List of services

Contact information

Directions

Exam-preparation information

17%

Appointments

Figure 4. Imaging-provider members of the Advisory Board’s Imaging Performance Partnership offering online information/services.

20 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

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COver | Patient Convenience

prevents patients from having to search elsewhere, eliminating an extra step.

Further, fewer than half of sites provide exam-preparation information (a service that benefits both patients and imaging staff). When the information is made available online, employees field fewer preprocedure phone calls and questions, allowing them to concentrate on other aspects of their roles. While the percentage of programs allowing online appointment requests has doubled, only 17% of websites provide that service (Figure 4).

Hospitals Versus IDTFs As part of this analysis, the IPP also audited the websites of a number of IDTFs. While hospitals’ and IDTFs’ websites are comparable for basic offerings, hospitals lag (by a wide margin) for more advanced services. Of IDTFs, 93% offer exam-preparation information online, compared with only 30% of hospital imaging programs. Bill payment, which 51% of patients prefer to conduct

online, is facilitated by 60% of IDTFs and 23% of hospitals.

IDTF websites also include information and services that work to build an online community among patients; 90% of sites offer information about radiologists, 83% provide a forum for patient feedback, and 87% provide education and news. These percentages greatly exceed those for hospital websites (33%, 10%, and 43%, respectively). Taken together, the data show that the IDTF cohort, already lower in its pricing, is also making it easier for patients to obtain an imaging exam—an appealing combination for the pricesensitive consumer/patient (Table 2).

There are, however, some hospitalbased programs that have advanced past the majority’s level and are offering extensive online services.

Many progressive imaging programs have tackled scheduling first, allowing patients to request an appointment (or even selfschedule) online.

For self-scheduling, the website typically lists available appointment

Table 2. Hospital and IDTF Website Comparison

Hospitals

IDTFs

Payments

23%

60%

Appointments

17%

37%

Exam-preparation information

30%

93%

Patient-feedback forum

10%

83%

Information about radiologists

33%

90%

Education/news

43%

87%

22 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

slots by modality, and the patient clicks on the most convenient slot. He or she then completes a scheduling form with key details, and when the visit is confirmed, the patient is expected to send the referring physician’s imaging order, by fax or email, prior to the exam.

Staff members frequently call the patient to confirm the appointment and obtain any further information that might be required prior to the exam.

Online scheduling (and the convenience it offers to patients) must be balanced against the challenges of securing preauthorization from the payor in time for an appointment. Some programs build in a lag time, prohibiting patients from scheduling appointments fewer than 36 to 48 hours in advance.

This lag allows ample time to secure preauthorization, avoiding the risk of lost revenue.

While enhancing online services isn’t an easy task, doing so increases convenience for patients who are expecting ever-higher levels of service from their health-care providers.

Enhancing online capabilities is one way that programs can simplify the process of obtaining an imaging exam for patients—and meet the growing consumer mandate.

Robin Brand is a consultant, research and insights, for the Advisory Board Co. References 1. Elliott VS. As premiums rise, are even the insured scrimping by skipping on doctor’s visits? Am Med News. http://www. ama-assn.org/amednews/2011/10/10/ bil21010.htm. Published October 10, 2011. Accessed October 6, 2012.

2. PwC Health Research Institute. Social Media Likes Healthcare: From Marketing to Social Business. New York, NY: PricewaterhouseCoopers; 2012.

3. Patients are seeking self-service convenience to manage health care expenses: NCR survey. http://www.newsmedical.net/news/20100622/Patientsare-seeking-self-service-convenienceto-manage-healthcare-expenses-NCRsurvey.aspx. Published June 22, 2010.

Accessed October 6, 2012.

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Imaging Market File

Imaging-technology Deployment in the Post-DRA Era Introduction: The reductions in reimbursement for medical imaging that began with the DRA have had an impact on providers’ ability to invest in technology (both upgrades and replacements).

As might be expected, reimbursement changes and uncertainty about the impact of health-care reform have affected the acquisition and maintenance costs of imaging technology as well.

In this issue of Imaging Market File, we present the equipment data collected for 2011 by the AHRA, in 2012, using the AHRAdatalynx tool. These data are representative of approximately 200 MRI and CT systems in operation, in both hospital and outpatient settings, across the country.

Technology adequacy: The acquisition cost for MRI systems of all field strengths now ranges from $100,000 to $2 million, and it is $150,000 to $2 million for the full range of CT systems. While the

broad range of acquisition costs could be expected to drive increased purchasing, 26% of respondents say that their current MRI services don’t meet the needs of referring physicians (Figure 1).

Of the deficiencies responsible, number one was capabilities, number two was speed of the exam, and number three was the image quality (Figure 2). This indicates market demand for upgraded technology, with the potential for increased equipment sales over the next couple of years.

Breakdown and age of equipment: While larger facilities were more likely to own 3T MRI systems, 1.5T MRI systems still outnumber 3T units by a ratio of seven to one (Figure 3). In CT-system deployment in this sample, 16-slice systems continue to be the most dominant technology, but are only slightly more common than 64-slice units. The most prevalent MRI system in this census is the 1.5T unit (Figure 3), while the 16-slice system is the most prevalent CT system (Figure 4).

12%

21% MRI

The average age of MRI systems in this dataset is six years (Figure 5), while the most common system, the 1.5T system, is an average of five years old. For CT, the average system age is five years (Figure 6), while the most prevalent type of CT system, the 16-slice system, is an average of six years old.

It’s not surprising that the CT systems that produce datasets of fewer than 16 slices are among the oldest in this census. In fact, the least advanced technologies in the sample, four-slice CT systems, are an average of 10 years old.

The MRI systems with the lowest field strength, those using the 0.3T technology, also are the oldest in the MRI inventory, at 13 years old. The 0.7T systems, however, are younger (at 5.6 years old) than is the 1T inventory (at 7.8 years old). The 1.2T technology is the youngest technology in the inventory, at 2.3 years old, suggesting that this field strength met a need (and possibly, a price point) in the market.

CT

79%

88%

Figure 1. More than 20% of owners of 200 MRI systems report that the technology does not meet physicians’ needs (left). More than 10% of owners of CT systems report that their technology falls short of meeting physicians’ needs (right).

Marketability Image quality

Sponsored Supplement

Speed of exam Capabilities

MRI CT MRI CT MRI CT MRI CT

0%

5%

10%

15%

20%

25%

30%

35%

40%

Figure 2. Where MRI and CT systems do not meet physicians’ needs, the top two deficiencies are capabilities and speed of exams.

October/November 2012

Imaging Market File

1%

4%

8%

5%

3%

1%

11%

2%

7% 4-slice

1%

0.3T

8-slice 0.7T

10-slice 16-slice

1T

32-slice

1.2T 1.5T

79%

40-slice 64-slice

32%

128-slice

3T

39%

2%

Figure 3. Deployed MRI systems, by field strength.

Figure 4. Deployed CT systems, by slice count.

14

10 9

12

8

10

7 6

8

5

6

4 3

4

2 Years

Years

2 0

320-slice

5%

0.3T

0.7T

1T

1.2T

1.5T

3T

Average

Figure 5. The average age of MRI systems is slightly less than six years, but this varies by field strength.

1 0

e

lic

4-s

e

lic

8-s

ce

sli

10-

ce

sli

16-

ce

sli

32-

ce

sli

40-

ce

sli

64-

ce

ce

ge

-sli 20-sli vera A 3

128

Figure 6. The average age of CT systems is slightly less than five years, but this varies by slice count.

Coming in the December Issue: Further Information on Equipment Utilization and Service Costs.

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Medicare Imaging SPending | 2003–2010

Trends in Medicare Part B Imaging Volumes, 2003–2010 Imaging volumes in the Medicare population have shown three years of precipitous decline

By Cheryl Proval

I

n looking at aggregate procedure counts in Medicare Part B medical imaging over the past eight years, the drama that unfolded between 2003 and 2010 is nowhere to be seen. Both rapid escalation in the imaging growth rate and a subsequent, nearly equivalent decline in volumes are lost in a compound

annual growth rate (CAGR) of –0.9% over eight years. That’s according to a new analysis of the Medicare Physician/ Supplier Procedure Summary annual master files, 2003 to 2010, performed by the newly established Harvey L. Neiman Health Policy Institute (HPI).

The HPI provided three tables based on partially scrubbed Medicare Part B data for 2003 through 2010. Imaging-service unit counts, by imaging modality, performed by radiologists and nonradiologists, were presented for the office setting (Table 1) and for all places of service (Table 2). Also provided was a breakdown of radiologists’ and nonradiologists’ shares of imaging in office; inpatient hospital; and hospital

Table 1. Service Units, Office, by Modality

outpatient, emergency-department, or other settings (Table 3).

