Radiology Business Journal December 2011 by imagingBiz

December 2011

Fourth Annual Ranking:

The 75 Largest Private Radiology Practices Ranked by Number of Radiologists and Including Number of Employees, Studies, and Imaging Centers

Featured in this issue How I Read It: Breast Tomosynthesis | page 16 Seeking Shangri-La: Alternate Models in Imaging Delivery | page 26 Meaningful Use of Health IT: Let the Attestation Begin | page 45

www.imagingBiz.com

December 2011

Fourth Annual Ranking:

The 75 Largest Private Radiology Practices Ranked by Number of Radiologists and Including Number of Employees, Studies, and Imaging Centers

www.imagingBiz.com

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CONTENTS

December 2011 | Volume 4, Number 6

Features

26 In Search of Shangri-La: Alternative Models of Imaging-service Delivery

By Julie Ritzer Ross As health care seeks to adapt to a new era of cost constraints and quality oversight, alternate forms of imaging delivery are beginning to develop.

The 75 Largest Private Radiology Practices

By Cheryl Proval Our fourth annual survey reveals that market conditions are taking a toll on growth, both in the median size of the largest practices and in the number of studies performed annually.

Radiology and Meaningful Use: Questions Loom As Attestation Begins

By Cat Vasko While some are taking a wait-and-see attitude, a few practices have begun the process of demonstrating meaningful use andâ&#x20AC;&#x201D;they hopeâ&#x20AC;&#x201D;collecting incentives.

52 Subspecialization and Teleradiology: An Uneasy Alliance

By Greg Thompson The specialty is moving toward subspecialization with an assist from teleradiology.

62 Revenue-cycle Management: Minimizing Denials and Maximizing Collections

4 Radiology Business Journal | December 2011 | www.imagingbiz.com

By Felix Okhiria, MPA, MA, CCPO, CMPE, CPC, CHC The shortest path to minimizing denials uses five basic steps to prevent them.

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CONTENTS

December 2011 | Volume 4, Number 6 Publisher Curtis Kauffman-Pickelle · ckp@imagingbiz.com

EDitor Cheryl Proval · cproval@imagingbiz.com

Departments

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

AdView

Technical Editor Kris Kyes

Radiology’s Nuclear Spring By Cheryl Proval

Associate Editor Cat Vasko · cvasko@imagingbiz.com

The Bottom Line

The Future of the Practice of Radiology

Priors 12 Leadership | Collaboration Trumps Control 14 Technology Acquisition | The Ultimate RSNA Wish List 16 In Practice | Breast Tomosynthesis: How I Read It

Online Editor Lena Kauffman · lkauffman@imagingbiz.com Online News Editor Julie Ritzer Ross · jritzerross@imagingbiz.com

By Richard Satre, MD

Contributing Writers Laurie L. Fajardo, MD, MBA; Thomas W. Greeson, JD; Vicky G. Gormanly, JD; Feilx Okhiria, MPA, MA, CCPO, CMPE, CPC, CHC; Jeong Mi Park, MD; Julie RItzer Ross; Richard Satre, MD; Greg Thompson; Limin Yang, MD, PhD

By Laurie L .Fajardo, MD, MBA; Limin Yang, MD, PhD; and Jeong Mi Park, MD

Regulatory Issues | Seeking Meaning in Meaningful Use

By Thomas W. Greeson, JD, and Vicky G. Gormanly, JD

Advertiser Index

Final Read

Production Coordinator Jean Lavich · jlavich@imagingbiz.com Special Projects Coordinator Emily Kawka · ekawka@imagingbiz.com Webmaster Robert Elmquist · relmquist@imagingbiz.com

Leadership As Performance Art By Curtis Kauffman-Pickelle

Sales & Marketing Director Sharon Fitzgerald · sfitzgerald@imagingbiz.com

Corporate Office imagingBiz 17291 Irvine Blvd., Suite 105 Tustin, CA 92780 (714) 832-6400 www.imagingbiz.com PResident/CEO · Curtis Kauffman-Pickelle VP, Publishing · Cheryl Proval VP, Administration · Mary Kauffman

Radiology Business Journal is published bimonthly by imagingBiz, 17291 Irvine Blvd., Suite 105, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. December 2011, Vol 4, No 6 © 2011 imagingBiz. All rights reserved. No part of this publication may be reproduced in any form without written permission from the publisher. POSTMASTER: Send address changes to imagingBiz, 17291 Irvine Blvd., Suite 105, Tustin, CA 92780. While the publishers have made every effort to ensure the accuracy of the materials presented in Radiology Business Journal, they are not responsible for the correctness of the information and/or opinions expressed.

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

6 Radiology Business Journal | December 2011 | www.imagingbiz.com

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Radiology’s Nuclear Spring While it’s too early to see green shoots, the field of radiology is well prepared for the journey ahead

ilting toward RSNA and entering the home stretch of 2011, I haven’t had a lot of time to reflect on the year, but I know that I am not alone. Everywhere I go, I hear a common chorus (no time!) followed by a plaintive refrain (at least I still have a job). When I walked into my primary-care practitioner’s office recently, even he repeated that refrain—evidence that the atmosphere of uncertainty and change has permeated all strata of US society, and, specifically, medicine. He said that unemployment and loss of benefits have taken a toll on his employed multispecialty practice, which is providing significantly more uncompensated care. The news of the past few months has done nothing to dispel this atmosphere of uncertainty, but I am seeing signs that radiology is stepping beyond its fear of both the known and the unknown. This is a very good development because, as we all know, fear paralyzes. The assault on the professional component induced a great amount of dread. After threatening a 50% discount on the professional component for procedures that fall under the Multiple Procedure Payment Reduction (MPPR), CMS settled on a 25% figure in the final Medicare Physician Fee Schedule, issued in early November. It doesn’t matter whether two different radiologists read the multiple procedures: In its final rule, CMS has expanded the MPPR to include multiple providers in the same group practice. A technique generously applied in the rehabilitation field, this cost-cutting measure is relatively new to physician reimbursement, although CMS has used it in the surgical realm. Applying the discount to multiple procedures performed for the same patient in the same practice seems to have been invented expressly for radiology. It’s impossible to cast this in a positive light, but perhaps it will have a positive

effect. To date, the profession has been somewhat divided on CMS reimbursement matters, with those who do not own imaging equipment remaining somewhat remote on the issue of cuts to the technical component. With this latest development, radiologists will feel the pain equally, and this could be a unifying moment for the profession.

Dose, e-Dose In 2009, excess-radiation events were reported by a highly respected Southern California hospital, setting in motion a great deal of uncomfortable media attention (as well as a redoubling of the effort begun by pediatric radiologists, physicists, vendors, and organized radiology to manage radiation dose). Achievements since then include the establishment of the ACR® national Dose Index Registry, the endorsement by the National Quality Forum of a dose-tracking quality measure (Participation in a Systemic Dose Index Registry), the adoption by many radiography vendors of an international standard that could eliminate technologist confusion in the DR/CR suite, and the widening of the Image Gently campaign to encompass other modalities that emit ionizing radiation. What has lagged behind is a sense of individual responsibility on the part of radiologists, but that appears to be changing, too. Interviewed at the ACR’s First Annual Imaging Informatics Summit and Dose Monitoring Forum (held in Washington, DC, on November 3–4), Richard Morin, PhD, Mayo Clinic (Jacksonville, Florida), acknowledged that the radiology community still has work to do before a dose report can be issued to patients (as California law mandates, effective July 1, 2012). Individual radiologists must begin by looking at their protocols. “How much radiation are they using, and if they are using more than their colleagues, why are they doing that?” Morin asks. Also interviewed in Washington was Marilyn Goske, MD, a pediatric radiologist at Cincinnati Children’s Hospital in Ohio. She believes that the department has an obligation to parents and patients to be

8 Radiology Business Journal | December 2011 | www.imagingbiz.com

as informative as possible, but allows that radiology must still find a way to communicate complex concepts more simply. “Patients have to be told clearly [what the risk is] when they come in; when they leave the department, they should know more about the test than when they arrived,” she says. “We have to get our house in order first.”

The Informatics Wrench If there is a task to be accomplished or a problem to be solved, radiologists are quick to reach for the informatics wrench, so it is somewhat ironic that practices are struggling with the decision of whether to attest to meaningful use of health IT (see articles beginning on pages 24, 45, and 49). The news from the Washington forum is that the ACR has successfully engaged with the Meaningful Use Workgroup and the Office of the National Coordinator on the need for specialty accommodations in subsequent stages of meaningful use. As one who has participated in that effort, Keith Dreyer, DO, PhD, vice chair of radiology computing and information sciences at Massachusetts General Hospital in Boston, says, “The meaningful-use pathway is really a health-care reform ascension path.” The path progresses from capturing and sharing data (in stage 1) to implementing decision support (in stage 2) to outcomes analysis (in stage 3). On the exhibit floor in Chicago, Illinois, look for signs of what many predict is an impending leap in innovation in informatics: dose-mitigation and dose-tracking solutions, meaningful-use attestation, practicemanagement tools, and decision-support advances. From the depths of the radiationdose crisis to the assault on the professional component, radiology is emerging stronger, more focused, more unified, and better equipped to communicate its value to medicine.

Cheryl Proval cproval@imagingbiz.com

The Bottom Line

The Future of the

Practice of Radiology

The president of one large Western practice predicts a vibrant future for practices that invest in their professional relationships

have great optimism for the survival of the practice of radiology. I believe that many groups will thrive, and that there is the opportunity for continued professional satisfaction. For many of us, however, success will need to be redefined. There are many changes occurring around us. In the region where I practice, the two largest hospital competitors have just merged. My group is one of six to serve this new regional system, and we will not know the impact of this for two to three years. Therefore, we not only are facing the reimbursement issues affecting the rest of the country, but the stability of our contracts is at issue. While we need to make every reasonable effort to maintain our income, I have accepted that it will decrease. The federal government is bankrupt, so Medicare cuts are inevitable. My state, like most, is running deficits, and Medicaid is being cut. At the same time that we are trying to maximize our payments from the private insurance companies, every business owner I have spoken to is trimming the offerings in employee health plans and increasing copayments for the recipients of care under those plans. We have several Fortune 500 manufacturing and software companies in our area—and they are all making similar decisions, so that bucket has a bottom as well. In addition to decreases in the revenue available to fund all of medicine, RVUs are being shifted from imaging services toward primary care. Many groups have responded to declining revenue by focusing on productivity. This has helped many groups blunt the impact of declining reimbursements. If we focus on productivity to the detriment of service or quality, however, it will hurt us. If we don’t answer phone calls from our referring providers and hospital administrators, sooner or later, the phone will stop ringing,

patients will stop being referred, and the contracts will run out or be terminated. Why, then, am I optimistic? I know that appropriate imaging adds value to the treatment of patients. I know that hospitals and referring physicians need our help to serve their patients, and most referring physicians and hospital administrators know that they need us. There can be a significant disconnect, however, between what they want from us (and consider their needs to be) and what we deliver to them—despite our best intentions.

The Problem and the Solution The problem is knowing what it is that they want from us. We need to be humble enough to ask those we interact with what they want—and not just in the context of what our groups can now offer. What would the ideal radiology group provide to them and to their patients? The answers we have heard include 24/7 neuroradiology coverage, a defined musculoskeletal pool with extended hours of coverage, timely reports (defined differently by each respondent), dedicated mammographers, 24/7 cardiac imaging, oncologic imagers, documentation of quality greater than RADPEER™ allows, utilization management, and even IT support. What you find when you ask might differ, but if you value your relationships with the hospitals that you serve, you need to ask the questions. As most business/marketing people will tell you, if you ask someone what he or she wants, you have to be prepared to act. I know that my radiology group cannot meet these stated service goals, and we will need to get significantly larger. If you are unwilling to ask a question because you are not ready to act on the answer, chances are that the national groups have already asked it—and if they haven’t, they soon will. In fact, this has happened to us. The primary reason that we have held off these

10 Radiology Business Journal | December 2011 | www.imagingbiz.com

By Richard Satre, MD

attempted incursions was our involvement in our medical communities. My group has made a concerted effort to have good relations with the hospitals that we serve. We sit on the medical executive committees of multiple hospitals; we serve on IT, credentialing, and quality committees; and the current presidents elect of the medical staff of two of our hospitals are members or our group. Because of our contributions to, and relationships with, the hospitals that we serve, we are informed when there is a threat to our service sites by other groups (such threats have come from both regional and national groups). Having strong relationships at multiple levels in the hospitals that we serve is no longer optional. Sitting on the sidelines is no longer possible; we must become indispensable. If we define success as maintaining the income levels that we currently enjoy, with a 5% to 10% increase every year, we are going to be very frustrated. I choose to define success as having strong, stable relationships with our hospitals and referring providers, along with the opportunity to have a meaningful impact on the patients we are fortunate to serve. I know we can achieve this. What will be required for success? Have strong political ties with your hospitals, ask your hospitals and referring providers what they want from you, and be prepared to meet their requests for expanded services. Become an active partner in helping them plan for (and negotiate) the coming changes. Pay attention to optimizing efficiencies and productivity, but do not lose sight of the need to serve on hospital committees, to present at hospital conferences, and to find reasons to talk to referrers and patients. Richard Satre, MD, is president of Radia, an 80-physician radiology and vascular-surgery practice based in Everett, Washington.

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{priors} leadership

Collaboration Trumps Control

op-down, authoritarian leadership in health care’s new era of collaboration is likely to find its currency on the decline. Particularly in a wired specialty such as radiology, leaders will be challenged to engage an increasingly distributed workforce in the broader team approach called for by new delivery models in health care. Writing in a recent issue of Harvard Business Review, Ibarra and Hansen1 offer the example of Marc Benioff, CEO of Salesforce.com (San Francisco, California), whose company had invested resources in a social-media–inspired application called Chatter to share information internally. In watching the exchange, Benioff realized that many of the people with critical customer knowledge (and, therefore, high value) were unknown to management. Conversely, the rank and file had limited insight into the activities of top management. What was the solution? Benioff blew the doors off of the next executive retreat by inviting all 5,000 employees to join the retreat—virtually. With massive video

monitors set up around the room to display the Chatter forum, tables equipped with mobile devices, and a video broadcast of the event, employees (and management) could instantly express their views on Chatter. The dialogue continued for weeks after the meeting ended. “More important,” the authors write, “by fostering a discussion across the entire organization, Benioff has been able to better align [sic] the whole workforce around its mission. The event served as a catalyst for the creation of a more open and empowered culture.” The authors note that businesspeople today are working more collaboratively than ever before—and not just with each other, but with suppliers, customers, governments, universities, and (within health care) payors. Leaders who rose using what the authors call command-and-control style can have a difficult time adapting to collaborative leadership, while managers intent on leading by consensus risk watching decision making grind to a halt. The authors, who have researched topperforming leaders worldwide, report that being a collaborative leader requires skills in four key areas. They also maintain that these skills can be learned. Four Key Skill Sets First, leaders need to be global connectors, a term that the authors borrow from Malcolm Gladwell’s The Tipping Point (Little, Brown and Company, 2000). Connectors are people who have ties to a variety of social and work worlds. Connector tactics used by David Kenny, president of Akamai Technologies (Cambridge, Massachusetts), include checking in on foursquare.com, a socialnetworking site where members can inform others of their locations; having lunch or coffee with 20 to 40 people wherever he goes; and making a point

12 Radiology Business Journal | December 2011 | www.imagingbiz.com

of seeing two to three people he knows in every location that he visits, usually with another Akamai Technologies employee in tow. Connecting with people from adjacent industries, hot spots of innovation, and other cultures and ethnic groups is another key tactic to further the connector activities of collaborative leaders. Second, the authors emphasize, if well led, diverse teams produce superior results. It is therefore advisable to build teams from people of different backgrounds, disciplines, cultures, and generations, and to leverage those differences (rather than doing what many companies do, which is to spend a lot of energy trying to make everyone the same). Nonnative English speakers, in fact, are passed over for promotions at many multinational companies. The French food company Danone (Paris) takes the opposite approach: It encourages employees to make presentations in their native tongues and spends heavily on translators to support them. Danone, therefore, excels at attracting top talent from competitors that are not as appreciative of diversity. In addition to cultural diversity, teams benefit from having people who are both experienced and new to their jobs, as well as members of different generations. The authors caution readers that the former executive team of one-time mobile leader Nokia (Espoo, Finland) was 100% Finnish. Monkey See Third, collaborative leaders must lead by example and model collaboration themselves. This is not as easy as it sounds, since most companies—and health-care systems—are operated by a leadership team that includes the CEO and a small team of directly reporting executives with their own fiefdoms,

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with neither the responsibility nor the incentive to collaborate, as a whole, on organizational goals. That is not the case at Brazil’s Natura Cosméticos (Cajamar), where competing executive agendas threatened to derail the company after a successful IPO in 2004. CEO Alessandro Carlucci asked members of the top team to embark on self-development journeys as part of their stewardship of the company. Aided by an outside coach who met with each person individually, as well as within the team, these executives explored their relationships with the company, their families, and themselves, resulting in a management that became better at team activity. The collaborative mindset filtered down into the organization, which repeated the exercise at the managers’ level, and the company grew 21% in 2010. While one executive believed that revealing their vulnerabilities to

themselves and to one another was the key to the experience, psychologist Carol Dweck attributes improvements in the ability to collaborate to a shift from using short-term performance indicators to setting longer-term learning goals. Vineet Nayar, CEO of HCL (Noida, India), demonstrated his commitment to collaboration by inviting a broad range of people (not just those who reported to them) to participate in 360° multisource evaluations for his managers, and he got the ball rolling by posting his own 360° evaluation on the Web. Fourth, collaborative leaders need to resist overdoing collaboration. You can’t collaborate on everything; instead, collaboration needs to be the oil that greases the wheel of innovation, rather than the sand grinding it to a halt, the authors write. Collaborative leaders need to develop the skills that will harness the power of all of their human resources by using their

influence, rather than their authority, to initiate collaboration. They also need to be ready to shut down unproductive discussions and politicking and to make final decisions. “Effective collaborative leaders assume a strong role directing teams,” the authors write. “They maintain agility by forming and disbanding them as opportunities come and go—in much the same way that Hollywood producers, directors, actors, writers, and technicians establish teams for the life of movie projects. Collaborative efforts are highly fluid and not confined to company silos.” Likewise, in radiology, collaborative efforts must not be confined to the department, the practice, or the institution. —Cheryl Proval Reference 1. Ibarra H, Hansen MT. Are you a collaborative leader? Harv Bus Rev. 2011;89(7-8):69-74.

tech nology acqu isition

The Ultimate RSNA Wish List

he annual meeting of the RSNA, already one of the largest medical conferences in the world, stands to reach new proportions this year. Total registrations for the 2011 meeting in Chicago, Illinois, which starts November 27, are up 7% over 2010’s total. The massive 459,000–square-foot convention space at McCormick Place expects to host 671 exhibits and close to 60,000 attendees. More than 1,800 scientific papers will be presented (along with 233 refresher courses) during the six-day event, making the 2011 RSNA meeting the premier conference worldwide in the field of medical imaging. Along with highlighting specific advances in 16 subspecialties, several common themes make the RSNA a unique place for receiving the latest cutting-edge research across the field. The association received more than 12,474 abstracts and chose to accept 3,014 of them for formal and informal presentation. Many of the papers and educational sessions touch on radiationdose reduction—a hot topic, this year, in

By david rosenfeld

the popular press (and a subject of deep concern among radiologists). Radiologists and radiology executives in a variety of practice settings also have several other challenges on their minds, heading into this year’s conference. New ways to reduce exposure levels (while still getting highquality images) are likely to receive considerable attention on the Fergus Coakley, MD exhibit floor, according to Fergus Coakley, MD, vice chair of clinical services and chief of the abdominal-imaging section at UCSF Medical Center in San Francisco, California. He says that he will be looking for new innovations that vendors might provide to lower the risk to patients. “I know vendors are working on newer algorithms to get the same quality image with a lower dose,” Coakley says. “I’ll certainly be interested in seeing what’s available.”

14 Radiology Business Journal | December 2011 | www.imagingbiz.com

Another hot topic for Coakley, this year, is MRI-focused high-intensity ultrasound, along with the promise that it might hold for prostate cancer, chronic lower-back pain, and essential tremor. “People are starting to push the envelope, and we’re seeing some new applications,” he says. This Year’s Buyers If the size of the conference reflects the ever-growing field of radiology, the RSNA meeting this year also demonstrates the changing landscape of buying decisions. With more freestanding imaging centers falling under hospital ownership, department heads such as Stephen George, MD, chair of the radiology department at North Suburban Medical Center in Thornton, Colorado, have different roles to play. “There was a time where people in my position went to RSNA to look for equipment they might be interested in purchasing,” George says. “Now, with most of the big hospital systems, many of those decisions are made at a different level.”

George also is president of Diversified Radiology of Colorado in Lakewood, a 60-member radiology group serving 10 hospitals in and around Denver; he says that he attends the RSNA conference mainly for the educational benefits and to keep up with federal policy developments. As Congress debates another Medicare budget, radiology could, once again, end up on the chopping block. “The biggest thing we’re concerned about is the formula for the Stephen George, MD sustainable growth rate (SGR)—whether they are going to come up with a permanent fix for that, instead of dealing with it every year,” George says. The final Medicare Physician Fee Schedule, issued November 1, included an across-the-board 27.4% physician pay cut to satisfy the SGR. Continuum Health Partners, New York, New York, is a nonprofit system that includes St Luke’s Hospital, Roosevelt Hospital, Beth Israel Medical Center, New York Eye & Ear Infirmary, and outpatient centers. Marc Katz, corporate director of radiology for the system, says that he might be seeking new CT, MRI, and DR equipment, but with decreased reimbursements, any purchasing decision would be made cautiously. “There’s always a value in being ahead of the curve, but that comes with a double-edged sword, in terms of shrinking assets,” Katz says. Katz adds that he’s looking forward to seeing the latest developments in high-tech equipment and advances in radiation-dose reduction, as are many others at this year’s conference. “It’s on everyone’s radar,” Katz says. “You need the right technology that provides the lowest dose possible. I think we’re going to hear a lot about that not only in the papers and the presentations, but certainly with the equipment manufacturers as well.” Multitasking Technology Luann Culbreth, CRA, executive director of cardiology, medical imaging, and radiation oncology for Saint Thomas Health in Nashville, Tennessee, also is looking for

technology that serves multiple purposes to replace outdated equipment. “A lot of people are trying to reduce expenses because Luann Culbreth, CRA revenue doesn’t flow in like it used to,” Culbreth says. “I’ll be looking for technology that helps the hospital work more efficiently.” At one of the medical system’s five hospitals, separate imaging machines serve cardiology, neurosurgery, radiology, and vascular surgery, but they perform largely the same tasks, she says. “As we look at replacing equipment, we want to make sure it’s no longer a piece of equipment that only serves that one area,” Culbreth says. “I’m hoping to see from some vendors that they’ll have the perceived solution for multidisciplinary, integrated delivery systems, so it’s a complement to all of those specialties and not a capital drain because you have to have the same thing in four different places.” Performance-enhancing IT For Worth Saunders, MHA, CEO of Greensboro Radiology in North Carolina, the 2011 RSNA conference is all about IT. “Our focus will be on IT integration products and Worth Saunders, MHA ways to improve performance, but we’re really not purchasing any big medical equipment,” Saunders says. High on his list of priorities are products that can help the group’s 45 radiologists (at 11 hospitals and 25 outpatient sites) meet meaningful-use criteria for electronic health records—and qualify for the associated incentive payments. Finding ways to improve distributed reading (with software that promotes better interpretation) should be another hot topic in informatics. Saunders says that he attends the conference for its networking opportunities, as much as anything else. “It’s a great place to meet with vendors—and, possibly, partner to improve products,” he says.

In radiology’s answer to the quest for the Holy Grail, Gary Wendt, MD, MBA, neuroradiologist and enterprise director of medical imaging for the University of Wisconsin Hospital and Clinics (UWHC) in Madison, hopes to further the institution’s pursuit of a single work environment for the practice’s approximately 100 radiologists who cover multiple disparate sites throughout the region. “The big thing we want to do here is try to pursue a unified place environment, so that we don’t have to be going one place to collect images, one place to process images, one Gary Wendt, place to report, and MD, MBA one place to look at patient data,” Wendt offers. “We want to create a unified work environment so that no matter where our radiologists are in our work system, they have a single workflow.” From the neuroradiology perspective, Wendt will be looking at advanced postprocessing functionality available on systems that can be tightly integrated with PACS. On the enterprise imaging side, Wendt will focus on what PACS and RIS vendors are doing to help radiologists meet meaningful-use requirements, as well as decision-support software. UWHC is one of five participants in the CMS Decision Support Demonstration Project, and Wendt is interested in hearing what colleagues and vendors are doing to promote decision support in imaging. “The other big focus will be qualityassurance and quality-improvement tools—things like dose monitoring and peer review; tools to make our jobs more efficient and improve patient care,” he adds. A Paradigm Shift Seeing the latest advances in PET/MRI will be a highlight for George Segall, MD, president of the Society of Nuclear Medicine and chief of the nuclearmedicine service at the VA Palo Alto Health Care System in California. “Here we are in 2011, one decade past the introduction of the first PET/CT system in the United States,” Segall says. “A

www.imagingbiz.com | December 2011 | Radiology Business Journal 15

priors

decade later, we are faced with a whole new imaging technology, which poses lots of questions. PET/MRI is a really interesting technology that has engaged the imagination of many people.” While everyone wants to jump on board, however, fewer are prepared to buy their first systems. “They are extremely expensive,” Segall says. “There’s a huge

investment, and the stakes are quite high for everybody—for the companies that develop them, for the health-care systems and universities that might buy them, and for the patients who might benefit from them. It’s unclear whether this will be successful or not.” Bifunctional chelating agents that combine a photon signal picked up by

nuclear-medicine equipment with a magnetic signal that can be detected using MRI are another advance that Segall will be seeking. “These are exciting because they expand the capability of our existing systems in new ways,” he says. David Rosenfeld is a contributing writer for Radiology Business Journal.

in practice

Breast Tomosynthesis:

How I Read It By Laurie L. Fajardo, MD, MBA; Limin Yang, MD, PhD; and Jeong Mi Park, MD

ow that digital breast tomosynthesis (DBT) has gained FDA approval, many breastimaging providers find themselves excited about the new technology, but facing uncertainty about reimbursement, implementation, and interpretation workflow. There remain a number of questions related to the display of (and approach to interpreting) DBT that need to be addressed if DBT is to be incorporated optimally into routine practice. As they were for digital mammography (DM) in the recent past, the acquisition and dissemination of DBT technology will be marked by early and late adopters. Early adopters will be willing to work with uncertainty and develop the nuances of implementation and interpretation in their own unique environments; later adopters will pattern their practices on the reported experience of others. Clearly, those who determine how to interpret DBT exams best (and most efficiently) will influence its acceptance and clinical implementation. The mechanism of DBT image acquisition has been well described.1,2 Though standards from the industry and the Mammography Quality Standards Act (MQSA) do not yet exist for all aspects of this technology, practitioners are rapidly becoming knowledgeable and gaining experience in the nuances of best displaying and reviewing 3D DBT image datasets. In general, DBT is displayed as 1-mm image slices that are reviewed using cine or manual scroll modes on dedicated

soft-copy workstations. The first DBT image slice begins at the detector, for craniocaudal (CC) and mediolateral oblique (MLO) DBT projections. At the compression-plate aspect of the image set, five additional slices are included to ensure that all tissue is displayed. Thus, one can estimate breastcompression thickness from the number of 1-mm BDT slices in the dataset by subtracting 5 mm from the total number of slices. Having location information readily available from DBT image slices makes evaluating masses, calcifications, or other findings related to the skin very straightforward on any routine screening exam, without the necessity for additional views to clarify that a mammographic finding is dermal in origin. Currently, there are a few artifacts related to image reconstruction that radiologists need to understand and adapt to when interpreting DBT studies. Coarse calcifications (macrocalcifications), metallic (BB or scar) markers, postbiopsy clips, and other high-density objects within or applied to the breast create a coil-spring or slinky artifact (Figure 1, page 21). While these are initially distracting, many radiologists find that they are quickly able to read through these artifacts. In the future, advanced reconstruction software might reduce or eliminate these artifacts, and many DBT users agree that the benefits of the technology outweigh its current limitations. Another concept to recognize is that, unlike 3D

16 Radiology Business Journal | December 2011 | www.imagingbiz.com

datasets acquired by breast-MRI volume acquisition techniques, the CC-DBT and MLO-DBT datasets cannot be crossreferenced with display software as, for example, a sagittal and axial breastMRI imaging sequence. DBT CC and MLO projection data are acquired with nonisotropic voxels and with two separate breast positionings, rendering impossible the cross-referencing easily performed with breast MRI 3D datasets. Currently, both a 2D standard DM image and a 3D DBT dataset are acquired with a single positioning and a single exposure for each of the standard screening views. This is commonly referred to as 2D/3D combo imaging and is performed with a total dose that is less than the maximum permitted by MQSA requirements. Many radiologists learning to interpret DBT find that having the standard 2D to correlate with the 3D DBT images is of value in gaining confidence and reducing the learning curve. In addition, studies3,4 have shown, based on screening ACR BIRADS® ratings, that the combined use of DM and DBT was superior to DM alone in terms of significantly reducing recall rates for further diagnostic work-ups. In the future, one of two scenarios might emerge. In the first, after a period of time when patients have undergone more than one DBT study, radiologists might be comfortable viewing only DBT images. In the second, the standard 2D DM images will be replaced by synthesized 2D

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Imaging Market File

The Radiology Staffing Market, Temporary and Permanent Introduction: As pressures on reimbursement and utilization continue to have an impact on the imaging marketplace, radiology-staffing data suggest a shift in the availability and use of professional services over the past decade. This installment of the Imaging Market

File tracks current and recent developments in the supply of radiologists, the demand for their temporary (locum tenens) and permanent services, and related staffing trends, based on data collected by AMN Healthcare (San Diego, California) and Staff Care (Irving, Texas).

The active candidate pool in diagnostic radiology: While the physicians in the pool number 26,027, 88% of whom are board certified (Figure 1), almost 75% of those in the current pool are older than 45, and nearly 20% are older then 65 (Figure 2).

Total diagnostic radiologists International medical graduates

26,027 3,721 (14%) 23,015 (88%)

Board-certified radiologists Last-year residents

Age group: < 36 Total: 1,331 Percentage: (5%)

1,011 (4%)

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Figure 1. The total active-candidate pool available to organizations seeking diagnostic radiologists, based on numbers tracked by the AMA Physician Masterfile, is 26,027.

The pipeline: The number of radiology residents in 2011 far exceeds the number in 1999, indicating that medical-school graduates continue to be attracted to the specialty (in contrast with areas such as primary care, where the number of US medical graduates has generally declined). The number of medical-school graduates selecting radiology residency programs decreased in the late 1990s (Figure 3), when it was widely predicted that managed care would decrease utilization of radiology services—and, by extension, would reduce practice opportunities and income for radiologists. Ongoing radiology reimbursement cuts and the introduction of new delivery models (such as accountable care) could similarly reduce the number of medical-school graduates selecting radiology in the future. It should be noted, however, that the 2001 requirement of a fifth-year clinical rotation in radiology has not reduced the overall number of radiology residents and that the specialty remains attractive.

36–45 46–55 56–65 > 65 5,507 7,365 7,173 4,640 (21%) (28%) (27%) (19%)

Figure 2. Active radiologists include only diagnostic radiologists active in patient care; almost half (46%) of radiologists are older than 55 and might be at or near retirement age.

4,909 4,236 3,687

1994

1999

2011

Figure 3. The number of radiology residents has fluctuated over the years. December 2011

Imaging Market File

Demand: Recent demand for diagnostic radiologists is reflected in the number of radiology searches conducted by national physician-search company Merritt Hawkins (Irving, Texas), particularly when viewed as a percentage of total physician searches conducted in the same years (Figure 4). Merritt Hawkins reports that in the years 2000, 2001, and 2002, diagnostic radiology was the most requested physician search. In 2010, in contrast, radiology was the 17th most requested search. Merritt Hawkins attributes the decline in demand for radiologists to the economic downturn, which has decreased the use of elective and other procedures; to the continuing reduction in reimbursement for radiology services; and to a robust supply of newly trained residents entering the field. Though demand for radiologists has slackened in recent years, starting salaries have generally held steady (Table 1). The most recent (2010) salary numbers from Merritt Hawkins for radiologists, however, suggest that salaries might be on a downward trend. General physician demand: While the current supply of radiologists appears to be adequate for demand, the growth in the use of temporary physicians is evidence of the ongoing physician shortage, which has obliged hospitals, medical groups, and other facilities to use locum tenentes to maintain services and revenue while seeking physicians to fill permanent positions. Numbers from Staff Care1 (Figures 5 and 6) suggest that the use of locum tenens physicians remains common in health-care facilities. Table 2 compares costs per day for permanent and temporary radiologists. References 1. Staff Care. 2011 survey of temporary physician staffing trends based on 2010 data. http://www.staffcare.com/ pdf/2011_survey_of_temporary_physician_staffing_ trends.pdf. Published 2011. Accessed November 10, 2011. 2. Medical Group Management Association. Highlights of MGMA’s 2011 physician compensation survey. http:// blog.mgma.com/blog/bid/67161/Highlights-of-MGMAs -2011-Physician-Compensation-survey. Published July 19, 2011. Accessed November 10, 2011.

2004

2007

2010

2,525 total MD searches 202 radiologist searches (8%) 3,116 total MD searches 87 radiologist searches (6%) 3,150 total MD searches 63 radiologist searches (2%)

Figure 4. The number of diagnostic-radiologist searches, by year, as a percentage of total physician searches conducted by Merritt Hawkins.

Table 1. Starting Salaries for Radiologists, According to Merritt Hawkins

Year 2010 2009 2008 2007 2006

2010 2009 2007 2005

Low $225,000 $225,000 $300,000 $230,000 $250,000

85% 72% 77% 79%

Figure 5. Percentage of health-care facilities surveyed that had used locum tenens physicians in the previous 12 months.

2010 2007 2004

Average $402,000 $417,000 $391,000 $401,000 $380,000

High $450,000 $650,000 $500,000 $750,000 $500,000

7% 12,728 days (of 181,834) 12% 26,349 days (of 219,576) 15% 34,729 days (of 231,527)

Figure 6. Radiologists’ temporary staffing assignments (as a percentage of total staffing assignments).1

Summary: Though the numbers cited Table 2. Cost of Permanent and Temporary above indicate that demand for radiologists Diagnostic Radiologists has declined in recent years, long-term PERMANENT STAFF trends point to a gradual (but steady) 2 $463,226 revival in demand for radiology services. Median income $73,342 Radiology is an aging specialty, and it can be Benefits anticipated that the supply of radiologists Malpractice coverage $19,300 will be significantly reduced in the next five Daily cost (250 days/year) $2,224 to 10 years due to retirement and attrition. LOCUM TENENS (including travel, housing, Supply might be further constrained, and malpractice coverage)1 should medical graduates be dissuaded from Daily cost $2,150 selecting the specialty due to reimbursement cuts. Demand, by contrast, will be driven upward by an aging population, as it has been demonstrated that imaging use greatly increases after age 65.