Radiology Business Journal compared the imaging-service units of radiologists and nonradiologists to arrive at the growth rate for 2003 through 2007, when imaging hit its peak number of units in this population (Table 4). We also looked at the percentage change in units between 2007 and 2010, a period during which the number of imaging procedures performed in this population declined by 15% (Table 5), as well as the change in the same period in the office setting only (Table 6). We then looked at the changes in the site of service between 2003 and 2010 (see figure).

Table 2. Service Units, All Settings, by Modality

2003 2010

Average annual growth rate

All Physicians

2003 2010

Average annual growth rate

All Physicians

All

78,090,283

66,914,350

–2.2%

All

Mammography

3,347,800

3,046,416

–1.3%

Mammography

198,669,220

186,745,774

–0.9%

8,142,524

7,925,560

–0.4%

Nuclear imaging

5,526,324

2,167,488

–13.4%

Nuclear imaging

10,345,770

3,237,941

–16.6%

Radiography

38,066,491

27,767,776

–4.5%

Radiography

95,452,303

88,198,456

–1.1%

CT

2,736,505

5,088,701

8.9%

CT

17,575,724

25,331,850

5.2%

MRI

2,633,130

3,682,550

4.8%

MRI

6,186,466

8,414,333

4.4%

Ultrasound

17,841,889

16,001,761

–1.6%

Ultrasound

38,334,434

31,707,716

–2.7%

Radiation oncology

5,705,049

6,171,628

1.1%

Radiation oncology

9,863,710

9,671,684

–0.3%

Interventional radiology

2,233,095

2,988,030

4.2%

Interventional radiology

12,768,289

12,258,234

–0.6%

120,591,334

120,352,979

0%

7,348,714

7,245,873

–0.2%

Radiologists

Radiologists

All

30,471,946

25,754,718

–2.4%

All

Mammography

2,624,357

2,433,319

–1.1%

Mammography

459,204

209,079

–11.2%

Nuclear imaging

3,835,911

1,251,866

–16%

15,169,893

7,853,854

–9.4%

Radiography

64,900,063

58,738,939

–1.4%

Nuclear imaging Radiography CT

2,092,937

3,630,825

7.9%

CT

16,759,774

23,634,002

4.9%

MRI

1,749,673

2,237,601

3.5%

MRI

5,160,422

6,763,341

3.9%

Ultrasound

1,766,907

2,277,005

3.6%

Ultrasound

8,722,576

10,131,802

2.1%

Radiation oncology

5,445,750

5,988,898

1.4%

Radiation oncology

9,369,797

9,448,114

0.1%

Interventional radiology

1,163,225

1,124,137

–0.5%

Interventional radiology

4,494,077

3,139,042

–5.1%

78,077,886

66,392,795

–2.3%

793,810

679,687

–2.2%

Nonradiologists All Mammography

Nonradiologists 47,618,337

41,159,632

–2.1%

All

723,443

613,097

–2.4%

Mammography

Nuclear imaging

5,067,120

1,958,409

–13.6%

Radiography

22,896,598

19,913,922

–2%

Nuclear imaging

6,509,859

1,986,075

–17%

Radiography

30,552,240

29,459,517

–0.5% 10.5%

CT

643,568

1,457,876

11.7%

CT

815,950

1,697,848

MRI

883,457

1,444,949

7%

MRI

1,026,044

1,650,992

6.8%

16,074,982

13,724,756

–2.3%

Ultrasound

29,611,858

21,575,914

–4.5%

493,913

223,570

–11.3%

8,274,212

9,119,192

1.4%

Ultrasound Radiation oncology Interventional radiology

259,299

182,730

–5%

Radiation oncology

1,069,870

1,863,893

7.9%

Interventional radiology

www.imagingbiz.com | October/November 2012 | Radiology Business Journal 27

Medicare Imaging SPending | 2003–2010

A few cautionary notes about the data, lest readers be inclined to draw more than is warranted from the numbers: Imaging counts, in IDTF settings, are included in the nonradiologist imaging category.

CMS counts IDTF imaging not as a place of service, but as a specialty—and due to the inability to separate radiologistowned IDTFs from other IDTFs, IDTF imaging is included in the nonradiologist counts. What would appear to be a dramatic decline in nuclear imaging from 2009 to 2010 and a smaller (but significant) decline in mammography are both the results of a CMS decision to bundle certain myocardial-imaging and mammography codes.

Spike and Decline Over the eight-year span of 2003 through 2010, volumes dropped slightly in 2004 and then hit their peak in 2007 (Table 2), the year that the DRA reductions were fully implemented. Medicare paid

No one who deals with these data is surprised anymore that imaging has slowed down; in 2007, you had a marked drop-off in imaging.

—Danny Hughes, PhD Harvey L. Neiman Health Policy insitute

for a total of 218,826,552 units of medical imaging in 2007, after which imaging volumes steadily declined by 15% over the next three years (Table 5). The decline was even more pronounced in the office setting (Table 6), where imaging volumes declined by 25% between 2007 and 2010.

Danny Hughes, PhD, research director and senior research fellow at the HPI, says, “It’s a fresh story, but it’s also an old story. No one who deals with these data is surprised anymore that imaging has slowed down; in 2007, you had a marked drop-off in imaging.”

Table 3. Service Units, by Place of Service and Modality

Office

Inpatient

Outpatient/emergency department/other

2003 2010 2003 2010 2003 2010

All Physicians 39.3%

35.8%

26.7%

23.4%

34%

40.7%

Mammography

All

41.1%

38.4%

0.3%

0.1%

58.6%

61.4%

Nuclear imaging

53.4%

66.9%

18.9%

12.1%

27.7%

20.9%

Radiography

39.9%

31.5%

27.2%

26%

32.9%

42.5%

CT

15.6%

20.1%

35.2%

28.2%

49.3%

51.7%

MRI

42.6%

43.8%

19.8%

17.5%

37.6%

38.8%

Ultrasound

46.5%

50.5%

32.3%

24.8%

21.1%

24.7%

Radiation oncology

57.8%

63.8%

3.4%

1.9%

38.8%

34.3%

Interventional radiology

17.5%

24.4%

38.6%

30.2%

43.9%

45.4%

Radiologists All

25.3% 21.4% 31.9% 29.4% 42.8% 49.2%

Mammography

35.7%

33.6%

0.3%

0.2%

64%

66.3%

Nuclear imaging

12%

16.7%

35.1%

30.6%

52.9%

52.7%

Radiography

23.4%

13.4%

39.1%

38%

37.5%

48.7%

CT

12.5%

15.4%

36.5%

29.9%

51%

54.7%

MRI

33.9%

33.1%

23.2%

21.2%

42.9%

45.7%

Ultrasound

20.3%

22.5%

35%

32.2%

44.7%

45.3%

Radiation oncology

58.1%

63.4%

3.3%

1.9%

38.6%

34.7%

Interventional radiology

25.9%

35.8%

22.8%

23.7%

51.3%

40.4%

Nonradiologists 61%

62%

18.7%

12.6%

20.3%

25.4%

Mammography

All

91.1%

90.2%

0%

0%

8.8%

9.8%

Nuclear imaging

77.8%

98.6%

9.3%

0.5%

12.9%

0.9%

Radiography

74.9%

67.6%

2%

2.3%

23%

30.1%

CT

78.9%

85.9%

7.7%

4%

13.4%

10.2%

MRI

86.1%

87.5%

2.7%

2%

11.2%

10.5%

Ultrasound

54.3%

63.6%

31.5%

21.4%

14.2%

15%

Radiation oncology

52.5%

81.7%

5.2%

1.5%

42.3%

16.8%

Interventional radiology

12.9%

20.4%

47.2%

32.5%

39.9%

47.1%

28 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

Hughes says that the HPI will be issuing its first policy brief addressing this and providing in-depth analysis. He attributes a small part of the decline to the DRA and other health policies—and a more significant portion to technology maturation.

“There was a period, in the early 2000s, where you really had a ramping up,” he notes, adding that high-end technology has begun to diffuse. “Once you have the latest and greatest in these technologies, and the technologies are fully diffused, utilization adjusts to account for these new technologies and their use—then, it plateaus,” he says.

Hughes is not projecting further declines, and he anticipates that volumes will plateau (except, perhaps, in rural areas, where access to imaging centers and technology is currently limited).