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images, created from the DBT dataset— which would reduce radiation dose. A Dynamic Study In general, the interpretation of a 2D/3D combo screening study begins with a review of the 2D images. After reviewing the four standard 2D DM images and comparing them with any prior studies, the radiologist reviews the individual DBT image sets in conjunction with the corresponding 2D DM projection (using two monitors). This permits careful correlation of 2D image findings with the DBT image slices. There will, undoubtedly, be differing opinions on how best to view a 3D DBT image set, but the overarching goal is to evaluate all images thoroughly and completely. DBT is a dynamic study; as one scrolls through the DBT slices, both images and the reviewer’s eyes are moving. For radiologists who do not spend a majority of their time viewing 3D image datasets, it is important to develop techniques to ensure viewing all aspects of the image data. Initially, it is useful to approach the DBT study as if the 2D DM exam were negative. Choose specific subsections (retroareolar, medial, lateral, superior, or inferior) of the image dataset on which to focus for each CC or MLO DBT, and manually scroll forward and backward through the image stack until you feel confident that you have looked at all areas of the exam. Then, refocus on any specific findings noted on the 2D DM and search for a similar finding on the DBT. It is especially useful to have the 2D exam for detecting and rendering initial evaluations of microcalcifications. After viewing each DBT projection alongside the corresponding 2D DM image, it will be necessary (in the future) to compare last year’s DBT with the current DBT. Here, it will be quite helpful to have display software that intelligently considers compressionthickness differences, that links the prior and current DBT image datasets, and that enables the radiologist to scroll fluidly through both datasets simultaneously to review and analyze the images. When the 2D DM and 3D DBT images are reviewed side by side, the DBT often resolves 2D DM findings that would result in recalling the patient if DBT were not immediately available. A common example is a summation artifact or pseudomass.

Figure 1. Cropped craniocaudal (left) and mediolateral oblique digital breast tomosynthesis image slices demonstrate the typical coiled-spring or slinky reconstruction artifact created by breast calcifications.

Scrolling through the DBT image stack and focusing on the location where the finding was noted on the 2D exam will show normal tissue or a series of normal anatomic structures (Cooper’s ligaments, vessels, and parenchyma) that sum to create the spurious 2D finding. If a 2D finding is a real mass, it generally appears more conspicuous on the DBT because the underlying and overlying structures are eliminated on DBT image slices. Value Proposition and Pitfalls The value of resolving or reducing summation artifacts using DBT is a reduction in recall rate, with improved screening specificity. The reduction of summation of tissue on DBT means, however, that there is the potential to see benign masses not visible previously in the breast parenchyma on prior DM exams. This phenomenon is similar to the early DM experience, when microcalcifications not previously depicted on screenfilm mammography were seen on DM, resulting in a transient increase in the recall rate for magnification views. In evaluating DBT-only (probably benign) masses, there is a need to balance the ordering of additional mammographic views or ultrasound with creating more follow-up DBT cases and/or increasing recall or work-up rates. Detecting microcalcifications on DBT can be challenging because individual calcifications in a cluster might be located on different DBT slices, creating a perceptual challenge. The radiologist might not appreciate the clustering of the calcifications because, as he or she scrolls through the DBT images, one calcification might appear and then disappear, while others become apparent in the next slice,

but are not present on the subsequent slice. The calcifications might be quite conspicuous, but the radiologist doesn’t appreciate the clustered distribution. Having the 2D mammogram performed with the 2D/3D combo imaging set enhances detection. In addition, several 1-mm DBT image slices can be grouped into a slab of any thickness to promote better appreciation of the size and extent of a calcification cluster. Although increasing slice thickness will increase the ability to perceive the 3D configuration of a cluster of calcifications, the spatial resolution of each individual calcification is compromised by slabbing. While DBT often negates the need for additional mammography views to evaluate summation artifacts, masses, and architectural distortions, it generally does not negate the need for microfocus magnification views to evaluate the morphology of microcalcifications. In the future, DBT will be augmented by computer-aided detection to identify high-frequency image information present on DBT image slices indicating microcalcifications; it will aid in the perception, classification, and characterization of calcifications on DBT. Computer-aided detection software for DBT is currently being evaluated and tested in Europe. DBT enhances the detection and conspicuity of breast masses and architectural distortions (Figures 2 and 3). In many cases, DBT images alone are sufficient to make a BI-RADS assessment of these findings, without additional spot-compression mammography. In reviewing masses and distortions on DBT, radiologists should be aware of certain precautions to be taken to prevent

www.imagingbiz.com | December 2011 | Radiology Business Journal 21

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Figure 2. Cropped 2D digital mammography image (left) and 3D digital breast tomosynthesis image slice of a 9-mm spiculated breast carcinoma; on the left, the mass is obscured by overlying breast tissue, but it is depicted well on the right.

undercalls and overcalls. It is important to evaluate mass borders based on information gleaned from all DBT slices encompassing the mass. Because overlying parenchyma is eliminated in DBT image slices, a mass with a border that is not well visualized on the 2D DM might be well visualized on DBT; however, one should avoid assessing mass margins on the basis of a few DBT slices. It is important to assess mass shape and borders based on all DBT slices containing the mass—to avoid designating the mass as circumscribed, while overlooking spiculations or lobulations. If there are lobulated borders, consider a BI-RADS 4a designation (so that a circumscribed-but-lobulated malignant mass is not undercalled). Similarly, architectural distortions often appear more prominent and easily detected on DBT. When one is first reading DBT images, however, normal structures (such as Cooper’s ligaments) might simulate a distortion or spiculation on a single DBT slice. Therefore, it is advisable not to dwell on a 1-mm slice that appears to have a distortion. Rather, evaluate the finding in conjunction with several slices above and below it before determining that additional work-up is indicated. Experts recommend scrolling at a uniform rate through at least 10 DBT slices (to evaluate a potential area of architectural distortion fully) before designating the finding as actionable and making it a callback case. With practice, one can avoid overcalling distortions. In your initial experience with DBT, it is useful to pay close attention to the borderline findings that you recall for additional work-up so that you can knowledgeably adjust your interpretation threshold over time.

Figure 3. Cropped 2D digital mammography image (left) and 3D digital breast tomosynthesis image slice of a 7-mm spiculated breast carcinoma; on the left, the mass is obscured by overlying breast tissue, but it is depicted well on the right.

Another pitfall to be aware of is that malignant masses sometimes demonstrate areas of lucency of fat within them on DBT. This should not dissuade one from calling for additional work-up if the mass is lobulated or irregular. Only encapsulated fat-containing masses, indicative of lipoma or hamartoma, should be considered benign (BI-RADS 2). As with breast MRI, there will be a subgroup of suspicious masses or architectural distortions identified on DBT that cannot be found on diagnostic mammography, ultrasound, or even MRI. For these lesions, a DBT-guided needle localization can be performed in a manner similar to that used for conventional DM localization. After acquiring a 2D/3D combo image (and without releasing compression), scroll through the 1-mm image stack to locate the lesion and then insert the localization needle. Next, obtain an orthogonal 2D/3D combo image, which will have a needle artifact on each slice. In the slice best depicting the lesion, the relationship of the needle tip to the lesion will be seen, and the needle depth can be adjusted accordingly. A single DBT slice from each projection can be printed for the operating surgeon. Although there are different ways to implement and use DBT in a breastimaging practice, DBT is likely to be most valuable for screening mammography, where its ability to depict small cancers will enhance screening sensitivity, while the potential to reduce recalls will improve specificity. The addition of DBT images to a screening or diagnostic evaluation does increase interpretation time and, like any new technology, there is a learning curve—but it is a relatively rapid one.

22 Radiology Business Journal | December 2011 | www.imagingbiz.com

Because DBT and DM images are acquired similar ways, radiologists are immediately familiar with structures and parenchymal patterns. The primary difference is that the structures and patterns are visualized with greater clarity on DBT because superimposed or obscuring structures are eliminated. Thus, with training and experience, radiologists quickly gain comfort and efficiency with this new breast-cancer– detection technology. Laurie L. Fajardo, MD, MBA, is chair of the department of radiology at the University of Iowa Hospitals and Clinics in Iowa City. Limin Yang, MD, PhD, is clinical assistant professor at the University of Iowa Carver College of Medicine. Jeong Mi Park, MD, is clinical professor at the college.

References 1. Park JM, Franken EA, Garg M, Fajardo LL, Niklason LT. Breast tomosynthesis: present considerations and future applications. Radiographics. 2007;27: S231-S240. 2. Smith A. Full-field breast tomosynthesis. Radiol Manage. 2005;27(5):25-31. 3. Gur D, Abrams GS, Chough DM, et al. Digital breast tomosynthesis: observer performance study. AJR Am J Roentgenol. 2009;193:586-591. 4. Gur D, Bandos AI, Rockette HE, et al. Localized detection and classification of abnormalities on FFDM and tomosynthesis examinations rated under FROC paradigm. AJR Am J Roentgenol. 2011;196:737-741.

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Seeking Meaning in Meaningful Use

By Thomas W. Greeson, JD, and Vicky G. Gormanly, JD

he Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs provide for incentive payments to eligible professional who are meaningful users of certified EHR technology—and future downward adjustments for eligible professionals who fail to demonstrate meaningful use. The Medicare version of the program is generally applicable to primary-care physicians, causing some confusion among specialists (such as radiologists). Initially, confusion existed as to whether diagnostic radiologists even qualified as eligible professionals (generally, physicians who are not hospital based). Hospital-based practice was subsequently defined to specify that 90% or more of the physician’s services are furnished in a hospital inpatient or emergencydepartment setting. Although radiologists typically provide imaging services for both inpatients and outpatients, the overwhelming majority do not come close to providing 90% of their services in inpatient or emergency-department settings. Many radiologists, therefore, qualify as eligible professionals. Another challenge facing radiologists is that of convincing hospitals that no EHR ownership or investment is required. Some hospitals have suggested that because they (not radiologists) have made the investment in the certified EHR, the radiologists may not use their systems to demonstrate meaningful use and obtain incentive payments. At first blush, this position seems to make sense. After all, isn’t the incentive payment designed to promote investment in certified EHRs? The underlying reason for investment in EHRs is so that they can be used, ultimately resulting in substantially improved care. In a National Provider Call (transcribed at www.cms.gov/ehrincentiveprograms/65_ CMS_EHR_Listserv.asp) on September 9, 2011, CMS confirmed that there is no purchase requirement. CMS noted that many eligible professionals demonstrate meaningful use of the certified EHRs of

their employers (or through user licenses or other agreements). CMS acknowledged the special challenges facing radiologists and anesthesiologists, noting that as long as the physician is not hospital based (as defined in the rule), he or she may demonstrate meaningful use of a hospital’s ambulatory (but not inpatient) EHR. CMS expects to address some of these special challenges in the stage 2 rule; the proposed rule should be published in February 2012. Chasing the Wind Clearly, diagnostic radiologists who are not hospital based are eligible professionals and need not purchase or invest in certified EHRs. How can such radiologists actually demonstrate meaningful use? Not only is this the most daunting challenge, but the failure to clear this hurdle could cause eligible professionals to be penalized by Medicare payment reductions. Unfortunately for radiologists, many of the measures associated with demonstrating meaningful use are more applicable to primary-care physicians; some of the measures are meaningless to specialists. Although exclusions are available for some of the measures, it is unclear whether radiologists will be able to demonstrate meaningful use. Further, it appears that certified EHR technology must still possess the ability to meet these meaningless meaningfuluse measures. In many instances, radiologists practicing in hospital settings are given access only to inpatient EHR technology, which generally has the functionality necessary for radiologists’ purposes. Eligible professionals, however, must use ambulatory EHR technology in order to demonstrate meaningful use. This appears to be because eligible hospitals’ incentive payments are based on total inpatient services (which is why hospital-based physicians are ineligible to participate in the incentive program). It would constitute double payment

24 Radiology Business Journal | December 2011 | www.imagingbiz.com

if both hospitals and hospital-based physicians were paid incentives for use of the same EHR. Therefore, using inpatient technology does not appear to be an option for eligible professionals; they must demonstrate meaningful use of ambulatory EHR technology. Even if a given hospital possesses a certified ambulatory EHR, that EHR may not provide the functionality necessary and pertinent to the practice of radiology. A hospital might see little (if any) incentive to finance an overhaul of its ambulatory EHR in order to provide radiologists with the opportunity to demonstrate meaningful use. To Use or Not To Use Our experience has been that many hospitals might be unwilling to offer radiologists access to the ambulatory EHR. There appear to be some hospitals willing to modify their ambulatory EHRs to allow radiologists access, but we anticipate that those hospitals might also expect shared investment in such an overhaul. Whether a specialty practitioner ultimately participates in the incentive program might come down to simple arithmetic. Eligible professionals who find the investment prohibitive might simply take the hit. After all, the program is voluntary. The maximum possible incentive payment for which an eligible professional can qualify is, over a five-year period, $44,000. Downward payment adjustments begin in 2015 and continue indefinitely. Certain aspects of the program have yet to be implemented by regulation. Diagnostic radiologists and other physician specialists would be prudent to keep abreast of issues relating to the program, and they should consider helping to shape policy by participating in the rulemaking process. Thomas W. Greeson, JD, is a partner in Reed Smith LLP, Falls Church, Virginia. Vicky G. Gormanly, JD, is a partner in the firm.

Alternative Models | Imaging-service Delivery

In Search of Shangri-La: Alternative Models of Imaging-service Delivery

As health care seeks to adapt to a new era of cost constraints and quality oversight, alternate forms of imaging delivery are beginning to develop By Julie Ritzer Ross

or decades, the radiology practice partnership model has been the dominant form of imaging delivery. Change, however, is afoot. Healthcare reform and other factors are driving the development of new imaging-delivery models that merit a close look, if imaging providers are to weather the storm of change that is remaking the health-care landscape. Radiologist Lisa Bielamowicz, MD, is managing director and national imaging practice leader for the Health Care Advisory Board and Technology Insights programs of The Advisory Board Company (Washington, DC), a global research, technology, and consulting company. She says that savvy health-care providers must recognize that the final rule1 implementing the Medicare Shared Savings Program (MSSP) is likely to kickstart the formation of MSSP accountablecare organizations (ACOs). Chalk it up, for the most part, to the many providerfriendly changes made (and features added) between release of the proposed and final rules. “The overall structure of the program has not changed, but CMS has scaled back many of the obstacles to operating in ACO mode and made the concept of participation more appealing to providers,” Bielamowicz notes. The reduction in the number of mandated quality-reporting measures tops the list of compelling revisions. Other attractive changes specify that providers can band together into an MSSP ACO without assuming any financial risk during the initial three-year contract period; allow for a prospective beneficiary-identification process, with

retrospective reconciliation; and provide access to previously unavailable, identifiable patient-claims data generated under Medicare Parts A, B, and D. CMS also has reduced, through a revision of fraud and antitrust rules, the legal risks inherent in forming and operating ACOs. While the ACO model, as a whole, is in its infancy, some of its pieces are beginning to take shape, and providers have begun to move along the establishment continuum. Premier, Inc (Charlotte, North Carolina), a member alliance of more than 2,500 hospital systems and 76,000 outpatient facilities, currently has 20 to 30 provider partners with which it is collaborating on ACO formation. It is also assisting another 53 provider partners in determining whether following such a path would work well for them—and, if so, how to proceed.