Long and Short Views The broad trend in imaging-volume reductions over eight years (Tables 1–3) indicates that volumes for imaging performed by radiologists appear to have declined slightly more than those for imaging performed by nonradiologists in the office setting, but less than for nonradiologist-performed imaging in all settings. When viewed over the past three years, however, the drop in volumes has taken a greater toll on nonradiologistperformed imaging, and that’s true in all settings.

In the office setting, radiologistperformed imaging declined 19% from 2007 through 2010; nonradiologistperformed imaging declined 28% (Table 6). In all settings (including hospital inpatient, outpatient, and emergencydepartment settings), radiologistperformed imaging declined 6% between 2007 and 2010; nonradiologist-performed imaging declined by 27%, suggesting

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Medicare Imaging SPending | 2003–2010

that some self-referral might have had its incentives reduced or reversed by payor policies put in place since 2006. A portion of the decline also can be attributed to CMS policy decisions that required the bundling of certain codes.

“This is, perhaps, not a mainstream talking point yet,” Hughes says, “but anyone working with these data for the past three years is aware of it, and it is just now rolling out in the peer-reviewed literature.” While the overall eight-year trend for all modalities shows a –0.9% annual growth rate from 2003 to 2010, some individual modalities registered single-digit annual growth rates, despite the steep declines of the past three years: CT grew 5.2% annually and MRI grew 4.4% per year (Table 2).

These two high-tech modalities show higher eight-year CAGRs in the office setting: For CT, the CAGR was 8.9% annually for 2003 through 2010, and MRI had a 4.8% CAGR over the same period,

offering a scent of the meteoric growth that initiated CMS scrutiny (Table 1). Growth rates for nonradiologist-performed imaging in both modalities and both settings were higher than growth rates for radiologistperformed imaging in CT and MRI. Place of Service A trend that is more interesting to observe over the eight-year span is the shift in place of service (Table 3 and figure).

In 2003, 39.3% of imaging done by all physicians was office based; 26.67% was performed in the inpatient hospital setting; and 34% was delivered in an outpatient, emergency-department, or other setting.

By 2010, volumes in both office-based and inpatient hospital-based imaging had eroded, but the category of hospital outpatient, emergency-department, and other setting picked up share. In 2010, 35.8% of imaging performed by all physicians took place in the office setting; 23.4% of imaging occurred in the hospital

Table 4. 2003–2007 Change in Service Units, All Settings, by Modality

2003 2007 Change

All Physicians All

inpatient setting; and 40.7% of imaging was performed in a hospital outpatient, emergency-department, or other setting.

Office-based imaging peaked at 40.5% in 2007, the same year that overall imaging volumes hit their highest level (Table 3). Hospital inpatient imaging volumes peaked in 2004, at 28%, and appear to have been declining fairly steadily ever since. While volume for the hospital outpatient, emergencydepartment, or other setting has been flat or posting incremental increases since 2003 (when it accounted for a 34% share of imaging), it took off in 2007, peaking in 2010 with a 40.7% share.

A number of factors could be driving this migration: The onset of the worst economic contraction since World War II might have played a role, as the unemployed population lost health benefits and more people sought care in emergency departments. Declines in hospital inpatient imaging volumes could

Table 5. 2007–2010 Change in Service Units, All Settings, by Modality

2007 2010 Change

All Physicians 198,669,220

218,826,552

10%

All

218,826,552

186,745,774

Mammography

8,142,524

8,459,954

4%

Mammography

8,459,954

7,925,560

–15% –6%

Nuclear imaging

10,345,770

11,674,659

13%

Nuclear imaging

11,674,659

3,237,941

–72% –10%

Radiography

95,452,303

97,792,843

2%

Radiography

97,792,843

88,198,456

CT

17,575,724

23,628,902

34%

CT

23,628,902

25,331,850

7%

MRI

6,186,466

8,501,132

37%

MRI

8,501,132

8,414,333

–1%

Ultrasound

38,334,434

45,301,174

18%

Ultrasound

45,301,174

31,707,716

–30%

Radiation oncology

9,863,710

10,957,450

11%

Radiation oncology

10,957,450

9,671,684

–12%

Interventional radiology

12,768,289

12,510,438

–2%

Interventional radiology

12,510,438

12,258,234

–2%

127,947,595

120,352,979

–6%

7,605,875

7,245,873

–5%

Radiologists All Mammography

Radiologists 120,591,334

127,947,595

6%

All

7,348,714

7,605,875

3%

Mammography

Nuclear imaging

3,835,911

3,361,039

–12%

Nuclear imaging

3,361,039

1,251,866

–63%

Radiography

64,900,063

64,724,254

0%

Radiography

64,724,254

58,738,939

–9%

CT

16,759,774

21,853,058

30%

CT

21,853,058

23,634,002

8%

MRI

5,160,422

6,709,223

30%

MRI

6,709,223

6,763,341

1%

Ultrasound

8,722,576

10,011,129

15%

Ultrasound

10,011,129

10,131,802

1%

Radiation oncology

9,369,797

10,624,878

13%

Radiation oncology

10,624,878

9,448,114

–11%

Interventional radiology

4,494,077

3,058,139

–32%

Interventional radiology

3,058,139

3,139,042

3%

90,878,957

66,392,795

–27%

854,079

679,687

–20%

Nonradiologists All Mammography

Nonradiologists 78,077,886

90,878,957

16%

All

793,810

854,079

8%

Mammography

Nuclear imaging

6,509,859

8,313,620

28%

Nuclear imaging

8,313,620

1,986,075

–76%

Radiography

30,552,240

33,068,589

8%

Radiography

33,068,589

29,459,517

–11%

CT

815,950

1,775,844

118%

CT

1,775,844

1,697,848

–4%

MRI

1,026,044

1,791,909

75%

MRI

1,791,909

1,650,992

–8%

Ultrasound

29,611,858

35,290,045

19%

Ultrasound

35,290,045

21,575,914

–39%

493,913

332,572

–33%

Radiation oncology

332,572

223,570

–33%

8,274,212

9,452,299

14%

Interventional radiology

9,452,299

9,119,192

–4%

Radiation oncology Interventional radiology

30 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

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Medicare Imaging SPending | 2003–2010 Table 6. 2007–2010 Change in Service Units, Office, by Modality

2007 2010 Change

All Physicians All

88,631,338

66,914,350

–25%

Mammography

3,419,352

3,046,416

–11%

Nuclear imaging

7,273,827

2,167,488

–70%

Radiography

36,785,958

27,767,776

–25%

CT

4,708,610

5,088,701

8%

MRI

3,903,252

3,682,550

–6%

Ultrasound

23,055,773

16,001,761

–31%

Radiation oncology

6,570,204

6,171,628

–6%

Interventional radiology

2,914,362

2,988,030

3%

All

31,653,317

25,754,718

–19%

Mammography

2,668,273

2,433,319

–9%

Nuclear imaging

480,651

209,079

–57% –41%

Radiologists

Radiography

13,424,522

7,853,854

CT

3,203,088

3,630,825

13%

MRI

2,341,359

2,237,601

–4%

Ultrasound

2,326,508

2,277,005

–2%

Radiation oncology

6,332,550

5,988,898

–5%

876,366

1,124,137

28%

56,978,021

41,159,632

–28%

Interventional radiology Nonradiologists All Mammography

751,079

613,097

–18%

Nuclear imaging

6,793,176

1,958,409

–71%

Radiography

23,361,436

19,913,922

–15%

CT

1,505,522

1,457,876

–3%

MRI

1,561,893

1,444,949

–7%

Ultrasound

20,729,265

13,724,756

–34%

237,654

182,730

–23%

2,037,996

1,863,893

–9%

Radiation oncology Interventional radiology

be attributed partly to payors’ efforts to direct imaging to lower-cost outpatient sites and partly to deferred care.

Office-based imaging volumes might have declined with the onset of the DRA, when the reimbursement environment became very challenging. The hospital inpatient and outpatient, emergencydepartment, or other settings were the dominant places of service for the radiologist both at the beginning of the period examined and at the end; however, the outpatient, emergency-department, or other setting grew in importance for radiologists over time.

In 2003, 25.3% of all radiologist interpretations were provided in the office setting; 31.9% were done in the hospital inpatient setting; and 42.8% were done in the outpatient, emergencydepartment, or other setting (Table 3). In 2010, the breakdown was 21.4% office; 29.4% hospital inpatient; and 49.2% outpatient, emergency-department, or other. By far, the dominant place of

39.3%

34%

35.8%

40.7%

23.4%

26.7% 2003 All Physicians

2010 All Physicians

21.4%

25.3% 42.8%

49.2% 29.4%

31.9%

2003 Radiologists

2010 Radiologists

20.3% 18.7%

25.4% 62%

61% 12.6%

2003 Nonradiologists Office

2010 Nonradiologists

Inpatient

Outpatient/emergency department/other

Figure. Share of Medicare Part B count of assigned service units, 2003 and 2010.

service for nonradiologists was the office setting, which accounted for 61% of nonradiologist-interpreted imaging in 2003 and 62% in 2010 (Table 3).