26 Radiology Business Journal | December 2011 | www.imagingbiz.com

Josh Bennett, MD, MBA, serves as Premier’s partner for integrated care and delivery. He notes that no matter what the overall ACO structure will be, it is important to recognize that the general model brings with it a spate of additional reporting requirements. “For ancillary functions in a high-value network— and radiology is among them—there is significant mandatory reporting around patient satisfaction with the care at the imaging site,” he explains, “l look at everything from the experience at the registration desk to whether the radiologist had contact with the patient (and the caliber of that contact).” Reports required under the ACO umbrella must also cover instances of unnecessary or duplicated imaging services and whether alternative studies to those deemed inappropriate could have been

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Alternative Models | Imaging-service Delivery

ACOs are holding radiology and radiologists to a high standard and, when selecting from among providers in a particular community, will partner with the one that offers not just the most cost-effective services and best clinical outcomes, but the highest degree of imaging appropriateness. —Josh Bennett, MD, MBA Premier, Inc

28 Radiology Business Journal | December 2011 | www.imagingbiz.com

ordered. Moreover, the MSSP demands information pertaining to adverse affects and conditions noted during imaging procedures: “the gamut, from the fact that a patient became extremely agitated in the middle of an exam to an adverse reaction to a contrast agent,” Bennett says. Documentation regarding quality assessments and improvements—such as peer audits of radiologist’s reports—falls into this category as well. At the same time, lines are being written into the ACO script from an accountability standpoint. The expectation is that participating radiologists will undertake initiatives aimed at achieving radiationdose reduction: for example, adhering to the use of doses as low as reasonably achievable, or ALARA, as well as to the Image Gently guidelines for pediatric imaging. Similarly, a proactive approach to ensuring exam appropriateness is expected. Bennett says, “ACOs are holding radiology and radiologists to a high standard and, when selecting from among providers in a particular community, will partner with the one that offers not just the most cost-effective services and best clinical outcomes,” Bennett says, but the highest degree of imaging appropriateness. “This is going to become even more important as ACOs shift from fee-forservice and volume-based incentives to quality- and value-based incentives,” he believes. “It will be all about the right test, for the right patient, at the right time.” Bennett adds that wise radiologists are adopting a proactive stance in order to satisfy or exceed expectations on the imaging-appropriateness side. They are requesting of ACO leadership the right to counter a referring physician’s imaging request (should they conclude that the exam ordered would not be of value) and to propose alternative studies. The emerging ACO model calls for radiologists to receive, from referring physicians, patient information with a scope extending far beyond what’s seen on the typical imaging requisition. Detailed insurance and demographic data are only the tip of the iceberg, according to Bennett. Extensive information on preoperative procedures (as applicable)

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Alternative Models | Imaging-service Delivery

When you bring a corporate-type employer/employee structure to a radiology practice, decision-making power rests on the shoulders of one individual. That is a key benefit. —Paramjit (Romi) Chopra, MD Midwest Institute For Minimally Invasive Therapies

and on the reason that imaging services are to be provided is also being shared; so is access to electronic health records (EHRs). Bennett says, “The expectation, now, is that if radiologists are to produce clear, concise reports for primary-care physicians, with the answers to questions neatly laid out,” radiologists must be given patient histories and related information on which to build these reports. “The days of orders such as ‘Go see a radiologist for an MRI’ or ‘MRI for lower back pain’ are over,” he adds. Bennett also believes that while adopting the ACO model might not, for radiologists, generally entail attending many governance meetings, it behooves providers to involve themselves in governance nonetheless. “There is a wide berth for practitioners, primary-care physicians, and other types of providers on ACO governing boards,” he says.

factors like declining reimbursements as favoring the employed model. MIMIT, a provider of interventional-radiology services and minimally invasive surgical procedures, operates under an employed model in which physicians (currently, four) work for the practice strictly on a salaried basis. Chopra had multiple reasons for embracing this practice structure. He did not want to grapple with the governance headaches typically experienced in traditional partnerships. In that environment, he says, “Every partner wants to have a say in the decision to be made, whether it is about a major investment, an operating policy, or something in between. More often than not, there is infighting, and getting a group of partners to come to agreement can be like herding cats.” He continues, “When you bring a corporate-type employer/employee

Ports in a Storm While the ACO model probably is the most frequently discussed radiologydelivery option, Bielamowicz points out, external forces make a compelling case for adopting one of the models wherein physicians are employed by a health plan, hospital, or practice owner. “We are seeing that about 50% of physicians, across all specialties, are employed,” Bielamowicz reports. “Economic pressure in general, reimbursement issues, and the uncertainty of what will happen next with health-care reform are pushing many, including radiologists, to seek employment ports in a storm.” Like Bielamowicz, Paramjit (Romi) Chopra, MD, director of the Midwest Institute For Minimally Invasive Therapies (MIMIT) in Melrose Park, Illinois, perceives 30 Radiology Business Journal | December 2011 | www.imagingbiz.com

structure to a radiology practice, decisionmaking power—from strategies to the way in which money will be spent—rests on the shoulders of one individual. That is a key benefit.” In the case of MIMIT, that person is Chopra. Chopra also was uncomfortable with the costs inherent in governance by partnership. “The cost of governance in a partnership is huge, and radiology expenditures are going through the roof,” he says. “Partners want massive salaries and weeks and weeks of vacation.” In contrast, the employed model affords owners/practitioners “the advantages of control and the ability to pay based on performance. For physicians, the attraction is that they are paid a salary and know what they will be earning and what they need to do to get the job done. It’s less ambiguous, all around,” he explains. The employed model under which MIMIT and other practices deliver imaging services has its drawbacks, compared with employment by a hospital or health system, Chopra acknowledges. For instance, he says, individuals working for private radiology practices run the risk of job loss, should procedure volumes and reimbursement rates decline precipitously. Hospitals and health systems could present superior job stability because declining procedure volumes and reimbursement do not have as much of an impact on these

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Alternative Models | Imaging-service Delivery

Suppose, for example, that a new MRI system is needed. In a university setting, you may have researchers leaning toward a cutting-edge, new model, while the hospital is clamoring for something that’s going to allow it to improve throughput. In a closed HMO, you have one agenda. It is a lot simpler. —Greg T. Mogel, MD Colorado Permanente Medical Group, PC

large institutions as they have on private practices. There is a downside to the golden handcuffs, however. Many hospitals, Chopra says, are demanding faster, better, cheaper imaging services from the radiology sector. They do not always provide employees with incentives for their effort. Radiologists who are on the staff of private practices stand a much better chance of enjoying these incentives, Chopra says. Further complications might arise down the road. Despite the forces that recommend the employed model— namely, the languishing economy and health-care reform—Chopra entreats those who are interested in exploring an employed private practice to keep in mind other factors that threaten its viability. For one thing, larger hospitals are acquiring smaller hospitals and/or imaging centers, enabling them to bring imaging services in-house or offer them under their own auspices instead of under contractual agreements with private practices. Teleradiology providers are also eating a share of the imaging-services pie, leaving an increasingly smaller slice for practices like MIMIT.

than 400,000 Colorado residents, CPMG is one of eight such groups that operate under the Kaiser Permanente name. Like its counterparts, CPMG is self-governing, has its own board of directors, and functions as a contract service provider to Kaiser Foundation Health Plan (Oakland, California), one of the largest US nonprofit integrated health-care systems. Greg T. Mogel, MD, serves as CPMG’s regional department chief of radiology. He is quick to cite the benefits of a closed-HMO model for radiology, the most significant being, he says, “less burdensome, less red-tape–encumbered, more appropriate” delivery of imaging services because all physicians within the practice regard each other as partners in patient care. “In this direct model, with everyone working within the same partnership, it is easier to say (and gain acceptance of the fact) that maybe a patient needs an

The HMO Option For other radiology players, the employed model in a far different incarnation—the closed HMO—not only works well, but will probably continue to do so, by virtue of its scope. Consider Colorado Permanente Medical Group, PC (CPMG), Denver, Colorado, a multispecialty physician group made up of more than 800 members. Serving more 32 Radiology Business Journal | December 2011 | www.imagingbiz.com

additional study, or a study with contrast versus a study without contrast,” Mogel says. “We don’t need to discuss it with 20 or 30 people and multiple payors. There’s a straighter line between radiologists and other physicians, as under the model, we are all coming at care with the same patient-oriented motivations and goals, as opposed to delivering care from multiple agendas.” Mogel adds that the straighter line, aligned goals, and simplified decision making inherent in the closed-HMO model contrast somewhat with typical private-practice and academic models. He says, “For example, in a university center, there can be divergent goals and a lot of parties at the table, whereas here, there is a synergy. Suppose, for example, that a new MRI system is needed. In a university setting, you may have researchers leaning toward a cutting-edge, new model, while the hospital is clamoring for something that’s going to allow it to improve throughput. In a closed HMO, again, you have one agenda. It is a lot simpler.” Payor Benefits The advantages to the payor rival the advantages to the radiology department. According to Mogel, the single angle from which imaging services are decided upon and provided (coupled with the fact that the model features a preventive focus, rather than a fee-for-service focus) reduces barriers to patient care, keeping costs in check; so, too, does the fact that the closed-HMO structure facilitates the

T RSNA V IS IT U S A 7 1 1 9 B O O TH IL D IN G U B TH R O N R Mo du le! uc ing No w int rod

Alternative Models | Imaging-service Delivery

sharing of patient information through EHRs. Mogel says that the lower patientservice barriers afforded by the closedHMO model also benefit Kaiser Foundation Health Plan in that they reduce the time and human resources needed to coordinate care across various sites. “We have more than 20 clinics in the Denver/Boulder area, and patients can go to any one of them without reams of paperwork and preapproval,” Mogel notes. “That is a big plus.” Even more significant gains come in the form of more appropriate utilization, cost, and productivity. Unlike what Mogel refers to as a straight RVU-generating model, the closed-HMO structure incorporates enough time to let radiologists assess the appropriateness of studies, truly review the questions that clinicians would like a given study to answer, determine whether the requested exam is the best choice, and (in general) engage in what would otherwise be considered activities that do not generate RVUs. In addition, the model makes enhanced throughput and productivity possible, despite the fact that greater productivity (in line with this model’s structure) does not result in individual provider gain. Much of the improvement is rendered possible through the use of incentives and bonuses tied to performance measures. “The goals and metrics do not remain the same; maybe, one year, it’s decreased imaging utilization, and another year, something entirely different,” Mogel states. Providers are involved in developing the goals and metrics (to ensure buy-in). Many positive changes in practice patterns, Mogel adds, are attributable to bonuses and incentives. For instance, CPMG set an objective of reducing the interval of time between the completion of a report’s dictation and its signing by the radiologist. A bonus pool was created, with the time decrease as one of the measures; the strategy proved very effective. Mogel says, “Increased imaging appropriateness, well-controlled utilization, and better productivity— coupled with an emphasis on prevention, wellness, and coordinated care” are the attributes wanted from radiology. He

adds, “I believe the closed-HMO model is in a good position to provide them.” Emerging Models As the ACO, employed, and closedHMO models of radiology services delivery take hold, others continue to emerge. Bielamowicz points to the clinical-integration model, wherein individual physicians across a range of specialties align with each other (and with additional entities) to deliver coordinated care, under the terms of joint contracts with payors. She cites Greater Rochester Independent Practice Association in New York, a partnership comprising 885 physicians and two community hospitals, as an example. Others include Catholic Medical Partners Independent Practice Association (Buffalo, New York); Mount St Mary’s Hospital and Health Center (Lewiston, New York) and its network of associated physicians; and Advocate Physician Partners (Oak Brook, Illinois). On the physician side, Bielamowicz observes, better rates that result from providing coordinated care to patients and lowering payor expenditures constitute the biggest benefit of this particular model. Enhanced access to IT and support for patient-care management from a clinically integrated network and more exclusive access to referrals round out the list of advantages that Bielamowicz

34 Radiology Business Journal | December 2011 | www.imagingbiz.com

predicts will foster heightened interest in the model. The model followed by Sheridan Healthcare (Sunrise, Florida), which can be described as a clinical-services model, fits loosely into the mold that Bielamowicz describes: It is a multispecialty practice of more than 1,400 physicians and other health professionals. Specialties represented encompass radiology, anesthesiology, children’s services, and emergency medicine. Physician led and managed, it offers services, on an outsourced basis, to 114 hospitals and outpatient facilities nationwide. Maria Rodriguez, MD, is Sheridan Healthcare’s chief of medical radiology services. She states that the organization’s model is dedicated to serving facilities with a single-source solution to their needs by providing clinical guidance and support for new government policies, quality initiatives, revenue issues, and patient-care concerns. “Our providers are given the flexibility to work in a multitude of environments in which they will thrive, and in turn, they are incentivized for bringing additional skills or time to the practice,” she notes. A Key Acquisition In a 2006 push to create a more comprehensive medical-specialty roster, Sheridan Healthcare established its radiology-service line through the

Alternative Models | Imaging-service Delivery

We also collect an extensive scope of data pertinent to radiology, including a multitude of physicianrelated items (such as productivity) and quality metrics, to include peer review, report-turnaround times, voicerecognition, self-edit rates, and critical-results data, in accordance with Joint Commission guidelines. —Maria Rodgriguez, MD Sheridan Healthcare

Ask ‘How can we be a partner in this model? How can we be sure imaging is delivered in the most beneficial way? What can we bring to this table to make it happen?’ Be proactive, not reactive— or you will be left behind. —Lisa Bielamowicz, MD The Advisory Board Company

acquisition of Florida United Radiology. The radiology division has since grown to include 63 fellowship-trained/boardcertified radiologists who provide on-site diagnostic, pediatric, nuclearmedicine, mammographic/breast MRI, musculoskeletal, and ultrasound services to 30 facilities. An after-hours teleradiology component is also part of the radiologyservice line, but it is not the only valueadded service that Rodriguez deems critical to Sheridan Healthcare’s infrastructure and the appeal of its model; providers pursing a clinical-integration model must play up additional elements if they are to stand out from the pack, she says. Interventional-radiology services and subspecialty radiology consultations head the list of added values. An internal quality-assurance program affords monitoring of (and ensures compliance with) the existing and new requirements of local, state, and federal agencies and accrediting bodies, including CMS and the Joint Commission. As a means of shoring up the high caliber of care and bolstering clinical and operational efficiencies, the radiologyservices department has deployed its

own PACS, accessible by all 30 facilities. “We also collect an extensive scope of data pertinent to radiology, including a multitude of physician-related items (such as productivity) and quality metrics, to include peer review, report-turnaround times, voice-recognition self-edit rates, and critical-results data, in accordance with Joint Commission guidelines,” Rodriguez observes. While which of these existing and emerging imaging-delivery models will remain firmly grounded—and how health care will alter their shape—remain to be seen, one thing is certain: Radiologists themselves must proactively align themselves with payors and all others involved in forming partnerships. “Get involved at the get-go, take a

36 Radiology Business Journal | December 2011 | www.imagingbiz.com

seat at the table, and participate fully in the discussion. Ask, ‘How can we be a partner in this model? How can we be sure imaging is delivered in the most beneficial way? What can we bring to this table to make it happen?’ Be proactive, not reactive—or you will be left behind,” Bielamowicz concludes. Julie Ritzer Ross is a contributing writer for Radiology Business Journal. Reference 1. US DHHS. Medicare program; Medicare shared savings program: accountable care organizations. Fed Regist. http://www.gpo. gov/fdsys/pkg/FR-2011-11-02/pdf/201127461.pdf. Published November 2, 2011. Accessed November 9, 2011.

Fourth Annual Ranking:

The 75 Largest Private Radiology Practices

Ranked by Number of Radiologists and Including Number of Employees, Studies, and Imaging Centers Sponsored by

COVER | The 75 Largest Radiology Practices

Introduction During the break of a radiologygroup retreat, a young radiologist was congratulating a radiologist 30 years his senior on his upcoming retirement. The young radiologist commented on how lucky the retiring radiologist was to have lived through the glory years of radiology. The senior radiologist replied he would trade places with him in second for the opportunity to be in his 30s again. The outlook might seem tough for radiology, but it is all a matter of perspective. The marketplace continues to consolidate. Some of it shows in this survey; however, some major radiology service providers were eliminated from the survey because they were not radiologist owned. We will need to reconsider whether these groups should be included, in future years, as the lines become blurred between traditional groups and teleradiology organizations. In comparison with last year, there appears to be more stability in groups. More of the top 50 groups have added radiologists, while the number that have shown decreases is about the same as it was last year, with most of the decreases being very small. Advanced Radiology Services (Grand Rapids, Michigan) continues to lead the country in size, with 113 FTE radiologists, and is operating under a divisional model. While I believe that this model allows various groups to come together, it does have its challenges, when it comes to continued growth. This makes me think of a joke that I heard the other day: What do you call a 99-to-1 vote in a radiology group? It’s a tie. Mountain Medical Physician Specialists (Murray, Utah) made the biggest jump on the list, adding 13 FTE radiologists and going from 15th to sixth place on the list. 2012 will present continued challenges. I am confident that the leaders of the larger groups will continue to adapt and make the necessary adjustments to continue to be successful. We recognize that many large groups choose not to participate and thus the survey is not 100% accurate. We want to thank those who do choose to be a part of the survey. Be strong and prosper in the coming year. Joseph P. White Principal, Health Care LarsonAllen LLP: CPAs, Consultants, & Advisors Minneapolis, Minnesota

The 75 Largest

Private Radiology Practices Our fourth annual survey reveals that market conditions are taking a toll on growth, both in the median size of the largest practices and in the number of studies performed annually By Cheryl Proval

f annual procedure counts are an indicator, the seemingly endless growth in imaging volumes appears to have stalled at the nation’s largest practices, lending a note of truth to anecdotal reports that volumes are down in imaging centers and hospital radiology departments nationwide. After logging procedural volume increases in all practicesize categories in 2009, the nation’s largest radiology practices reported either reduced volumes or modest increases in 2010. This factor might have contributed to a slowing of the steady growth trend in median practice size seen since we instituted the survey in 2008. While the overall median group size of participating practices increased just 0.2 FTE in 2011, the median size of the very largest practices continued to climb. Nonetheless, all size categories (with the exception of the very largest practices) reported increases in the number of FTE employees in 2011. Remarkably, the median revenue per FTE employee has stabilized across all size categories to a nearly equivalent number, perhaps indicating that efficiency and productivity measures instituted at the nation’s largest practices—with 19 to 113 FTE radiologists—have contributed to a kind of economic equilibrium across all size segments. The financial information reported by the practices is confidential, so the sole criterion used to rank the 75 practices was the number of FTE radiologists. A Webbased survey was made available to readers of Radiology Business Journal at www. imagingbiz.com from July 15 to September 15, 2011.

This year, survey collaborators Radiology Business Journal and LarsonAllen (Minneapolis, Minnesota) increased the number of practices ranked from 50 to 75. A total of 87 practices participated, and the sponsors wish to express their gratitude not only to those who are listed in the ranking, but to who took the time to fill out the survey, yet had too few radiologists to be included. The information provided by all 87 practices was used to identify trends affecting the practice of radiology in 2011. Participation is voluntary, and results are based solely on self-submitted data, so the list cannot be considered a complete ranking of all of the nation’s practices. The survey, however, continues to become more representative each year, with 11 established practices appearing in the largest 50 practices for the first time, and an overall additional 24 practices included (because two practices tied for the 50th ranking last year). Expanding the ranking from 50 to 75 practices resulted in a decrease in the smallest practice size, from 31 radiologists last year to 19 this year. If two or more practices had the same number of FTE radiologists, we assigned a rank based on the number of FTE employees. Medians for selected practice variables (Figures 1–4, page 43)—number of imaging centers, procedures performed, and radiologists and employees per practicesize category—were based specifically on input from the 75 ranked practices and might not be representative of the industry at large. The results, however, are likely to provide useful insight into current privatepractice trends.

About the Survey The survey to rank the 50 Largest Radiology Practices is the result of a collaboration between LarsonAllen and Radiology Business Journal. LarsonAllen is a nationwide professional services firm based in Minneapolis, Minnesota, and counted among the top 20 accounting firms. Radiology Business Journal is a next-generation bimonthly economics journal serving leaders in medical imaging. The sponsors gratefully acknowledge the support of Laura Tierney, manager, health care, LarsonAllen LLC, Minneapolis, Minnesota, who provided the computations for this survey.

COVER | The 75 Largest Radiology Practices Table. The 75 Largest Private Radiology Practices for 2011 (Ranked by FTE Radiologists) 2011 Rank

Group

Location

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75

Advanced Radiology Services PC Radiology Associates of North Texas, PA University Radiology Group Charlotte Radiology, PA Austin Radiological Association Mountain Medical Physician Specialists, PC Consulting Radiologists, Ltd Radiology Associates of South Florida, PA Southwest Diagnostic Imaging, LLC Riverside Radiology & Interventional Associates St Paul Radiology, PA Suburban Radiologic Consultants Radiology Imaging Associates, PC Radiology Inc Radiology Imaging Consultants, SC American Radiology Associates, PA Bay Imaging Consultants Medical Group, Inc Inland Imaging Clinical Radiologists, SC Diagnostic Imaging, Inc Diversified Radiology of Colorado, PC Wake Radiology Radiology Associates of Hollywood, PA TRA Medical Imaging Radiology Alliance, PC Jefferson Radiology New York Radiology Alliance Eastern Radiologists, Inc Northwest Radiology Network, PC MBB Radiology Radiology Affiliates Imaging Desert Radiologists Drs Harris, Birkhill, Wang, Songe and Associates, PC Greensboro Radiology Huron Valley Radiology, PC Northside Radiology Associates, PC Radiology Ltd NRAD Medical Services PC Quantum Radiology Radiology Associates of Clearwater, PA Vista Radiology, PC Mid-South Imaging & Therapeutics, PA Tower Radiology Center Atlantic Medical Imaging, LLC Newport Harbor Radiology Associates Medical Group, Inc Radiology Associates, PA Summit Radiology PC Columbus Radiology Corp Radiology Associates of the Fox Valley, SC Lancaster Radiology Associates, Ltd Progressive Physician Associates, Inc High Plains Radiology Associates Milwaukee Radiologists, Ltd, SC Advanced Diagnostic Imaging, PC Advanced Radiology Consultants Professional Radiology Inc Radiology Associates of Northern Kentucky Radiologic Associates of Fredericksburg ProScan Reading Services Radiology & Imaging, Inc Toledo Radiological Associates, Inc Association of Alexandria Radiologists, PC Radiology Consultants of Little Rock, PA Advanced Medical Imaging Consultants Radiology Inc Doctors Imaging Group Radiology Consultants of Iowa North Broward Radiologists, PA Radiology & Imaging Specialists Danbury Radiology Associates Radiology Physicians, Inc Lake Medical Imaging and Vascular Institute Valley Regional Imaging Steinberg Diagnostic Medical Imaging Centers Comprehensive Radiology Services

Grand Rapids, MI Fort Worth, TX Mark J. Kleinschmidt East Brunswick, NJ Thomas Dunlap Charlotte, NC Mark Jensen Austin, TX Doyle W. Rabe Murray, UT Clark A. Davis Minneapolis, MN Neeraj Chepuri, MD Miami, FL Ricardo Cury, MD Phoenix, AZ Columbus, OH Marcia Flaherty St Paul, MN Minneapolis, MN Jim Tierney Englewood, CO Powell, OH Harvey, IL Jay Bronner, MD Dallas, TX Walnut Creek, CA Mary Gerard Spokane, WA Steve Duvoisin Thomas C. Dickerson, FACHE Springfield, IL Trevose, PA Lakewood, CO Chris (Kip) McMillan Raleigh, NC Robert E. Schaaf, MD Pembroke Pines, FL Tacoma, WA Dennis Carter Nashville, TN Keith Radecic East Hartford, CT Ethan B. Foxman, MD Bedford Hills, NY Greenville, NC Indianapolis, IN Vincent Mathews, MD Jacksonville, FL Hamilton, NJ Robert Carfagno Las Vegas, NV William P. Moore II Dearborn, MI Worth Saunders, MHA, FRBMA Greensboro, NC Ann Arbor, MI Eric C. Ferguson, MD Atlanta, GA Tucson, AZ Garden City, NY Marietta, GA Clearwater, FL Knoxville, TN Memphis, TN Brian Barbeito Tampa, FL Larry Smith Galloway, NJ Robert M. Glassberg, MD Newport Beach, CA Little Rock, AR Fort Wayne, IN Mark Schaefer Columbus, OH Paul Embry Neenah, WI Lancaster, PA Bethlehem, PA Amarillo, TX Milwaukee, WI Nashville, TN Michael Moreland Trumbull, CT Alan Kaye Cincinnati, OH Robert J. Ernst, MD Crestview Hills, KY C. Chad Wiggins Fredericksburg, VA Edwin W. Swager Cincinnati, OH Stephen J. Pomeranz, MD Springfield, MA Toledo, OH Springfield, VA Sid Greenwell Little Rock, AR Fort Collins, CO S.H. Podolski III Huntington, WV Gainesville, FL Rob Hardin Cedar Rapids, IA Fort Lauderdale, FL Lakeland, FL Ed Goodmote Danbury, CT Centerville, OH Leesburg, FL Fayetteville, NC Las Vegas, NV Hattiesburg, MS Mike Villalonga

CEO

Lead Physician Konstantin Loewig, MD John Queralt, MD Robert E. Epstein, MD Arl Van Moore, MD Gregory C. Karnaze, MD Michael Webb, MD Neeraj Chepuri, MD Ricardo Cury, MD Christian Dewald, MD; Rodney Owen, MD Mark Alfonso, MD Michael Madison, MD Kevin Gustafson, MD; Aaron Binstock, MD Peter Ricci, MD G. Patrick Cain, MD Perry M. Gilbert, MD; Jay Bronner, MD J. Mark Fulmer, MD Ira Finch, MD Daniel Murray, MD Charles E. Neal, MD Bruce Lehrman, MD Steve George, MD Robert E. Schaaf, MD Benjamin Freedman, MD Michael T. Dowd, MD Greg Lassiter, MD Ethan B. Foxman, MD Kenneth Schwartz, MD Michael G. McLaughlin, MD, MBA Vincent Mathews, MD Dennis Wulfeck, MD Donald S. Ostrum, MD Robert B. Poliner, MD David S. Yates, MD Eric Mansell, MD Eric C. Ferguson, MD Steve Moss, MD Edward J. Woosley, MD Jay Bosworth, MD Alan Zuckerman, MD John Fisher, MD Samuel H. Feaster, MD Dexter Witte, MD Raul Otero, MD Robert M. Glassberg, MD Michael Roossin, MD Kathleen Sitarik, MD John Bormann, MD Jason H. Fox, MD Marc J. Miller, MD Robert F. Latshaw, MD Hal Folander, MD Rahul Mehta, MD Emil Hurst, MD Chad Calendine, MD Alan Kaye, MD Robert J. Ernst, MD Bradley L. Miller, MD David L. Glasser, MD Stephen J. Pomeranz, MD Laurie E. Gianturco, MD Daniel A. Dessner, MD Keith M. Sterling, MD Scott B. Harter, MD Peter Koplyay, MD Hans G. Dransfeld, MD Kim Jong, MD Brian C. Randall, MD David Ring, MD Christian Schmitt, MD Arnold Newman, MD William Lavin, MD Catherine E. Keller, MD David R. Fisher, MD David L. Steinberg, MD Gregory Vickers, MD

2011 FTE 2010 FTE 2009 FTE 2008 FTE 2011 FTE Imaging Hospital Lead Nonphysician Radiologists Radiologists Radiologists Radiologists Employees Centers Contracts Procedures Bill Ziemke 113 105.7 106.2 89.2 110.2 0 Mark J. Kleinschmidt 105 230 14 Thomas Dunlap 85 80 61 295 10 Mark Jensen 81.5 80 65 61.3 302 20 Doyle W. Rabe 80 76 78 84 654 15 Clark A. Davis 73 60 150 2 Charles Engmark II 71 67.7 67 65 125 4 Dennis Wiseman 66 65 57 25 0 Lisa Mead 65 67 65 610 19 Marcia Flaherty 63 64 63 60 100 0 Mark Martin 63 80 85 83 151 7 Jim Tierney 63 63 65 65 225 7 Jeff Morey 62 268 11 Michael Murphy 61 50 61 0 2 Steven Newell 60 61 71 7 0 Craig Cunningham 57 54 12 1 Mary Gerard 56 56 150 7 Steve Duvoisin 56 63 60 61 459 8 Thomas C. Dickerson, FACHE 55 56 44 65 0 Richard Zimmerman 55 58 58 58 1 Chris (Kip) McMillan 55 55 55 63 0 Margaret King 55 53 50 50 290 16 Dan Strub 53.2 58 52 34.3 52.49 0 Dennis Carter 52 50 52 200 9 Keith Radecic 51 45 45 63 1 Jonathan Pine 50 50 41 45 346 10 Jonathan Schwartz 50 55 Walter Lindstrand 49.1 51 51 136.6 7 Linda Wilgus, CPA 48 47 41.5 41 120 3 Jason Carter 45 75 0 Robert Carfagno 45 100 5 William P. Moore II 42 38 38 39 216 5 Dawn E. Portelli 42 43 23 0 Worth Saunders, MHA, FRBMA 41 41 150 5 Keith Collin 40 40 30 12 1 John Friedel 40 40 40 5 0 Chip Hardesty 40 39 423 11 Paul Strohmenger 39 33 35 28 500 11 Adam Fogle, MBA 38.4 39 37.5 58 4 Patrick L. Epting 36.35 37.5 39 3 0 Charles McRae 36.2 39 38.1 30 4 Brian Barbeito 36 32 34 30 22 0 Larry Smith 35 118 12 Abe B. Lawal, CPA, MBA 34.8 36 30 31 298 9 Michael Madler 34 3 0 Alicia Kunert 34 36 38 45 120 3 Mark Schaefer 34 75 0 Paul Embry 33 65 0 Monica Nichter 32.5 32 5.5 0 Bob Still 32 105 6 Kate Haney 31.8 21.88 0 Cindy Keesee 31 25 50 3 Russ Lein 31 35 33.1 20.2 3 Michael Moreland 30 30 221 9 Nicholas Christiano Jr 30 167 7 Joseph R. Hudepohl 30 31 39 0 C. Chad Wiggins 30 27 29 41 0 Edwin W. Swager 29.5 26.5 31 6 Judith Turner 28 26 29 25 354 23 Vasilos Tourloukis 28 28 27 64 6 Richard G. Wagner Jr, FACMPE 28 28 15 2 Sid Greenwell 26 26 28 6 R. David Humphrey Jr 25.58 28 83.5 1 S.H. Podolski III 25 25.2 26.7 28 50 Bill Wright, MBA 25 36 0 Rob Hardin 24 150 3 Kathy Epley 24 22 62 1 Robert Gallup 23 4 1 Ed Goodmote 23 5 Nelia Thompson 22 3 5 Nadine Daugherty 22 3 0 Troy E. Purcell, MSF 21 20 175 3 Rhonda Mayorga 21 43 1 Marc Williams 19 303 5 Mike Villalonga 19 0

Preliminary Teleradiology Teleradiology Interpretations States

Subspecialty Coverage

16 1,601,790 1 In-house, 24/7 24 In-house, 24/7 6 1,000,000 20,000 3 In-house, 24/7 11 1,344,000 12,000 2 In-house, 24/7 15 1,568,583 191,156 1 In-house, 24/7 11 750,000 In-house, 24/7 70 1,007,731 37,600 5 In-house, 24/7 5 741,000 1 In-house, 24/7 6 1,300,000 2 In-house, 24/7 17 1,075,000 1 In-house, 24/7 14 1,100,000 In-house, 24/7 15 In-house, 24/7 15 900,000 3 In-house, 24/7 6 845,000 1 In-house, 24/7 15 1,150,000 3 In-house, 24/7 4 650,000 1 In-house, 24/7 12 1,000,200 75,500 1 In-house and outsourced 15 800,000 3 In-house, 24/7 24 1,000,000 53,550 3 In-house, 24/7 11 875,000 3,500 2 In-house, 24/7 13 725,378 0 In-house, 24/7 15,000 7 650,000 1 In-house, 24/7 6 850,000 0 In-house, 24/7 8 725,000 0 In-house, 24/7 10 1,000,000 In-house, 24/7 6 712,000 2 In-house, 24/7 12 900,000 15,000 3 In-house, 24/7 12 733,329 1 In-house, 24/7 18 825,000 In-house, 24/7 12 946,808 300,000 1 In-house, 24/7 8 900,000 20,000 3 In-house and outsourced 10 1,250,000 1,284 2 In-house and outsourced 6 898,113 1 In-house, 24/7 8 750,000 2 In-house, 24/7 7 740,000 1 In-house, 24/7 3 598,304 1 In-house, 24/7 3 630,000 In-house and outsourced 0 360,000 None 5 732,000 2 In-house, 24/7 6 700,000 1 In-house, 24/7 10 700,000 80,000 4 In-house, 24/7 10 573,743 2 In-house, 24/7 2 1 In-house, 24/7 3 569,300 3 500,000 1 In-house, 24/7 12 640,000 1 In-house, 24/7 16 680,000 2 In-house, 24/7 4 699,214 2 In-house, 24/7 10 544,000 1 In-house, 24/7 2 435,000 1 In-house, 24/7 5 458,358 In-house, 24/7 22 605,000 3 In-house and outsourced 10 487,880 908 3 In-house, 24/7 5 750,555 88,977 7 In-house, 24/7 2 367,065 1 In-house, 24/7 5 500,000 2 Outsourced (teleradiology) at night 6 600,000 1 In-house, 24/7 2 445,797 1 In-house, 24/7 20 250,274 87,596 50 In-house, 24/7 3 400,000 2 In-house and outsourced 4 435,000 4,500 1 Outsourced (teleradiology) at night 3 1 In-house, 24/7 7 517,959 1 Outsourced (teleradiology) at night 11 418,108 84,000 3 In-house, 24/7 5 607,000 3 In-house, 24/7 2 430,000 1 In-house and outsourced 14 445,574 500 1 In-house, 24/7 4 660,509 0 In-house, 24/7 5 14 1 In-house, 24/7 2 265,000 2 In-house, 24/7 2 360,000 1 In-house, 24/7 2 300,408 0 In-house and outsourced 0 35,000 In-house, 24/7 0 257,000 1 In-house, 24/7 11 415,000 1 In-house, 24/7