The Economic Downturn Hughes is reluctant to discuss the role that the economy might have played in the imaging downturn, pending the outcome of a separate line of research that the HPI is conducting across a broad range of medical services and delivery sites. “Overall, the number of procedures peaked in 2007,” Hughes says. “Some have increased, some have decreased, but considering the aggregate figures, we can’t really attribute the broad decline in imaging at this time to the economy.”

He continues, “For the most part, it is largely due to market saturation, technology maturation, DRA changes, and other regulatory changes that have caused imaging to shift. Preliminary data suggest that some of it is really just a shift from office-based to hospital-based

32 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

imaging. That is something that bears greater scrutiny and something about which I won’t speak with authority until I have completed those studies.”

Nonetheless, the data speak for themselves: The overall number of imaging procedures peaked in 2007 and has been on a steep downward slide since then. Both the office and the hospital-inpatient settings have lost share to the outpatient, emergencydepartment, or other setting. All of this brings up a question: Why does radiology remain in the crosshairs as a target for reimbursement reductions?

“For a brief period of time, radiology grew at a much faster rate than many other services,” Hughes notes. “We also are a very tiny share of overall expenditures— now, with much slower growth—while other services are growing much more quickly.”

Cheryl Proval is editor of Radiology Business Journal.

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The Imaging Department | Customer Satisfaction

From Bad to Great:

How One Radiology Department Made the Transition Whenever a goal seems too hard to achieve, remember Advocate Condell Medical Center’s stunning transformation from laggard to leader in customer satisfaction By Julie Ritzer Ross

U

ntil a short time ago, Advocate Condell Medical Center (ACMC) in Libertyville, Illinois, was in the bottom quartile in customer satisfaction. Its growth was stunted, at best, and annual losses of $50 million had become the norm. The radiology department was a shambles.

Today, however, the picture is far more rosy. The hospital now ranks among the top 10% of comparable institutions in outpatient-imaging patient satisfaction, according to Press Ganey. With revenues growing at a steady clip, the radiology department alone has increased cash collections by $1 million per year.

The catalysts: initiatives and solutions implemented in accordance with an operations/service-excellence model and a roadmap for sustainable excellence that supports the execution of these changes.

Airica Steed, EdD, MBA, RN, CSSMBB, was formerly vice president of professional services and operations excellence at Advocate Healthcare Corp, the hospital’s parent company, and currently serves as enterprise chief experience officer and clinical assistant professor, health policy and administration, at the University of Illinois Hospital & Health Sciences System in Chicago. Steed copresented “Achieving World-class Service in Imaging by Embracing Transformational Excellence” on August 14 at the AHRA 2012 Annual Meeting and Exposition in Orlando, Florida. She chronicled the transformation undergone by ACMC and its radiology department.

Configured within what Steed deems a Malcolm Baldrige National Quality Award framework, ACMC’s operations/ service-excellence model is employee

led and takes into account the hospital’s main customers—patients and their families—as well as physicians and employees. It calls for harnessing the Six Sigma™ method and its DMAIC (for define, measure, analyze, improve, and control) approach. DMAIC calls for eliminating waste and for streamlining and standardizing operations; integrating people, processes, knowledge, and technology; migrating from a punitive culture, in which sticks rather than carrots dominate, to one that emphasizes high levels of performance; and instituting accountable leadership.

The roadmap used at ACMC lays out steps to be taken in the course of applying the model. These include establishing a reason for action, reviewing current performance (with applicable comparisons), identifying root-cause opportunities, and designing solutions that address identified problems. Other steps encompass celebrating outcomes and quick wins, performing pilot testing and implementing solutions, developing best (and next) practices and empowering those who will assist the organization in achieving them, monitoring and sustaining performance, ensuring continuous improvement and learning, and sharing lessons learned.

Building an Infrastructure The radiology department’s transformation initiative began with the establishment of an infrastructure for improvement without which, Steed says, creating change would have proved impossible. “We knew that neither change nor excellence happens in a vacuum,” Steed says. Comprising

34 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

leaders’ buy-in; comparative research on departmental performance (conducted in-house, through reviews of pertinent literature, and at conferences); and a set of multidisciplinary teams, “The infrastructure was essential to going forward,” Steed says.

To get leaders on board, Steed and her colleagues presented clear rationales for an imaging-services overhaul. In the radiology department, the reasons extended far beyond customer dissatisfaction. The intake process was cumbersome (at best), with multiple steps and phone calls required to accomplish the task.

“It wasn’t uncommon for patients to spend over an hour, be transferred to what seemed like 15 million people, and take a million different steps before they were finished,” Steed says. “It is not an exaggeration to say that if I were eight months pregnant and needed an ultrasound—well, good luck getting it done in time.”

Waiting times after scheduling were equally excessive; for example, reportturnaround time exceeded 16 hours. Noshow rates exceeded 6%, and patients’ frustration with being unable to reach a live person by phone resulted in a high percentage of abandoned appointments.

A root-cause survey—conducted as part of the research component—revealed that only 53% of appointments fell into the preregistered category. In addition, the department faced high rates of claim denial, significant bad debt, and poor morale among physicians and staff.

Multidisciplinary teams were formed to afford all constituents a voice in the improvement process, thereby empowering them and aligning them

with an employee-led, customer-focused model. Front-end employees were enlisted to participate—with department leaders and imaging professionals—in teams appointed to execute front-end changes; other staff members joined the teams dedicated to their areas. To attain the goal of patient-centered operation called for in the model, patients and their families were invited to participate in the teams as well.

On the Front Lines Following the completion of the infrastructure, solutions for front-end scheduling and registration problems were formulated. At the time, the two processes were treated separately, with four employees handling scheduling alone and patients required to speak with different staff members to make appointments and move through the registration scenario.

“We considered whether it would be more efficient to combine scheduling with registration or to keep them separate,” Steed notes. For the purpose of empowerment and as a morale booster, staff members were charged with devising a solution.

They opted for a one-stop method that they believed would best mitigate inefficiencies and enhance the patient experience. Appointment scheduling and registration now occur during a single phone call, minimizing patients’ frustration (and appointment abandonment) and ensuring that 100% of appointments are registered ahead of the day of service.

Reminder phone calls are placed to patients 24 to 48 hours prior to their www.imagingbiz.com | October/November 2012 | Radiology Business Journal 35

The Imaging Department | Customer Satisfaction

What we did was to take hospitality principles and bring them into the radiology department. When patients walk through the door, everything is ready for them. All the work has been done. There is no long line at the counter.

—Airica Steed, EdD, MBA, RN, CSSMBB University of Illinois Hospital & Health Sciences System

appointments; messages conveyed include explicit instructions for exam preparation, a brief description of what to expect when undergoing the planned procedure, and encouragement to contact the department with any questions.

Physicians, who were forced to endure a system rife with inefficiencies prior to this transformation, can schedule exams using a dedicated phone line.

This, however, is just the tip of the iceberg for front-end improvements.

FastPass, a VIP-style check-in mechanism, enables patients to check in rapidly, at one desk, rather than starting the process in one room and finishing it elsewhere, as was previously the norm.

Precertification and financial clearance for high-value services are obtained one day before scheduled appointments to prevent check-in headaches and lessen the likelihood of claim denial.

“What we did here was to take hospitality principles and bring them to the radiology department,” Steed says.

“When patients walk through the door, everything is ready for them. All the work has been done. There is no long line at the counter.”

Among other measures, hours of operation were expanded to match the demand for service, providing a wider range of convenient time slots to keep patients and referring clinicians away from competing imaging providers.

Scheduling was modified to match actual service times, and a stacked scheduling method was implemented.

Steed says, “The last thing we wanted to do was to schedule one patient for a procedure at 8 am, but the next, not until 4 pm. We wanted an appointment at 8 am

to be followed by appointments at 8:30, 9, and 9:30. It’s a much more sensible system.”

To minimize traffic surges and delays caused by unscheduled appointments, the department created a reserve of set appointment slots for walk-in and emergency-department patients, based on past patterns. Steed also put the brakes on scheduling same-day highvalue services to optimize reimbursement through preauthorization and limit what had been considerable losses.