COVER | The 75 Largest Radiology Practices At the Top Advanced Radiology Services (ARS) PC, Grand Rapids, Michigan, continues its fouryear run as the nation’s largest radiology practice, adding seven radiologists (for a total of 113) in 2011. This hospital-based practice added another client, for a total of 16 hospitals covered, and reported an increase of just fewer than 50,000 additional procedures performed, for a total 1,601,790 procedures (the greatest number of procedures performed). While ARS held the top spot for three years with a significant margin of more than 25 radiologists, the second-ranked practice, Radiology Associates of North Texas in Fort Worth, is within breathing distance, with 105 FTE radiologists. Radiology Associates of North Texas was formed this year when three practices merged: last year’s sixthranked practice, Radiology Associates of Tarrant County; Interventional Specialists; and Grapevine Radiology Associates. University Radiology Group, East Brunswick, New Jersey, added five FTE radiologists in 2011, moving it into third place, with 85 FTE radiologists. This is the one practice in the largest cohort (having more than 65 radiologists) that has steadily increased its standing since showing up on the list in 2009, at number 14. The nation’s fourth-largest practice, Charlotte Radiology in North Carolina, also has grown steadily since first appearing on the list, at number 13, in 2008, with 65 FTE radiologists. This year, Charlotte Radiology added 1.5 FTE radiologists, for a total of 81.5. The fifth-largest US practice, Austin Radiological Association (ARA) in Texas, is also the nation’s most productive practice. Its 80 FTE radiologists performed 1,568,583 procedures last year. This practice was an early adopter of PACS and has made a significant investment in IT and support staff. With 654 employees, ARA is a major employer in its practice setting, and it is the practice with the most employees nationwide. Practice Trends in 2011 While the average size of the 50 largest practices has grown steadily since we inaugurated the survey in 2008, one

would expect the average size to decline with the expansion of the listing from 50 to 75—and it did, from 52.7 in 2010 to 43.9 in 2011. What is somewhat surprising is the modest size of the increase seen in comparing the average size of 2011’s largest 50 practices with the 2010 list: The average size increased from 52.7 (median: 52) in 2010 to 52.9 (median: 52.5) in 2011. When looking at the progress of the 51 practices in this year’s ranking that were also ranked last year, more practices added radiologists (22) than decreased their size (16). Another 11 practices stayed the same size. Looked at another way, fewer than half of the 51 practices ranked last year grew in size, while nearly a third contracted and a fifth stayed the same. Practice size is contingent on procedural volumes, so in looking at median procedures performed, compared with previous years’ figures (Figure 2), it is not surprising that we saw very modest increases in procedural volumes for two size cohorts—and our first declines, in the smallest and largest cohorts, after two years of steady increases. The median procedural volume for groups of 35 to 49 radiologists increased less than 26,000 procedures; for groups of 50 to 75 radiologists, the increase was 27,500. In groups of more than 65 radiologists, the median procedural volume was 1,007,731 in 2008, compared with 1,3770,306 in 2009. Groups of fewer than 35 radiologists also experienced a decline in the median volume, from 500,000 in 2009 to 445,797 in 2010. It should be noted, however, that with the addition of 25 practices this year, the median size of the smallest practices declined from 32.3 in 2010 to 27.5 in 2011. All other size cohorts increased (Figure 3), so a procedural-volume decrease in that cohort would be expected. The median number of radiologists in all other size cohorts, however, increased. The Imaging-center Factor After staying flat or declining, the median number of imaging centers owned increased in all cohorts except the largest— a sign that the nation’s radiology practices continue to see the value of owning the technical component, despite the fact that

reimbursement has been dramatically reduced. The median number of imaging centers owned by the practices in the largest cohort dropped from 12 to seven, but one of the practices that joined that group this year owned no centers, and another practice with a large outpatient footprint dropped into a smaller size cohort (but maintained the same number of centers). The very largest of the nation’s practices tend to have a significant number of centers or none at all. The increase in the number of imaging centers is positive news on the job front due to the link between the number of imaging centers that a practice owns and its number of FTE employees. For instance, our largest practice, ARS, owns no imaging centers and employs 105.7 FTEs, but the practice that ranks number nine on our list, Southwest Diagnostic Imaging, Phoenix, Arizona, owns 19 imaging centers and employs 610 FTEs. The median number of hospital contracts held by the nation’s largest practices increased in all size categories in 2011, perhaps in reaction to the soft growth figures of 2010. Note that this year’s procedural volumes were from the last full calendar year (2010); this year’s number of hospital contracts is likely to be the number held when the practice submitted the survey. The size category with the largest increase was that of practices with fewer than 35 radiologists: These practices increased their median number of hospital contracts from two to six. This cohort was also the largest, representing 32 practices. The median number of hospital contracts jumped from 10 to 12 in the cohort having 50 to 65 radiologists (which had 19 practices); the 16 practices with 35 to 49 radiologists increased their number of contracts from seven to eight; and the smallest cohort, with eight practices, was that of groups with more than 65 radiologists. They increased their median number of hospital contracts from 12 to 13. Economic Equilibrium Although it was not mandatory to contribute revenue data to participate in the survey, 47 practices did so—well more than

Key < 35 FTE radiologists 35–49 FTE radiologists 50–65 FTE radiologists

2008 2009 2010 2008 2009 2010 2008 2009 2010 2008 2009 2010

2009 2010 2011 2009 2010 2011

2011 2009 2010 2011

2009 2010

2009 2010 2011 2009 2010 2011

2011 2009 2010 2011 2009

2011 2009 2010

2009

Figure 2. Median procedures performed, 2008–2010.

2010

2009 2010 2011 2009 2010 2011 2009 2010 2011 2009 2010 2011

Figure 1. Median imaging centers, 2009–2011.

2010 2011

2009 2010 2011 2009 2010 2011

> 65 FTE radiologists

Figure 3. Median FTE radiologists per practice-size category, 2009–2011.

Figure 4. Median FTE employees, 2009–2011.

Figure 5. Median hospital contracts, 2009–2011.

half of the practices in each size category. The good news is that median revenue per FTE radiologist is up in all size categories, with the exception of the cohort having 35 to 49 FTE radiologists. In that group, revenue dropped fairly substantially, but it is still the second-highest figure. The highest median revenue per radiologist was regained by the largest groups, with the smallest cohort (of fewer than 35 radiologists) experiencing the greatest gain. The most interesting aspect of the revenue data is the uniformity seen, across size categories, in the median revenue per FTE employee. While the revenue numbers per radiologist did not change very dramatically—the increases were modest, and the one decrease brought revenue more in line with other practice sizes—the revenue per FTE employee made great dips and leaps to arrive at relatively similar places for all cohorts. In years past, the largest differential between median revenue per FTE employee, for any two size categories, was more than $1 million, and this year, it was $80,000. What this suggests is that the nation’s largest practices (both the smallest and

the largest of them) are not just investing in the practice infrastructure required to both grow and expand their reach; to a great degree, practices also have sought and found operational efficiencies. For instance, all practice-size cohorts, with the exception of the very largest, added employees in 2011. It is not known whether this was to support imaging-center operations, implement IT solutions, or otherwise support the practices, but it is likely that as all size cohorts increased the number of hospital contracts, they also took a page from the largest practices’ playbook and made investments in IT to support distributed-reading solutions. The practices having more than 65 radiologists have always been the biggest employers, and this year was no different. As the only group with a decline in the median number of imaging centers, however, the largest practices also experienced a corresponding drop in the median number of FTE employees. Clearly, radiology practices have had to work harder to maintain income levels as reimbursement has taken a succession of cuts; the most recent (and those proposed for

2012) will be reflected in next year’s results (and those of following years). At the same time, a combination of high unemployment and preauthorization programs appears to have dulled the imaging growth curve. In last year’s ranking, just one group had more than 80 radiologists, and three others stood at 80. We wondered if there might be an optimal size for the radiology practice in this environment and whether more practices would approach the 100 mark. Looking at this year’s results, it is apparent that the ceiling is not 80, as three practices exceeded that mark, one surpassed 100, and a fourth achieved the 80 level. We conclude with a sincere expression of gratitude to all of those practices that participated this year, contributing to a broad portrait of the specialty. Next year, we intend to broaden the survey to include the 100 largest radiology practices, perhaps including academic practices, as well as teleradiology practices. Meanwhile, we salute you and your practice-building achievements. Cheryl Proval is editor of Radiology Business Journal.

Radiology | Meaningful Use

Radiology and Meaningful Use:

Questions Loom As Attestation Begins While some are taking a wait-and-see attitude, a few practices have begun the process of demonstrating meaningful use and—they hope—collecting incentives By Cat Vasko

t was the radiology community’s version of the shot heard ‘round the world: in April 2010, the Continuing Extension Act of 2010 revised the Health Information Technology for Economic and Clinical Health (HITECH) Act’s definition of a hospital-based eligible professional to include hospital-based physicians practicing in outpatient settings, thereby rendering more than 90% of radiologists eligible for the meaningfuluse program. Previously, imaging providers had believed that they would be exempted from the maze of attestation, incentives, and penalties prescribed by the HITECH Act, but suddenly, they (and their information systems) were in the loop. Radiologists have always been early adopters, when it comes to IT, but the stage 1 meaningful-use requirements were, predictably, written with a broader audience in mind. Therefore, they require the use of either an electronic health record (EHR) or a product certified by the Office of the National Coordinator (ONC) as a modular EHR—for instance, a RIS with additional capabilities worked into its millions of lines of code— for information aggregation and attestation. Keith Dreyer, DO, PhD, vice chair of radiology computing and information sciences at Massachusetts General Hospital in Boston, says, “We’re hoping that the stage 2 guidelines will be more attuned to radiologists. For many groups, there’s just too much money on the table to ignore this.”

With stage 2 requirements pending, Michael Peters, director of legislative and regulatory affairs for the ACR®, says that radiologists should brace themselves for more of the same. “I’d expect to see more inclusion of specialists through exclusions, but overall, more continuation of the onesize-fits-all approach,” he explains, adding that the ACR has been pushing for more in Washington. “Everyone understands that CMS and ONC regulators cannot conceivably create unique participation and technology requirements for each and every medical specialty, but there has to be a middle ground between that paradigm and the current approach,” he says. The Lay of the Land In June 2011, the ONC working group tasked with developing the requirements for the meaningful-use program indicated to radiology stakeholders working on Capitol Hill—Dreyer and the ACR among them—that it was in the process of carving out separate recommendations for medical specialties, and hinted that these recommendations might be rolled out as early as stage 2. Peters, however, is not optimistic that the changes will be seen so soon. “I and my counterparts in the other specialty societies have been trying to make sure this stays on their radar, but those recommendations may not be available until the stage 2 proposed rules are out the door and going through the necessary review processes prior to publication for comment,” Peters says. In the meantime, attestation for stage 1, a 90-day process of collecting and reporting patient information to CMS, can www.imagingbiz.com | December 2011 | Radiology Business Journal 45

Radiology | Meaningful Use

What I am telling people right now is get to your vendors and let them know what you need. There’s not enough pull coming from radiologists yet, and as a result, the response from the vendor community has been inconsistent. —Keith Dreyer, DO, PhD Massachusetts General Hospital

When it comes to government regulation, if you start preparing too early, you may find the change never actually happens or that the issue was overblown. —Mike Hawkins Zwanger-Pesiri Radiology

begin in either 2011 or 2012 for eligible providers hoping to capitalize fully on the incentives offered by the HITECH Act. Totaling $44,000 per eligible provider for those who follow the agency’s timeline and begin with stage 1 before the end of 2012, the incentives are tempting—and, of course, they will be replaced with penalties in later years. Steven Fischer, CIO for the Center for Diagnostic Imaging (CDI), Minneapolis,

Minnesota, says, “We did a financial assessment, and it makes sense for us to pursue this—not so much for the incentives, but because of the hammer coming down in 2015. The incentives do add up, however; it’s a pretty nice chunk of change, even after expenses.” Because the stage 1 requirements— and, if all indications prove true, the forthcoming requirements for stage 2— are geared toward physicians in general (not specific specialties), attestation can only be achieved using an EHR or an ONC-certified modular EHR. RIS vendors are scrambling to update their software to attain this certification, although the process is, obviously, a cumbersome one. At the June 2011 annual meeting of the Society for Imaging Informatics in Medicine in Washington, DC, vendors shared their progress on attaining the coveted certification, but for the most part, there was little to celebrate yet. “What I am telling people right now is get to your vendors and let them know what you need,” Dreyer says. “There’s not enough pull coming from radiologists yet, and as a result, the response from the vendor community has been inconsistent.” Weighing the Benefits As Dreyer suggests, one reason for the lack of response from vendors might be

46 Radiology Business Journal | December 2011 | www.imagingbiz.com

the lack of impetus from radiologists. David Mendelson, MD, is professor of radiology and chief of clinical informatics at Mount Sinai Medical Center (New York, New York), where the hospital is in the midst of its 90 days of continuous use. He says, “We’re waiting. We’re concerned CMS and ONC together might make some late-in-the-game changes in meaningful use for radiology, so we haven’t made any final decisions about technology.” This sentiment is echoed by Mike Hawkins, chief strategy officer at ZwangerPesiri Radiology, Lindenhurst, New York. “In the past, I’ve been burned by changes like this,” he says. “When it comes to government regulation, if you start preparing too early, you may find the change never actually happens or that the issue was overblown. From our perspective, it’s wait and see when our vendor delivers the software and implements it.” University Radiology Group of East Brunswick, New Jersey, on the other hand, found the incentives too high to resist, and is currently in the middle of attestation for stage 1. Tom Dunlap, MBA, the group’s CEO, says, “We have 90 radiologists, of whom 70 or so are candidates for this. When you’re doing this 70 times, twice a day, multiplied by the number of measures, it’s a fair amount of effort.” He adds, “This is an exercise, but with close to a million dollars in incentives on the table, it’s attractive enough that I think we’d be making a mistake if we didn’t try to get this done. Our hope is that everybody who is qualified under the rules is going to pass, and we’ll get the incentive by the end of this year.” The attestation is made possible by University Radiology’s electronic medical record (EMR), a product designed for private practices and sold by the practice’s RIS vendor. Alberto Goldszal, MBA, PhD, the group’s CIO, says, “We had the vision to choose a vendor that was well attuned to the requirements coming down the pike.” At CDI, the team took another approach to meeting the electronic requirements for attestation by developing (with its vendor) additional modules for the RIS that can fill in the gaps. “Things like drug interactions, computerized provider order entry, and HL7 continuity of care record

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Radiology | Meaningful Use

Once we get a handle on what modules exist for radiology and where the gaps are, we’ll decide if we want to build an interface from our EMR to our RIS. —David Mendelson, MD Mount Sinai Medical Center

What was critical, for us, was an early start. A multidisciplinary team is needed to make sure you have technology that’s been certified—that’s the invitation to the party—and then look at what you’ll have to change in your day-to-day behavior to capture these new elements. —Alberto Goldszal, MBA, PhD University Radiology

(CCR)/continuity of care document (CCD) capabilities—things a RIS doesn’t usually have—the vendor put together as separate modules, and it bundled that software for us,” Fischer says. “We were already requesting it because we probably would have gone ahead and done it ourselves, otherwise.” Whose IT to Use Demonstrating meaningful use poses a challenge to small radiology practices, for which the total incentive dollars will not be nearly enough to offset the IT investment required. “At the end of this, in 2015, some radiologists might still eat the penalty because they’re not in the position to do this,” Dreyer notes. Larger, hospital-based practices, on the other hand, face a different challenge: carving out who is responsible for supplying the necessary IT solutions. Sean McClure, clinical information system administrator for ProMedica (Toledo, Ohio), says, “We have four different radiology professional groups serving our seven hospitals. We have a common RIS and PACS, but one of our radiology groups owns its own PACS, so we have an interface with it. Every time you divvy it up like that, you diminish your central authority.” 48 Radiology Business Journal | December 2011 | www.imagingbiz.com

For the time being, McClure and his team have decided to allow the radiology groups to pursue the incentive dollars independently—but he has not ruled out the possibility of supporting them with data from the health system’s hospital information system, if necessary. “If they need support from us, we will certainly assist and comply, but we have not specifically done anything to assist any of those professional groups,” he says. “We thought they would ask, if they were interested, but if somebody needs information from us to help his or her practice, we’d be ready for it. One of our goals is to be ready for people to request information from us.” At Mount Sinai Medical Center, Mendelson’s responsibilities for clinical informatics extend well beyond the walls of the radiology department. He reports that the hospital’s EMR is likely to be leveraged to fill in the gaps not covered by the radiology group’s RIS, but for the time being, the hospital is focusing its efforts on the CMS Electronic Prescribing (eRx) Incentive Program. Because CMS prohibits collecting eRx incentives and the initial meaningfuluse incentives during the same year, Mendelson says, “At this point, there’s nothing lost in delaying collecting the meaningful-use data until next year,” he says. “Once we get a handle on what modules exist for radiology and where the gaps are, we’ll decide if we want to build an interface from our EMR to our RIS.” Mendelson adds that an emerging IT product category might prove to be the best solution for hospital-based radiology, providing an alternative to linking to the hospital EMR. “There are beginning to be announcements of products that will sit on top of your RIS, pick up what information your RIS already has, and then interface with an EMR product and use it to fill in the gaps,” he says. “A couple of companies have said they are developing this. We’re trying to determine which route to take, and we have the luxury of making that decision in early 2012.” Preparing for Attestation At University Radiology, where the 90day stage 1 attestation is well underway, a period of intense planning preceded the

Ready, Set—Attest

hen Keith Dreyer, DO, PhD, speaks to an audience of radiologists on meaningful use (something he does quite often, these days), he always asks for a show of hands to determine who is doing what with regard to demonstrating meaningful use of IT. Dreyer, vice chair of radiology computing and information sciences at Massachusetts General Hospital in Boston, reports that despite their eligibility for the incentives—and exposure to penalties in 2015—a scant few are in the process of attesting to meaningful use of health IT in 2011. In his keynote presentation, “Meaningful Use for Radiologists: A 10step Guide,” given at the First Annual ACR® Imaging Informatics Summit on November 3, 2011, in Washington, DC, Dreyer says, “The fuse is still burning. It is a year before you will lose some of the incentives.” Dreyer urges every practice to follow this 10-step strategy, to determine whether it should attempt demonstration of meaningful use and, if viable, to attest to it. First, consider the specific requirements of the program. To make a decision about whether or not your practice should participate, you must understand the fundamentals of meaningful use. Second, determine your eligibility. You are probably eligible, but do the math, Dreyer urges. Look at your group’s billing history to determine whether you are at the 90% threshold or below it (to be excluded, 90% of your work must come from inpatients or the emergency department). The incentives accrue per physician; how many radiologists do you have who fall within this threshold? What are the pluses (incentive dollars, as well as potential benefits of further IT investments) and the minuses (penalties begin in 2015)? Dreyer recommends using the eligibility calculator at www.healthmu.org. Third, determine the number of measurement requirements that you must meet. Work through the exclusions for the MU objectives to find out what you have to do, and the ones from which you can exclude yourself. Dreyer recommends getting general counsel involved on the

exclusions, but some of the measures that radiologists can potentially build an exclusion case for include those pertaining to performing immunizations and transitions of care, collecting syndromic information, office visits, and prescribing medications (contrast agents are considered supplies, not medications). At this point in the process, a practice should have determined whether it will proceed or not with demonstrating the meaningful use of health IT. If so, it proceeds through the next seven steps. Fourth, meet with practice stakeholders. These include your department or practice IT staff, your hospital IT staff or CIO, your CMO, and your medical group (if you are part of a multispecialty medical group). Find out whether there is something you can do collectively and what kind of support you can expect from the hospital, if any. Fifth, meet with your radiology vendors to understand their plans for the products relevant to demonstrating stage 1 meaningful use: RIS, reporting, and practice management. Sixth, plan and execute your technology purchases and operational strategy. Unless your RIS is already certified as a complete electronic health record (EHR)—and some have been—you may want to consider bringing in a consultant or appointing a staff person to explore this more deeply and make some decisions. These will be much like what happens in a PACS- or RISselection process. The goal is to minimize the radiologists’ workflow burden. Seventh, determine whether you need to acquire additional meaningful-use technology—or upgrades to implement meaningful use—through discussions with your vendors. One thing that a practice will need is a dashboard view that will enable all radiologists (or someone acting on their behalf ) to assess whether they are meeting their thresholds for each measure on an ongoing basis, so that if they are not, they can make adjustments. Complete certified products are dashboards, Dreyer says, so vendors must demonstrate in the certification process that they can make that functionality available. Modular certified RIS products will need to be interfaced with the complete EHR, however, and additional software and

technology could be required to provide that dashboard view for radiologists. Eighth, comply. Register (at www. cms.gov/EHRIncentivePrograms/20_ RegistrationandAttestation.asp), as 90,000 physicians already have, using your national provider number. Ninth, monitor your compliance regularly, using the dashboards. Tenth, complete your online attestation at the same website used to register. The time period for which you must attest is just 90 days, in the initial year of meaningful use, and you must maintain the documentation for six years, in case you are audited. —Cheryl Proval

www.imagingbiz.com | December 2011 | Radiology Business Journal 49

Radiology | Meaningful Use

We started last November and met once a week, and we’re still meeting once a week. This is not a trivial exercise: It requires the group to be fully engaged because there is a big investment of time and effort. —Tom Dunlap, MBA University Radiology Group