Moreover, technology has been deployed, as the model dictates, to spark positive change. For example, voicerecognition technology with self-editing capabilities was deployed to speed up report turnaround and bolster satisfaction among patients and referrers. Scheduling software was refined to support the stacked-appointments system.

In a somewhat different vein, to protect patients’ privacy and guard against embarrassment, the radiology department has abolished the traditional practice of calling names and specifying procedures in the waiting room. Instead, front-desk personnel record such patient identifiers as age, gender, and clothing when individuals arrive. The information is transmitted to personnel with patients’ paperwork and used to spot them as they wait.

“Screaming out patients’ names and announcing, within anyone’s earshot, what procedure they would be undergoing definitely was not a contributor to a good patient experience,” Steed says. In contrast, many individuals, she adds, “are very comfortable when a technologist comes up to them and quietly says, ‘You’re [name] and you’re here for this

36 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

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The Imaging Department | Customer Satisfaction

procedure, right? I’m [name], and I will be doing your exam today.’”

Required Operations Supporting these solutions is a fixed strategy for operations and excellence, also instituted according to the model.

Among other practices, the strategy entails check-in and exit interviews conducted by department leaders.

During the former, individuals sitting in the waiting room are asked whether

they will be undergoing an exam or are accompanying someone who is currently doing so—and how long they have been there.

Patients whose waits appear excessive are told that the elapsed time exceeds the acceptable standard and that the leader will check on them again in a few minutes.

They are also assured that if they have not been summoned by a technologist before the leader returns, he or she will address the problem.

In exit interviews, leaders ask patients to assess the service that they received and whether it was delivered as promised. Patients also are asked whether technologists introduced themselves and explained the duration of the exam. “We take a very proactive approach because, in line with the model, excellence cannot be sustained without continuous improvement and learning,” Steed states.

“There is always room for that.”

In a similar way, the hospital uses follow-up phone calls to obtain further insight into patients’ experiences and to elicit useful feedback. Mailed thank-you cards serve the same purpose. Consistent with the mission to reward and empower staff, employees receive individual recognition when returned cards indicate that they, in particular, have provided a high caliber of service.

Moreover, daily staff huddles and weekly action meetings are held to identify pressing issues and devise means of addressing them before they escalate.

Weekly meetings include radiologists, along with members of the leadership team. “The difference, now, is that if there is an issue, the huddles and the meetings allow us to determine right away how to resolve it,” Steed explains.

Significant Improvement In addition to propelling ACMC’s diagnostic-imaging customer-service ratings from the bottom quartile to the top 10% among comparable hospitals, these strategic and operational initiatives sparked a 50% improvement in staff and physician satisfaction, Steed notes. Overall procedure-volume growth rose by 8% in the first year after model implementation, exceeding initial expectations.

It’s just as significant that the radiology

38 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

department has seen a decrease in the incidence of no-show patients from 6% to less than 1.5%. Patients’ waiting times have been reduced from more than 30 minutes to an average of fewer than 10 minutes, the abandoned call rate is down by 70%, and 100% of appointments are preregistered. Steed says that experience and the positive outcome of ACMC’s radiology-department turnaround bring to bear a number of lessons that other imaging service providers should heed when attempting to achieve similar results.

She advises, “Understand and communicate reasons: Understand your business, strengths, and opportunities, as well as who your customers are. Don’t discount any customer groups—many of our staff members were identified as our customers, to our surprise. Insist on required accountability. Be transparent in your goals. Remember that the model is there for everyone—not just leaders— to see.” Process-improvement steps, she adds, need to be translated and communicated into easy-to-understand language.

Radiology-department constituents in charge of change, Steed continues, must ensure that the new culture is driven by high-level performance, with a relentless commitment to excellence and a refusal to accept mediocrity. Frontline staff must be empowered and engaged by being given the tools to solve problems on the spot and a license to think and act like CEOs. Creativity, next-practice thinking, and learning by doing should be encouraged, at all costs, to support toptier performance and maintain a positive morale.

Steed advises leaders to provide support, feedback, and praise, in addition to addressing mistakes and missteps with constructive criticism (rather than punitive measures or language). “Change requires accountability, excellent behaviors, and superior processes,” Steed concludes. “Strong leadership demands vision, willingness, and adaptability.

Transformation is a journey—not a place.”

Julie Ritzer Ross is a contributing writer for Radiology Business Journal.

Business Intelligence Series: TRA FIFTH PROFIlE In A sERIEs OF sIx

Agility in a Swiftly Changing Payment Landscape

Toledo Radiological Associates uses business intelligence to respond quickly to issues affecting its reimbursement outlook Toledo Radiological Associates Inc (TRA) in Toledo, Ohio, a 28-physician practice, made its decision to switch from in-house to outsourced billing based on factors that will sound familiar to many radiology practices. Richard Wagner, TRA’s practice administrator, says, “We looked at factors like the switchover to ICD-10 and what that would do to our coding needs. We had two coders who were doing a great job, but we knew it was risky, having only a couple of key people. The other thing that really made us look at outsourcing was the uncertainty resulting from health-care reform.”

That uncertainty, Wagner says, made having access to business intelligence particularly critical for the practice.

“Our billing system did a great job of getting money into and out of the practice, but it wasn’t telling me what I needed to know to make business decisions,” he notes.

“It’s a lot more critical now to have that information. It is a challenge, every day, to run a health-care business, especially if you don’t have the information to make projections.”

“Zotec provides us with a system that allows us to get the specific, customized data we need.”

— Richard Wagner

Zotec Partners. The total solution.

In consideration of this need, in March 2011, the practice transitioned to outsourced billing with Zotec Partners. “Radiologists are always looking for specific data points, such as how much they get for an MRI from Anthem versus Medicare. All that information is in a billing system, but you need a way to get it out,” Wagner says.

“Zotec provides us with a system that allows us to get the specific, customized data we need.”

Information from the Zotec system not only is customizable, but also is timely—a critical factor when the reimbursement outlook is changing as rapidly as it is for imaging. The practice was tracking some measures before using Zotec’s services, “but the information was always a couple of months delayed,” according to Michael Walsh, MD, TRA’s treasurer. “It’s real-time data and decision support that are most beneficial to us. Every month, it seems that something is changing, and we are able to monitor our financial measurements in real time and adjust to them as they happen, as opposed to getting them six months behind the curve.”

Regulatory Impact As Walsh observes, the challenging regulatory environment surrounding imaging has made business intelligence more important than ever for practices such as TRA. Daniel Dessner, MD, TRA president, says, “Everyone’s reimbursement is going down, and volumes are steady or falling.”

He continues, “You need to know where your business is coming from before you can make decisions about the direction in which you want to take your practice. That kind of detailed information wasn’t always necessary, but nowadays, you have to be smarter. You have to understand your practice a lot better, and the information from Zotec helps us do that. Zotec had the best suite of businessanalytics applications to pull information from billing data that we saw.”

PROFIlE “Nowadays, you have to be smarter. You have to understand your practice a lot better, and the information from Zotec helps us do that. Zotec had the best suite of business-analytics applications to pull information from billing data that we saw.”

“We are all trying to code properly for the work that we do, and Zotec lets us see the higher rates that result from that.” — Daniel Dessner, MD

— Daniel Dessner, MD

With reimbursement on the decline, every dollar counts, Walsh says. Real-time business intelligence from the Zotec system enables the practice to identify and address payment problems proactively, ensuring that it does not leave money on the table. “We have established our typical average revenue, and if there is a decrease, we can troubleshoot and find out why it happened,” he says.

For instance, he notes, “A couple of times this year, we have seen clerical errors with Medicare reimbursements where we have mistakenly been labeled as not ACR® accredited. When that happens, we are able to see, in real time, that our reimbursement has declined precipitously— and we can troubleshoot it the same month that the mistake occurred.”

Physician Involvement The ability to troubleshoot problems immediately is not limited to external issues, Wagner notes. The near–realtime access to data made possible by the Zotec system also enables the practice’s physicians to be more involved in streamlining timely reimbursement.

“The Zotec system allows me to go in daily and look at denials by physician, by month, and by reason,” he says. “In a medical group, giving physicians access to that information is more powerful than if I pointed out the issues myself. When another physician goes to them and says, ‘You need to do a better job of documentation, and I’m going to make sure you do,’ things change more quickly.”

Zotec Partners. The total solution.

Daniel Dessner, MD

Zotec’s physician portal enables TRA’s radiologists to self-monitor their denial rates, Dessner says. “We get really good feedback, straight to the radiologists, through the physician portal, so we try not to make the same mistake twice,” he says. “We are all trying to code properly for the work that we do, and Zotec lets us see the higher

rates that result from that.”