It has been an uphill battle, breaking through on this issue. All indications are that the ACR’s efforts—and those of the rest of specialized medicine—will need to continue for the foreseeable future. —Michael Peters ACR

commencement of the project. “What was critical, for us, was an early start,” Goldszal says. “A multidisciplinary team is needed to make sure you have technology that’s been certified—that’s the invitation to the party—and then to look at what you’ll have to change in your day-to-day behavior to capture these new elements. It’s all attainable, but attention to detail is crucial. One critical factor here is that there’s no partial credit—you pass or fail, so good planning and communication are needed from the get-go to the end.” Mendelson concurs that additional training will be a must for any radiology group that hopes to participate in the program. “There’s no radiology department I know that would naturally be able to fulfill these requirements,” he says. “You’ll have to change your workflow, and that may mean you have to hire some new collectors of information.” The Mount Sinai team plans to evaluate whether fulfilling the measures will have a significant impact on radiologists’ workflow and productivity. If so, Mendelson says, “My guess is we’ll come up with a number of FTEs we need to hire, and we’ll carefully look at how many dollars we have to gain versus how many we have to spend. My guess is it will still be worthwhile for us to participate.” To determine how best to meet 50 Radiology Business Journal | December 2011 | www.imagingbiz.com

the measures without interfering with productivity and quality, Goldszal and his colleagues established a multidisciplinary team that included the practice’s managers, its general counsel, an administrative technologist, an office manager, and a front desk manager. Dunlap says, “We started last November and met once a week, and we’re still meeting once a week. This is not a trivial exercise: It requires the group to be fully engaged because there is a big investment of time and effort.” Staff members at University Radiology were retrained to populate the new data fields for each patient, and in anticipation of patients’ resistance to answering certain questions, role-playing sessions were used to develop ideal responses. “You have to make sure everyone is saying the same thing, and saying it in a way that fits what we’re trying to do, without offending the patient,” Dunlap says. “It’s a fine line, and at the end of the day, if they don’t want to give the information, you’re not going to get it. What we say is, ‘This is part of the new health-care initiative to capture information to help set policy.’” Looking Forward While some radiology practices have jumped into the meaningful-use program with both feet, Dreyer estimates (based on anecdotal evidence) that they represent a small percentage of groups nationwide. “When I give a talk about this and I ask how many are doing something, it’s 10%; how many have a plan to do something, 10%; how many plan to make the attempt, 10%; and how many need more information, 70%,” he says. “People just don’t have the tools.” Dreyer adds, however, that he expects the landscape to change rapidly as RIS vendors get their products certified for the program. “Once that happens, thousands of radiology groups that couldn’t get anywhere with this before can upgrade,” he says. “To the radiologists, I would say that this is real, and it’s going to be a big deal. You need to buy a product based on what the federal government is telling you to do.” As providers await the stage 2 recommendations, Peters reiterates that the ACR and other groups have the radiology community’s back. “The ACR

If you dig deeply enough, thereâ&#x20AC;&#x2122;s some good that comes out of this, in terms of connectivity and exchanging CCD/CCR in stage 2 and later, which we see as very beneficial. â&#x20AC;&#x201D;Steven Fischer Center for Diagnostic Imaging

is meeting again with pertinent CMS and ONC regulators to discuss imaging considerations for stage 2, in the absence of specialist recommendations from the meaningful-use work group,â&#x20AC;? he says. â&#x20AC;&#x153;We are also continuing to work with other specialty societies and the AMA to try to enhance the clinical relevance of the program requirements for specialists.â&#x20AC;? Peters adds that the specialty societies might have more to do before the program is updated to reflect their constituentsâ&#x20AC;&#x2122; needs better. â&#x20AC;&#x153;It has been an uphill battle, breaking through on this

issue,â&#x20AC;? he says. â&#x20AC;&#x153;All indications are that the ACRâ&#x20AC;&#x2122;s effortsâ&#x20AC;&#x201D;and those of the rest of specialized medicineâ&#x20AC;&#x201D;will need to continue for the foreseeable future.â&#x20AC;? Looking even further ahead, however, Fischer is optimistic about the foundation being laid by the meaningfuluse measures, in spite of their lack of specificity. â&#x20AC;&#x153;If you dig deeply enough, thereâ&#x20AC;&#x2122;s some good that comes out of this, in terms of connectivity and exchanging CCD/CCR in stage 2 and later (which we see as very beneficial),â&#x20AC;? he says. He continues, â&#x20AC;&#x153;One of the challenges

we have, right now, is that integration between, for example, the specialist and the orthopedist isnâ&#x20AC;&#x2122;t very easy. If we can get to where thereâ&#x20AC;&#x2122;s a standard for exchange of patient demographics and history, that will be a home runâ&#x20AC;&#x201D;and I think thatâ&#x20AC;&#x2122;s one of the things the program is aiming to accomplish.â&#x20AC;? Dreyer concludes on a note of caution for radiology. â&#x20AC;&#x153;If anyone out there is thinking this is going to go away, he or she is wrong,â&#x20AC;? he says. â&#x20AC;&#x153;I cannot imagine anything, based on the countless hours Iâ&#x20AC;&#x2122;ve spent at the federal level, thatâ&#x20AC;&#x2122;s going to change thisâ&#x20AC;&#x201D;not a change in political party, not a change in support for the Patient Protection and Affordable Care Act, and not a change in having more radiologists at the table. I spend all of my time doing this, and radiologists are not going to be made exempt.â&#x20AC;? Cat Vasko is associate editor of Radiology Business Journal.

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www.imagingbiz.com | December 2011 | Radiology Business Journal 51

Subspecialization and Teleradiology | Uneasy Alliance

Subspecialization and Teleradiology: An Uneasy Alliance

The specialty is moving toward subspecialization with an assist from teleradiology By Greg Thompson

hy would orthopedic surgeons bypass a nearby hospital or imaging center when referring patients? If they happened to be in the Midwest, they might prefer the subspecialized interpretations offered by Linda L. Dew, MD, FRCPC. After more than two decades as a practicing radiologist, Dew has developed expertise in imaging of the feet, ankles, hands, and wrists. Choosy surgeons have come to rely on her, and they have no qualms about

asking patients to go slightly out of their way for an interpretation that they can trust. Dew, who works for a teleradiology company (headquartered in Southern California) that has a strong presence in Illinois, says, “Orthopedic surgeons and podiatrists do not tolerate mistakes, and they know, soon after surgery begins, whether what you said is correct or not.” Consistently excellent interpretations are important for radiologists, wherever they happen to practice, but Dew believes that the extra focus on subspecialization

52 Radiology Business Journal | December 2011 | www.imagingbiz.com

is particularly prominent within teleradiology companies. With patient outcomes and valuable pieces of the referral pie at stake, subspecialization is increasingly perceived as a necessity in a profession that has always embraced the latest in medical technology. Barry D. Pressman, MD, FACR, agrees that subspecialization benefits patients and referring physicians, but he is unwilling to concede that ground to teleradiology. This past president of the ACR® believes strongly that local radiologists can embrace subspecialization—and that they must, if they hope to remain relevant.

TELE

As chair of the S. Mark Taper Foundation Imaging Center and Department at Cedars-Sinai Medical Center (Los Angeles, California), Pressman has populated his staff with radiologists who have undergone additional training (primarily as fellows) and are experts in multiple subspecialties. The full subspecialization of the radiology department at Cedars-Sinai Medical Center essentially means that thoracic radiologists are reading chest CT exams and chest radiographs; neuroradiologists are reading spine CT and MRI exams, as well as spine radiographs. Pressman, who began practicing in 1975, says, “I don’t care what the modality is; it’s the body area that matters. There are some places that come at it via modality, but through that route, they become specialists in body imaging. Fully subspecialized means having people who cover the entire imaging spectrum of the human being, with subspecialty areas.” Everyone in such a practice should be doing work in his or her field of subspecialization, and no part of the body should fall into the category of “We’ll just have someone read that,” he says. In the past, that philosophy has been reserved for general radiology, a term that Pressman rejects in favor of broad-based, nonsubspecialized radiology. Far from disparaging the nonsubspecialized practitioner, Pressman views broad-based radiologists as well-trained specialists experienced in gastrointestinal and chest radiography. Many generalists have branched into other areas, such as body CT and neurological CT, without fellowship training. “People who are doing multiple things, but have not done any subspecialty training, I call multidisciplinary radiologists,” Pressman says. “To me, there is no such thing as true general radiology anymore. Radiology has gotten subspecialized to the point that I do not know what a general radiologist is.” Pressman’s message has not received unanimous acceptance within the profession, as evidenced by the reaction to a presentation1 that he made a few years ago. “I gave a presidential speech at the ACR on this subject, and many people in the audience were pleased and agreed

I don’t care what the modality is; it’s the body area that matters. There are some places that come at it via modality, but through that route, they become specialists in body imaging. Fully subspecialized means having people who cover the entire imaging spectrum of the human being, with subspecialty areas. —Barry D. Pressman, MD, FACR

with me—and some wanted to kill me,” he says (with a chuckle). “They were people who considered themselves general radiologists, and they felt I was deprecating what they do. I was saying, ‘Here is what you need to do to survive, going forward.’ Subspecialization is a crucial thing for the survival of radiology as a specialty. The alternative is to be subsumed by clinicians who do their own imaging and interpretation.” Prescription for Disaster Pressman and his staff take care of all the night coverage at Cedars-Sinai Medical Center, in an arrangement that staff physicians strongly prefer. “They want to know the radiologist well and would never accept a teleradiology arrangement,” Pressman says. “The other reason we do not use teleradiology is that I have always felt it was a prescription for disaster. Once a hospital gets the feeling that they can do without you at night, they can certainly think of ways to cover the day.” Pressman understands that small practices must often rely on teleradiology, but he views even these arrangements as inherently risky. “If you can do it, use consortia of groups at different hospitals, so that you are not using some third party who knows nothing about your hospital,” Pressman says. “It’s better to have people in the area who come by once in a while; introduce them to the staff. They may work in the hospital next door or in the next city. You can put a name with the face, and they are not stealing your practice from you.” Adding in-house subspecialization is incredibly important precisely because

the additional expertise has clinical value, and with it comes the crucial relevance that the profession has earned. Radiologists must work with highly specialized physicians, and Pressman believes that this is simply impossible if radiologists are not equally devoted to a narrow specialty. It comes down to clinician trust, and referrers will go wherever they must (and to teleradiology companies, if necessary) to get the expertise that they seek. “We, as radiologists, must become conversant with the language, thinking, conditions, and treatments that clinicians deal with; otherwise, they can read the images better than we can,” Pressman says. “If you don’t understand the medicine, and you don’t know the surgical approaches and the equipment they are using, then you don’t know what their problems are—and then, you become superfluous.” In areas such as cardiology, Pressman acknowledges, radiologists are beginning to lose the turf battle. “We must show them what they don’t know about imaging, and do that in the context of their specialty,” Pressman says. “Ultimately, is it fair to the patient if the physician reading the imaging and advising the clinician is really not an expert in that imaging? Would anybody go to a neurosurgeon to have a baby delivered? Why would you go to a radiologist who primarily does obstetric ultrasound to have your head examined? If you do that, you should have your head examined.” Subspecialization is a growing trend, both in radiology practices/departments and at teleradiology companies, but Dew points out that she is not confined to foot/

www.imagingbiz.com | December 2011 | Radiology Business Journal 55

Subspecialization and Teleradiology | Uneasy Alliance

Instead of dictating something and having it typed by the transcriptionist hours later, when I finish looking at a case, I am done dictating it. I check the voice dictation right away, so I am doing the editing. I can sign off on the final report and send it out immediately. —Linda L. Dew, MD, FRCPC

ankle and hand/wrist work. She maintains her expertise in knee and shoulder imaging, and capably covers these areas, when necessary. “I keep up those skills, but a lot of podiatrists and foot/ankle surgeons will send their patients past six MRI centers to go to one of the centers I read for,” Dew says. Referring physicians appreciate expert subspecialty interpretations, but they also call to discuss the results. Dew and her staff members offer this level of service, while rejecting the notion that teleradiology companies are in some way less customer focused than local groups. Dew keeps the cellphone numbers of all orthopedic surgeons, podiatrists, and

hand surgeons with whom she works, so she can call them directly. “They also have my number, if they have a question about what kind of scan to perform or when they should perform it,” Dew says. “If an orthopedist is seeing a patient at 7 am and the patient was scanned at 6 pm the previous day, we make sure that patient’s interpretation is done.” She continues, “We have workstations in our homes, as well as in the MRI centers we are covering. All of us tend to work during the day, take a break, and then work in the evenings a bit also, to make sure everything is done—or we might get up very early the next morning to make sure those cases are read.” In many ways, Dew says, her company can provide greater speed thanks to better technology. “It’s a fallacy to think that teleradiology groups are not doing as good a job,” Dew says. “Instead of dictating something and having it typed by the transcriptionist hours later, when I finish looking at the case, I am done dictating it. I check the voice dictation right away, so I am doing the editing. I can sign off on the final report and send it out immediately. In the hospital, it can take a long time for things to get transcribed.

Inevitable Evolution

hen Barry D. Pressman, MD, FACR, began his radiology career, Nixon was resigning from the White House and neuroradiology was just developing as a specialty. Musculoskeletal radiology largely meant reading bone radiographs. Pressman says, “CT came on the scene in 1972, but we didn’t even know how to spell it yet. Now, we have all these new modalities that are sophisticated and that apply to different parts of the body.” As chair of the S. Mark Taper Foundation Imaging Center and Department at Cedars-Sinai Medical Center (Los Angeles, California), Pressman maintains a highly subspecialized department. He believes strongly that radiologists must continue to evolve if they are to deal with an increasingly competitive environment adequately. When he took the reigns as president of ACR® in 2008, he made his position

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clear in language that pleased some and dismayed others. In the words of his presidential address,1 “Nonradiologists are more and more interested in vertically integrating imaging into their practices, while teleradiology and PACS are resulting in greater isolation of radiologists. Commoditization is a realistic and devastating threat to the survival and professionalism of the specialty. To remain viable as a specialty, radiologists must elevate their practice by subspecializing, becoming more involved with clinical care, and actively interacting with patients and referring clinicians. Distinction will prevent extinction.” —G. Thompson

Reference 1. Pressman BD. Presidential address: distinction or extinction. J Am Coll Radiol. 2008;5(10):1036-1040.