Walsh calls this feature extremely useful. “The portal helps educate our physicians as to what is necessary for reporting, billing, and coding—and shows them what to say in their dictations, after they make a mistake,” he says. “That has been useful in decreasing the number of our first-pass declines.”

He adds that physicians can also access the Zotec system 24/7 for answers to questions that, in the past, it would not have been possible to have answered in real time. “I can log on through the portal at 3 am and determine whether we’re being reimbursed for cardiac MRI and what the rate is,” he says. “It was much harder for us to get that information, prior to using Zotec’s system.”

Finger on the Pulse Other measures that are tracked on a regular basis include payor mix, payor mix as a percentage of total business, denial rates by payor, and denial rates by code, Dessner says. “What we really like, however, is being able to break it down by referring physician,” he adds. “We can see that one particular group orders a lot of shoulder MRIs, so we should make sure that we’re making that

Sample Zotec graphics.

service available during the most convenient hours, and we can have our marketers ask the group about it to see how we can improve. We make sure we’re touching all the bases we need to touch.”

From a marketing standpoint, the practice can also see whether referrals have decreased from one of its providers and can take steps to find out why, Walsh says. “We follow up, in real time, to see whether our marketing works to increase procedure volume,” he says. “If something has fallen, our marketers can follow up with the referrers and reinforce our commitment to them. We can do quality control and see if there is anything we’ve done to make them change referral patterns.”

That ability to be nimble and responsive is especially critical in a time of potential reimbursement upheavals, Wagner notes. “In health care, we’ve been forced to react rather than plan. What other business do you know that works on a six-month budget?” he asks. “We don’t know how much our rates are going to be affected on January

1, 2013. What will that do to our revenue? We need to be able to project the impact of these cuts, and we need to evaluate new business opportunities very quickly.”

“With the Zotec system, we can quickly find out whether an opportunity is worth pursuing.”

— Richard Wagner

The evaluation process for those opportunities has been significantly improved by data from the Zotec system, Wagner says. “In the old days, we would take the Medicare Physician Fee schedule and apply it to the projected procedure volume to come up with a fairly decent estimate,” he says. “With the Zotec system, however, we can quickly find out whether an opportunity is worth pursuing. In an hour, we can know whether we want to be involved and should perform a more in-depth analysis.”

PROFIlE Looking Forward Walsh notes that TRA’s market is particularly challenging because of its degree of saturation. “Every market is different, and ours is tough right now,” he says. “It’s difficult for us to expand because there are very few places in which we can expand.”

For that reason, the practice’s strategy is much like that of many radiology practices nationwide. “We have limited resources, limited technology, and limited people. We need to be able to look at a business opportunity and decide whether it is going to pay off (if we spend the resources to pursue it),” Wagner says.

Dessner concurs. “It’s hard to establish a long-term strategy in radiology right now,” he says. “Having detailed information on your practice, where your referrers are coming from, and which payors are paying the most (and least) is really important to making decisions about what business to take on—and where to look for it.”

“I can email our Zotec representative in the middle of the night and get a response. If it’s a significant issue, it’s followed up with a plan of action within a week, at most.” — Michael Walsh, MD

Another upcoming project involves predicting the impact of pending reimbursement changes.

Walsh says, “Zotec is evaluating the potential impact and decreased revenue that we will see from the Multiple Procedure Payment Reduction (MPPR) that may be coming up next Michael Walsh, MD year, and Zotec did the same thing, in retrospect, for the MPPR this year—to show us that our attempts to mitigate the impact of the MPPR were beneficial.”

The ability to model multiple scenarios in this way allows the practice to strategize as much as it can. “I need to do multiple scenarios to anticipate what will be happening in just six months,” he says. “That’s what business intelligence enables me to do.”

For that reason, Walsh says, TRA has been particularly happy with Zotec’s responsiveness to its needs. “I can email our Zotec representative in the middle of the night and get a response,” he says. “If it’s a significant issue, it’s followed up with a plan of action within a week, at most.”

Currently, TRA is working with Zotec to develop realtime productivity tracking for its physicians. “We want to be able to monitor our average RVUs per day, per physician, to establish our workflow requirements on a day-by-day basis,” Walsh says.

11460 N. Meridian St. Carmel, IN 46032

317.705.5050 sales@zotecpartners.com zotecpartners.com

ICD-10 | Planning the Transition

ICD-10 Is Coming:

How to Ensure an Optimal Transition Radiologists must finally address the longstanding problem of inadequate referringclinician documentation

By Melody W. Mulaik, MSHS, CPC, CPC-H, RCC

O

nce again, there is an official implementation date for ICD10: October 1, 2014. In some circles, there is still much discussion as to whether this date, too, will be moved. While no one can predict the future in the ever-changing healthcare regulatory environment, it is highly unlikely that the date will be pushed further into the future, given that CMS (arguably) overstepped its bounds by pushing it out to 2014.

Responses to the one-year extension for implementation have been mixed. Many hospitals and vendors have stated that they would have been ready on October 1, 2013, so they are using the additional year to expand their preparations—with the goal of an even smoother transition.

Physicians, in many cases, tell a different story, with some still choosing to delay preparation while others embrace the opportunity to prepare their practices better for the expected impact on the coding process.

Many radiology practices have either dedicated staff or a supporting billing company to help them through the transition. Radiologists could be in a better position than many other specialists in terms of what steps they must take in order to be 100% ready for ICD-10 implementation.

ICD, the International Statistical Classification of Diseases and Related Health Problems, is a list maintained by the World Health Organization and used throughout the world to report clinical information for a variety of purposes.

The United States is the only country that also uses ICD, in the form of the US Clinical Modification (ICD CM), for reimbursement purposes. This creates many operational challenges.

In imaging, ICD CM codes are used to report either definitive findings or the patient’s signs/symptoms (if no definitive findings are present). The current US version, ICD-9 CM, has been in place since 1977; it is limited in terms of the number of codes used, as well as in its ability to describe modern care and to communicate important details about the patient’s condition. This is one of the many reason that the United States is joining the rest of the world with the implementation of ICD-10.

A Whole New World With ICD-10 CM, the number of diagnosis codes increases from

www.imagingbiz.com | October/November 2012 | Radiology Business Journal 43

ICD-10 | Planning the Transition

Greater specificity will also be needed in radiology reports to assign diagnosis codes to the findings. —Melody W. Mulaik, MSHS, CPC, CPC-H, RCC

approximately 13,000 to 68,000, and with this increase comes much greater detail in diagnosis-code descriptions, along with the creation of diagnosis codes that combine conditions, manifestations, and complications into a single code.

With the overall increase in the specificity of diagnosis codes, the level of detail provided by both the ordering physician and the interpreting radiologist becomes crucial.

Currently, an order for a lowerextremity duplex study for deep-vein thrombosis might be received with the diagnosis of leg pain, which is coded as limb pain in ICD-9 CM. In ICD-10 CM, limb pain has been further divided into specific anatomic sites (upper limb: axilla, finger, forearm, hand, or upper arm; lower limb: foot, lower leg, thigh, or toe), along with laterality designation (left or right). In order to assign the most specific diagnosis code, the treating physician now needs to indicate that the pain is lower-leg pain occurring in the left leg, right leg, or both legs.

Keep in mind that although the diagnosis code is assigned based on the findings in the final report, when the results are not definitive (or are negative), the code is assigned based on the diagnosis provided on the order. If the information provided on the order is too general or unspecific, assigning a diagnosis code for the procedure will be difficult. It is likely to require additional staff time to contact the treating physician and research the medical record.

Greater specificity will also be needed in radiology reports to assign diagnosis codes to the findings. For example, a patient might be sent for radiography of the forearm for a suspected fracture of the ulna. The requisition simply states ulnar fracture due to motor vehicle accident.

The radiology report documents that the fracture is in the shaft of the ulna.

With the current ICD-9 CM codes, this information is enough to assign the specific diagnosis code, but in ICD-10 CM, more information is required. Not only is the location of the fracture necessary, but also the type of fracture and the side involved (right or left). For example, the radiologist needs to indicate whether the fracture is greenstick, oblique, spiral, comminuted, or segmental, along with the side involved.

There are three main areas about which radiologists need to be concerned, when it comes to implementing ICD-10 CM: increasing the level of specificity documented in the radiology report, ensuring that referring physicians provide sufficiently detailed information, and having good staff or partners to address all the IT challenges associated with the implementation and ongoing maintenance.

Radiology Specificity The issue that radiologists have the greatest control over is the documentation provided in their radiology reports. The radiology report is the beginning and the end of the audit trail; therefore, it must support all the diagnosis codes that are assigned for a patient encounter. There is much greater specificity in the ICD-10 CM codes, so radiologists will be required to provide more information than was previously needed with ICD-9 CM. Clinical-documentation improvement is the process of reviewing patient records to locate opportunities for the provider to improve the documentation of the services that are provided to the patient.

Clinical-documentation improvement has a definite place in radiology as we prepare for increased documentation requirements.

From a radiology perspective, clinicaldocumentation improvement can be used to identify where radiologists will need to

44 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

improve or expand their documentation so that minimal clarifications or rework will be required. There is no one right way (nor one solution) to accomplish this task; clinical-documentation improvement has been accomplished through a manual review of radiology reports or by using a tool within an existing computer-assisted coding program.

Regardless of the method, the goal should be the same—clear, concise, and complete documentation to determine the correct ICD-10 code(s) accurately.

Practices should identify radiologists who will need to enhance their documentation in preparation for the transition to ICD10. Training should focus on the specific changes needed in their documentation and on the areas requiring additional information to assign diagnosis codes correctly and limit payment delays.

Radiologists evaluate and diagnose many medical conditions, but no area is more affected in ICD-10 CM than injury/trauma. In particular, the ICD10 CM trauma codes allow capture of a much greater amount of detail than the ICD-9 CM codes can. Currently, we have separate codes for open and closed fractures of the same bone, but in ICD-10 CM, we will also have separate codes to show whether the fracture is displaced, as well as specific codes for fractures that are transverse, oblique, spiral, comminuted, segmental, or torus.

In the case of open forearm fractures, there will be specific codes for the different Gustilo classes, so the radiologist can indicate whether the patient has a class I fracture (a small wound with minimal soft-tissue damage) or a class III fracture (a high-velocity or crushing injury with extensive soft-tissue damage).

To make the coding process even more challenging, the ICD-10 CM trauma codes require the provider to indicate whether this is the patient’s initial encounter for the injury, a subsequent encounter with routine healing, or a subsequent encounter with a complication (such as delayed healing, nonunion, or malunion). ICD-10 fracture codes have a seventh character to indicate the encounter.

For example, radiography might be ordered for a patient who broke her left

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ICD-10 | Planning the Transition

forearm four weeks earlier. The radiologist documents that the oblique fracture of the shaft of the left radius is healing satisfactorily. The correct ICD-10 code for this subsequent encounter is S52.332D (displaced, oblique fracture of the shaft of the left radius, subsequent encounter, for closed fracture with routine healing). The initial emergency-department visit would be coded with a seventh character of A. Areas besides trauma are affected by ICD-10 CM. In order to determine where

your opportunities lie, you must first determine which practice areas within radiology will be most affected by the changes. Once you have ascertained this, you should compare the radiologists’ documentation against new coding methods in these key areas to identify where changes are required.

As much as it is strongly recommended to have highly detailed radiologist reports, some unspecified codes will continue to exist in ICD-10 CM. Along

with all of the extremely detailed codes, ICD-10 CM also includes codes for vague and/or poorly documented diagnoses.

Providers will still be able to assign a code for a fracture of the radius, even if the physician doesn’t document that it was a closed, nondisplaced torus fracture of the upper end of the patient’s right radius.

Although there is a nonspecific code available in such instances, however, that does not guarantee payment. Once ICD10 is in place, payors will tend to be more specific in their coverage policies.

For example, a patient with varicose veins and stasis dermatitis of her right leg (I83.11, varicose veins of right lower extremity with inflammation) might come to a facility’s vein clinic. If the physician documents only the varicose veins and does not mention the stasis dermatitis, the facility will have to submit code I83.91 (asymptomatic varicose veins of right lower extremity). When the patient has an ablation procedure, which of those codes is more likely to get the facility its reimbursement for the procedure?

The Referring Physician’s Role The Balanced Budget Act requires the referring physician to provide the diagnostic information to the testing facility at the time the test is ordered. This requirement has not been strictly enforced

by CMS, but the referring provider must supply the diagnostic information, signs and symptoms, or diagnosis code on the order for it to be valid.

Orders received without any clinical indications (or with rule-out conditions) are not considered valid orders for Medicare beneficiaries. It is critical— not only from a clinical perspective, but also from a compliance and coding perspective—that this information be documented.

Just as the implementation of ICD10 CM will require greater specificity in radiology reports, it will also require more details for many of the orders.

Given how great the challenge is today for many radiology practices to get complete information on patient orders, imagine how dramatically ICD-10 will amplify that problem. Medical necessity becomes a big concern with the implementation of ICD-10.

46 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

“What’s Workflow Got to Do With It?” “We are early adopters,” Simmons says. “We continually strive to fix every issue that we run into, and we’re constantly trying to learn what works and what doesn’t. When we saw MEDxConnect from Compressus, it really piqued our interest. We had never seen anything like it. MEDxConnect provides an ease of access that has significantly boosted our productivity, reduced turnaround times, and increased patient satisfaction. Our referrers are more confident that all patient prior studies from the area are reviewed for all studies we read.”

Despite significant advances in medical-imaging technology in the past 10 years, physicians tell us they are significantly less productive. Part of the reason for their lack of progress has been the emphasis on technology improvements in diagnostics, in what is akin to a scanning arms race to see who can do more, faster. It’s a positive development, to be sure, but it has come at the expense of improvements in key business functions, without which the viability of the enterprise is threatened.

At Compressus, we do not believe that diagnostic improvements and business-side progress are mutually exclusive. Rather, they present a symbiotic relationship that, when thoughtfully constructed, provides the best possible patient care and the smoothest business operations— operations that result in maximum profitability.

After all this progress, medical imaging is still beset with challenges. In the past, there was the belief that single systems, integration engines, and even connectivity of data would be sufficient.

Instead, the new business technology has presented its own challenges: There are major gaps in productivity. In those facilities, users implement stopgap solutions instead of long-term productivity and profitability strategies. That approach often results in investment in something that is already outdated by the time it is operational.

Current challenges include accommodating

changes in growth, reimbursements, collaborations or joint ventures, and other dynamics without constantly having to invest significant revenue each time there is a problem to solve. The solution is to seek technology that not only can adapt to current, familiar issues, but that has the capability to provide solutions to unforeseen challenges as well.

Annette Simmons is the IT manager and network administrator at Medical Imaging Northwest (MINW) in Puyallup, Washington. Three years ago, Simmons and her team faced a host of problems. “The biggest challenge we had, at the time, was that we had just started a joint venture, but we were unable to share information with each other. That was a big issue for us.”

She adds, “The most important negative result of the disconnection was that we were losing money—because we had no exposure to a patient visiting our facility and what care they had received at another site. We were losing money because insurances weren’t paying (because the patient had already had a similar study). There was also the danger of overirradiating patients with the same exam, or—because there was a prior study that gave the information they were looking for to begin with—giving patients exams they didn’t need.”

There was more. “Our referring physicians didn’t understand why, if we were in a joint venture,

nIne In a serIes

9 we weren’t seeing the same data. We weren’t seeing the same data because even though we were in a joint venture, we were still separate entities with separate systems,” Simmons says.

The referrers’ complaints produced the tipping point. MINW began to look for a solution that solved its current problems and had the ability to adapt to unanticipated challenges as well.

“We are early adopters,” Simmons says. “We continually strive to fix every issue that we run into, and we’re constantly trying to learn what works and what doesn’t. When we saw MEDxConnect from Compressus, it really piqued our interest. We had never seen anything like it. MEDxConnect provides an ease of access that has significantly boosted our productivity, reduced turnaround times, and increased patient satisfaction. Our referrers are more confident that all patient prior studies from the area are reviewed for all studies we read.”

About MEDxConnect4 MEDxConnect4 offers proven interoperability solutions to connecting disparate systems.

Designed to manage the workflow of an imaging health-care enterprise, the MEDxConnect4 system provides a suite of offerings that has the power to connect systems from multiple vendors and that allows facilities with disparate multivendor systems to function as one virtual enterprise.

MEDxConnect4 features include drag-and-drop workflow modifications, an enterprise worklist/ rich end-user tool set, prior images and pertinent supporting information, advanced patient matching, business reporting and dashboards, and a platform for application plug-ins.

Visit us at RSNA To learn more about how MEDxConnect can provide you with proven interoperability solutions, and to see a demonstration, visit Compressus at RSNA booth 9347, Nov. 25-30, in Chicago.

To learn more…

MEDxConnect

TM

Tel: 202.742.4297 Email: info@compressus.com www.compressus.com /rbj

For copies of past columns, e-mail interoperability@compressus.com

ICD-10 | Planning the Transition

For example, there is still a coding option for an unspecified malignant neoplasm in ICD-10; however, it is not anticipated that claims submitted with this code will result in payment.

Clearly, we will not know for sure until after October 1, 2014, but based on information provided by payors, this is a reasonable assumption.

To ensure correct code assignment for neoplasms, the radiologists and referring physicians must clearly document the specific location of all neoplasms. Simply stating breast cancer or lung cancer will not be sufficient for many payors.

To prepare for correct neoplasm coding in ICD-10, it is recommended that you review the amount of detail that your referring physicians, as well as your radiologists, provide for all neoplasms.

For neoplasms that require more detail regarding location, it would be best to require this level of detail today, instead of waiting for the implementation of ICD10. Examples include reports involving neoplasms of the colon, lung, breast, and brain. Having physicians expand their level of detail will take time, but it will be well worth the effort.

There is great value, even two years before ICD-10 implementation, in addressing any order difficulties that you have today with your referring physicians and their staffs. Many practices shy away from addressing this because they are afraid that the referring physicians will send their patients elsewhere if they request additional information.

On the other hand, how many exams can any practice afford to perform for free? In our increasingly regulated

environment, we should not apologize because we are following the rules and trying to do what is best for the patient.

I would argue that not having complete and accurate clinical information on the front end potentially jeopardizes patient care.

How, then, do you address incomplete orders? Perform an internal assessment to determine which referring practices show an opportunity for improvement.

Once you have identified these practices, prioritize your list and begin making contact with the appropriate personnel in their offices. These conversations might be challenging, and change might be slow, but this is another reason to begin the process now (instead of waiting until problems erupt during ICD-10 implementation).

Remember that it is always better to have specific examples (not general, negative statements) to communicate.

For example, state that there were 12 orders from the referring practice last week that did not identify the reason for the exam requested; don’t state that the practice never sends you the information that you need. Try a positive approach based on documented facts.

IT is possibly the least stressful area of ICD-10 implementation for radiologists who are not actively involved in maintaining and updating this function, even though IT is not likely to be the least stressful part of implementation as a whole. Other staff and/or business partners, such as the billing company and clearinghouse, should be working hard to assess the IT challenges and to implement the plans necessary to ensure compliance on October 1, 2014.

There are many things that we can definitely begin to prepare for now, but unfortunately, since the United States is the only country that truly uses ICD for reimbursement, we don’t have a model that we can use from other countries.

We must recognize that this will be a work in process: There is no one way to accomplish a good result, and we must be nimble and flexible in our approaches.

Melody W. Mulaik, MSHS, CPC, CPC-H, RCC, is president of a coding and compliance consulting company.

48 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

advertiser index Affiliated Professional Services (800) 841-5200 www.affilprof.net......................................................... 29 Agfa (864) 421-1600 www.agfahealthcare.com............................................ 31 Compressus (202) 742-4297 www.compressus.com................................................ 47 eRad (864) 234-7430 www.erad.com............................................................ 45 Fujifilm Medical Systems (800) 431-1850 www.fujimed.com.......................................................... 5 Hitachi Medical Systems America (800) 800-3106 www.hitachimed.com.................................................... 2 iCRco Inc (310) 921-9559 www.icrcompany.com................................................. 21 Integrated Medical Partners (877) 816-1467 www.integratedmp.com.............................................. 13 Intelerad (514) 931-6222 www.intelerad.com........................................... 15–16, 52 LifeIMAGE (617) 244-8511 www.lifeimage.com..................................................... 49 MMP (800) 895-0002 www.cbizmmp.com....................................................... 7 PHC Philips (800) 934-7372 www.philips.com/healthcare....................................... 33 ProScan Imaging (877) PROSCAN www.proscan.com...................................................... 46 RamSoft (888) 343-9146 option 2 www.ramsoft.com....................................................... 51 Regents Health Resources, Inc (800) 423-4935 www.regentshealth.com......................................... 24–26 Sectra (203) 925-0899 www.sectra.com.......................................................... 37 Virtual Radiologic (vRad) (800) 737-0610 www.virtualrad.com....................................................... 3 Visage Imaging (703) 858-5758 www.visageimaging.com............................................ 11 Vital www.vitalimages.com................................................. 23 VMG Health (214) 369-4888 www.vmghealth.com..................................................... 9 Zotec Partners (317) 705-5050 www.zotec.com...................................................... 39–42

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10/24/2012 KNEE MRI

FinalREAD

Monopoly Money Monopoly might be a fun game, but in the real world, there is very little good that can be said about it By Curtis Kauffman-Pickelle

Y

ou know how good it feels.

You finally did the right trade and now own Boardwalk and Park Place. Everyone who has the misfortune of landing on your block of expensive property pays through the roof, and you smile all the way to the bank. It is great fun owning a monopoly—unless, of course, you have those pesky regulators at your back, asking difficult questions about escalating rates and poor service.

Converging issues in medical imaging bring to mind thoughts of the consequences of monopoly in health care. In the August 27, 2012, issue of the Wall Street Journal, Mathews1 chronicles the result of some of the deals currently in vogue in outpatient imaging. We have all experienced that little smile when we hear of a hospital acquiring majority control of an outpatient imaging practice, with the immediate upside of increasing reimbursement simply because of the change in ownership and the ability to bill at the hospital rate. Same physicians, significantly increased price: When you own Broadway and Park Place, you can do what you want.

One important element has been missing from the due-diligence equation in these transactions, and that is consideration of the implications of a consumer-driven health-care environment. Now that patients are asked to pay much larger portions of their health-care bills, and now that health savings accounts and high-deductible plans have become the norm, consumers (patients) are newly empowered and are asking questions that are, frankly, not easy to answer. In the case outlined by Mathews, the cost of a routine echocardiogram in a cardiologist’s office increased four times over that of the previous exam—done in the same office, by the same people, a year earlier.

For those who thought this was only of concern to health-care insiders, the article

is very specific in stating, “As physicians are subsumed into hospital systems, they can get paid for services at the systems’ rates, which are typically more generous than what insurers pay independent physicians.

What’s more, some services that physicians previously performed at independent facilities, such as imaging scans, may start to be billed as hospital outpatient procedures, sometimes more than doubling the cost.”1 The case is made for the role that competition plays in keeping costs (prices)

As a raving capitalist, I am all for deals that make sense to everyone and that realign providers in ways that benefit the enterprise, while also providing for optimum patient care. down, and the case is made for a strong, continuing role for independent outpatient imaging providers. Consumer-driven choice, price transparency, and the generally negative effects of monopolies will drive business toward providers offering superior service, especially in those cases where it is obvious that the quality is comparable—and it is tough to argue that quality improves in acquisitions such as the one described earlier, when the physicians and protocols remain exactly the same. In California, arrangements such as these not only are having a negative impact on patients, but have also drawn the attention of the state’s attorney general, who is investigating whether affiliation agreements between physicians and hospitals violate antitrust regulations.

As a raving capitalist, I am all for deals that make sense to everyone and that realign providers in ways that benefit the

50 Radiology Business Journal | October/November 2012 | www.imagingbiz.com

enterprise, while also providing for optimum patient care. Virtually every radiology practice that I have visited over the years has, as one of its core values, a focus on doing what is right for the patient: patients first, superior quality, excellence in care delivery, and so forth.

We all have the right to maximize the wealth of our respective organizations, and in a free-market economy, the smart and hard-working among us will (and should) enjoy financial success. It is painfully obvious, though, that behindthe-scenes deals structured simply to get a short-term price increase—because the resulting monopoly can get away with it— are not in the best interest of the patient; will not succeed, in the long term; and are antithetical to the notions of competition and consumer choice.

This profession has been wonderful for all of us. It provides a great deal of professional satisfaction, its financial rewards are exemplary, and the contribution that medical imaging has made to humanity gives us all a sense of pride in the roles that we have played in these achievements. As a result of the trust and responsibilities that we have earned, it is important that we continue to be worthy stewards of these precious resources.

Monopoly might be a fun game, but in the real world, there is very little good that can be said about it. The national media and state regulators see through it, and they are shining daylight on deals that seem structured to control both Boardwalk and Park Place. Those who are currently benefiting from these arrangements had better enjoy them while they last.

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. Mathews AW. Same doctor visit, double the cost. Wall Street Journal. August 27, 2012:B1.

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