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Subspecialization and Teleradiology | Uneasy Alliance

Bring the teleradiology group on in a deliberate fashion, and foster a dialogue between referring physicians and the outsourced group. Most important are close oversight and management by the chair, as if he or she had one team. —Steven C. Garner, MD, CHE

The quality here is high, and I’m proud to be part of the group.” Us and Them Steven C. Garner, MD, CHE, believes that teleradiology can be an excellent way to supplement the skills of a department that might lack some key subspecialties. He reasons that a critical mass of radiologists must remain onsite for teaching, consultations, needle localizations, biopsies, and special

procedures, so any us-versus-them attitude is wasted energy. The degree of subspecialization needed ultimately depends on the facility. Garner, chair of the radiology department at New York Methodist Hospital in Brooklyn, says, “At a tertiary/ university center, you’ll have a different demand for subspecialty work than you would have at a community hospital. The superspecialist complex procedures are not done in enough numbers to support

58 Radiology Business Journal | December 2011 | www.imagingbiz.com

a physician at a community hospital. Patients are best served at a hospital where radiologists are doing a large number of cases, and somebody is experienced at doing them.” Even if a facility is lucky enough to have a neurointerventional radiologist on board, Garner says, it only makes sense if the community knows about it. “It takes proper marketing of the department to let people know about the services because many referring physicians are not aware that a service is available, or what it would be used for,” Garner says. “We rely heavily on teaching, educational courses, and rounds to introduce physicians to new services and new modalities.” When it comes to relatively new endeavors such as neurointerventional radiology, spreading the word is crucial. “We can actually provide therapy to reverse strokes, if physicians and patients are aware of the importance of getting to the emergency department as soon as possible,” Garner says. He continues, “It is often possible for the neurointerventional radiologist to remove a clot or put a catheter in the

Joint IMPAX PACS solution brings more consistent, unified, and productive data displays to merged hospitals Palmetto Health’s high-quality care (combined with free or reduced-cost health services) is made possible by an enterprise-wide IT network supported by Agfa HealthCare’s IMPAX 6.5 PACS To cultivate their decades of community service, two major providers in South Carolina’s capital, Columbia, combined—more than a decade ago—to form Palmetto Health. Both providers were longtime users of separate IMPAX PACS solutions. A smooth, highly successful fusion of both into a single IMPAX 4.5 solution in 2005 and an upgrade to IMPAX 6.5 this year bring one of the most extensive desktop menus in the industry to the radiologists, with advanced image processing for most modalities—contributing to a consistent, productive electronic medical record (EMR) with a single portal. The creation of Palmetto Health has resulted in five separate hospitals (including individual heart and children’s facilities), with one more hospital under construction. Palmetto Health now has 1,138 beds and employs 8,400 people. The system treats nearly half a million patients annually. Charity care provided by Palmetto Health in 2009 was almost five times greater than it was in 2001, increasing from $33.5 million to more than $157 million. In addition, there are many reduced-cost services, including an on-campus dental-health clinic and a partnership with special offerings for HIV/AIDS patients. There’s also a unique clinic treating sickle-cell anemia, and there are outreach programs for those over 55, teens, and cancer patients, among others. Communication Among Locations is Key Hospitals & Health Networks magazine recently rated Palmetto Health as one of the 99 most wired organizations in the United States. This puts tremendous challenges on its IT and PACS networks to keep pace with ever-increasing change, both in technologies and in workflow processes that benefit patients through enhanced support of all clinical staff. Michelle Edwards, Sr. Vice President and CIO at Palmetto Health, says, “Patients move between physicians, consulting physicians, clinicians, and facilities with incredible regularity. Today, we have a full EMR, for each patient, that includes a single–sign-in access portal to PACS images (encompassing those from cardiology) that instantly follows patients as they traverse the organization. We’re always deploying new systems to pass information across entire clinical teams, wherever they’re located, to manage patient conditions and outcomes better.” As an example, she cites growing staff use of wireless tablets throughout Palmetto Health facilities to record and transfer data, to maintain contact with primary caregivers, and to go paperless. “IT provides the infrastructure and solutions to report, access, and store data for more streamlined workflows,” Edwards adds. “Nearly all clinical patient data are kept on the EMR, with the goal of bringing remaining Palmetto Health departments online by next year.” Furthermore, interfaces allow data exchange between clinical and billing systems, minimizing manual data entry, costly input errors, and wasted time.

“We have a full EMR for each patient that instantly follows them as they traverse the organization.” Michelle Edwards, SVP/CIO

Enterprise IMPAX PACS Enhances the EMR Palmetto Health’s systemwide radiology service performs more than 380,000 general, specialty, and cardiovascular imaging procedures annually, using the latest CT, MRI, PET, nuclear-medicine, DR, CR, and full-field digital-mammography (FFDM) systems. A separate data center houses its PACS servers, securely accessed either wirelessly or through hardwired links between sites. Desktop line speeds of 1 gigabyte per second are available at most Palmetto Health locations. Pat Stevenson, PACS administrator, says that the relationship with Agfa HealthCare predates the 1998 consolidation, as both of the thenseparate hospitals used earlier versions of IMPAX PACS. “We stayed with IMPAX for the next decade, upgrading software for the system as new features proved beneficial in supporting our growing operations,” Stevenson says.

Agfa HealthCare’s Contribution

MPAX PACS is a single workflow-based system designed to meet medical/clinical needs within (or outside) a multisite health-care group’s walls. It streamlines study reviews with persona-based operating parameters, enabling users to achieve improved reporting and results distribution.

IMPAX PACS with RIS This combination provides: n workflow optimized for different users in an enterprise—medical, clinical, and administrative; n Web deployability for access from any location— local or remote; n enhanced worklist manager and advanced CT/ MRI navigation to facilitate faster service (to improve the delivery of care to patients); n seamless, efficient upgrades; and n integration of disparate information systems at the desktop. With overall IT services flourishing, the need for a single, enterprise-wide PACS capable of supporting an integrated EMR (as well as combined clinical reports from other medical departments) was most apparent, she adds. Competitive bidding for this centralized platform linking all locations resulted in 10 contenders, which the group’s selection committee narrowed to five; finally, it selected Agfa HealthCare. A deciding factor was the inclusion of Palmetto Health in clinical field trials for the then-newest edition of IMPAX in 2006, version 6.0. New IMPAX 6.5 Facilitates Fast, High-quality Service “We knew this solution was already proven in the enterprise environment, and the ability to migrate data easily from previous IMPAX platforms greatly guided our selection,” Stevenson says. “The newest release also helps us better manage our caseloads by quickly identifying critical tasks for higher-quality patient care.” She adds that not only does IMPAX 6.5 provide high-quality images, but it also offers a single sign-in portal to the EMR (as well as full-featured desktop menus with advanced image processing, for most modalities). It includes teaching-file management and a fully integrated nuclear-medicine processing function.

www.agfahealthcare.com

Agfa HealthCare IT specialists ensured that the upgrade was planned well and executed smoothly. Stevenson says, “It was a nonevent for the radiologists. The new version came up and ran well, and any minor concerns were addressed on the spot. New features— including advanced multislice CT and MRI navigation, the enhanced worklist manager, and specialized applications for displaying digital mammography—are highly valued by radiologists and referring physicians because they simplify data compilation for quicker reporting. Its management of FFDM imaging is also important in making our highly visible women’s care services more efficient.” She concludes, “Even software features from earlier IMPAX versions that our team had voiced liking at user-group meetings were actually retained in the new solution. Agfa HealthCare really listens to its customers—a quality we appreciate.”

Did You Know?

almetto Health is the only hospital group in the state to be named for four consecutive years by Modern Healthcare magazine as one of the top 100 best places to work in health care nationwide.

right part of the brain to dissolve a clot. This is amazing treatment, but it doesn’t do us any good if referring physicians are not aware of it and don’t send patients to the hospital at the first sign. This even involves teaching ambulance drivers so they can bring patients safely to our hospital.” Economic factors fuel the need for education throughout the health-care continuum because underused hightech equipment does not bring in the reimbursement that it should. “If you’re not doing the specialized procedures, you may not be using equipment in an efficient way,” Garner says. “You want to do the procedures that your new piece of equipment allows you to do, not just the bread-and-butter procedures.” He adds, “We just bought a new and expensive interventional suite. We would not want to use it exclusively for everyday procedures such as femoral angiograms. We do want to use it to treat fibroids with embolization, to stop bleeding in a patient after multiple trauma, or to reverse a stroke.”

it for subspecialty consultations, when necessary. “I consider myself a general radiologist,” Ballentine says. “I need to be able to interpret most of the imaging modalities in a hospital of this size. Basically, you must be able to recognize every malady, and you need to do basic interventional radiology.” As a veteran of more than 30 years in radiology, Ballentine sees the trend toward subspecialization as beneficial and inevitable. “It’s a good thing because it’s good for patients,” he says.

“Subspecialists can usually come up with the answer more quickly, and when they need to, they can share images and form a more firm opinion. Crosstalk among the different subspecialties can only benefit patients.” Greg Thompson is a contributing writer for Radiology Business Journal. Reference 1. Pressman BD. Presidential address: distinction or extinction. J Am Coll Radiol. 2008;5(10):1036-1040.

Key Dialogue Choosing a teleradiology partner to help read subspecialty images should be a deliberate process because many referring physicians are accustomed to reports from hospital-based physicians. “When they get reports from an outside source, they’re not as familiar with the person reading it and may not like the style,” Garner explains. “Bring the teleradiology group on in a deliberate fashion, and foster a dialogue between referring physicians and the outsourced group. Most important are close oversight and management by the chair, as if he or she had one team.” For solo radiologists at criticalaccess hospitals, teleradiology can be an invaluable resource for primary interpretations and consultations. At other times, using teleradiology can simply mean a chance to get some rest. Kinchen Ballentine, MD, the only radiologist at Abbeville Area Medical Center in South Carolina, says, “Occasionally, I send out interpretations so I can sleep all night.” Ballentine uses a large teleradiology group (primarily for CT and MRI exams) and relies on www.imagingbiz.com | December 2011 | Radiology Business Journal 61

RCM | Denials and Collections

Revenue-cycle Management: Minimizing Denials and Maximizing Collections

The shortest path to minimizing denials uses five basic steps to prevent them By Felix Okhiria, MPA, MA, CCPO, CMPE, CPC, CHC

he best way to minimize denials is to prevent them in the first place, by making sure that medical claims meet the requirements for clean claims. A clean claim is defined as a claim that meets the standards required by insurance carriers for payment on first submission. The components of a clean claim include (but are not limited to) conducting accurate demographic and insurance registration of patients, meeting timely filing deadlines, performing insurance verification, complying with utilizationmanagement requirements (such as preauthorization of advanced imaging), and reconciliation of incompatible diagnosis and procedure codes. Accurate Registration Registering the patient with the correct demographics involves gathering such patient information as his or her full name, correct address, date of birth, email address, and telephone number. This task is important not just in preventing a denial, but in ensuring that subsequent claims are filed for the correct patient. The information collected at registration also is important in enabling the practice to reach the patient, should there be a need to do so. With the wrong demographic information, patients might not receive information on the status of their medical conditions, and they might not receive results from their medical exams. Without a current address, the practice will be unable to bill uninsured (self-pay) patients, resulting in potential revenue loss. While accurate demographic information could prevent unnecessary

denials, the implication of inaccurate registration goes far beyond lost revenue. In performing the registration task, the practice must maintain a consistent pattern of registration to minimize the possibility of duplicating a patient’s record. A practice might decide always to register patients with middle initials or to include the apartment number in a patient’s address, but whatever pattern the practice chooses, it is important to maintain consistency. It is absolutely vital for a practice to verify the patient’s demographic information at every encounter. The verification process can be as simple as having the front-desk staff confirm a patient’s current address, telephone number, date of birth, and email address—or the process could involve having a preprinted form with the patient’s demographic information for the patient to confirm (or change, as necessary). Making sure that the practice has pertinent insurance information necessary for claims payment is another strategy that can minimize denials. This process entails gathering the patient’s insurance information (subscriber number, group number, and effective/expiration dates). For patients with two insurance carriers, the information on the secondary insurance must also be gathered and entered into the billing system. It is important for the registrar to designate the primary and secondary insurance carriers appropriately during the registration process (to prevent future claim denials due to coordination of benefits). The information on the primary and secondary carrier should be confirmed at every encounter to prevent

62 Radiology Business Journal | December 2011 | www.imagingbiz.com

claim denials, should the patient change or drop one of the two carriers. Coordination-of-benefits denial occurs when a claim that should have been filed with a primary insurance carrier is filed with a secondary carrier instead. When a claim is denied for coordination of benefits, the practice must then determine which of the carriers is primary. This could involve something as minor as switching the insurance priority in the billing system, or it might require contacting the patient to find out which insurance is primary. The insurance-registration process also requires the practice to identify a relationship between the patient and the subscriber (self, spouse, or parent/

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RCM | Denials and Collections

guardian) who is ultimately responsible for the medical bill. The identification of the relationship between a subscriber and the patient is important; it enables the practice to assign financial responsibility and follow up on unpaid claims. Timely Filing Denial for late filing occurs when a claim is submitted after the expiration

It is important for practices to pay attention to the filing deadlines of their insurance carriers to prevent avoidable claim denials, as some claims denied for late filing could actually have been filed before the deadline. In fact, in my experience, about half of the claims denied for late filing are incorrectly denied, and such claims are subsequently paid on appeal. A practice need not

In fact, in my experience, about half of the claims denied for late filing are incorrectly denied, and such claims are subsequently paid on appeal. —Felix Okhiria, MPA, MA, CCPO, CMPE, CPC, CHC NYU Langone Medical Center

of the time allowed for submission. Insurance carriers generally designate the time period; for Medicare in New York, New York, it is 12 months from date of service, with managed-care carriers’ requirements ranging from 45 to 180 days. Ideally, practices will submit their claims before filing deadlines, but denials for late filing could still occur when a claim is initially filed with the wrong insurance carrier. If the claim is not refiled with the correct insurance carrier on time, it might be denied for late filing. Another situation where late-filing denials could occur, despite the good intentions and diligent efforts of the practice, involves performing medical services in hospital settings. If the registration information sent by the hospital is incorrect, the process of verifying the information might be so lengthy as to compromise the filing deadline for some claims. A useful idea for minimizing bad data being fed into your billing system is to create a filter. This filter dumps new information on existing patients into a work queue for manual corroboration before the information is passed to your billing system. The idea is that the information in your billing system is constantly updated through your billing process and is probably more accurate than information coming from the hospital interface will be.

automatically write off claims denied for late filing, but should take the time to go through the claims to determine whether these denials were warranted. Insurance Verification Validation of the insurance information provided by patients during appointment scheduling, to be effective, should be completed before the patient’s appointment. The verification process requires the practice to confirm the insurance information provided by patients with the insurance carrier, prior to claim submission. Patients might inadvertently provide the wrong insurance information during transition from one job to another; they might not know when insurance coverage from a previous employer terminates or when coverage from a new employer becomes effective. Unless verification is done, a practice might not be aware that a patient’s insurance coverage has terminated until the claim is submitted and denied. If verification is performed, however, the practice will be able to find out that coverage from the previous employer has terminated. At that point, the practice just needs to contact the patient for new insurance information. A patient could also inadvertently give the wrong insurance information after switching insurance coverage during a

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re-enrollment period. While mistakes do happen, it is incumbent upon the practice to verify insurance coverage. If, after the verification process, it is discovered that a patient has no insurance, the practice will need to switch the registration to indicate that this is a self-paying patient. In such instances, the practice will need to activate its selfpayment policy, which might require that the patient be billed after the service—or could require payment in full at the time of service. Whatever the policy is, it is important for the policy to be communicated to the patient. At NYU Langone Medical Center (New York, New York), my preferred policy on self-paying patients is to require at least 50% payment at the time of service. This preference is rooted in the following principle: Since it is more difficult to collect accounts receivable from self-paying patients, it is important for collection to be made at the time of service. At the same time, a patient might not be able to pay the entire bill for advanced services such as MRI, CT, or PET. In such cases, the practice is not turning away patients (with the implication of lost revenue) and the practice is assured of collecting 50% of its standard charge. Preauthorization Requirements Meeting the requirement for preauthorization for high-end exams prevents avoidable denials for imaging practices. If a practice employs simple processes, there should be no reason to perform an exam without preauthorization. Preauthorization is required by many carriers for advanced imaging, such as CT, MRI, PET, and nuclear-medicine studies. Obtaining preauthorization usually involves a call made by the referring physician’s clerical staff to the utilizationmanagement office of an insurance carrier to request the approval of an exam. The utilization coordinator (usually a nurse) will ask questions relating to the patient’s condition—and, if satisfied that the exam is needed, will grant the request. Once the referring physician’s office has the authorization, it is now ready to schedule the exam. The radiology department must request the insurance

authorization for the exam before scheduling the exam (although some radiology departments will give a tentative appointment to a referring physician’s office, pending authorization). Once the imaging practice obtains approval, it should contact the insurance carrier to confirm the authorization. Claim denial for preauthorization failure usually occurs not because of the absence of approval, but because the approval provided could be for a different exam or for a different date of service—or the approval provided might have expired or could already have been used. Therefore, a practice must routinely confirm preauthorization with insurance carriers to prevent denials. This process works well for future appointments, but sometimes, a referring physician’s office requests a same-day exam for an urgent problem. In this case, imaging practices must evolve contingency plans to deal with same-day appointments. One method is to have a

dedicated staff member responsible for validating authorizations for same-day appointments. In some instances, the utilization coordinator for an insurance carrier will deny an authorization request, if the information provided by the referring physician’s office is deemed insufficient to confirm the need for a high-end exam. In other cases, an authorization request might be kept pending for more rigorous scrutiny. In either case, the practice should inform the patient and give the patient the opportunity either to reschedule the exam or to pay for it. Incompatible Codes Denials resulting from the incorrect association of diagnosis codes and procedure codes constitute one area that is not well understood by imaging practices. Medicare has a list of published diagnosis codes payable for most procedure codes, and any deviation from the published list will result in denial.

This practice puts the medical offices at a disadvantage, since exam coding cannot (and should not) be based solely on payable diagnosis codes. It is, therefore, important for imaging practices to educate their scheduling and front-desk staff to request additional information, when the diagnosis codes are not reimbursable, about signs and symptoms that might fall under payable categories. For instance, any diagnosis listed as ruling out a condition generally is not reimbursable by insurance carriers; when a patient presents with this type of diagnosis, staff members should request additional information about the signs and symptoms that brought the patient to the medical office in the first place. In some cases, these signs and symptoms could be reimbursable. While denials for incompatible diagnosis and procedure codes used to be the exclusive province of Medicare, other carriers have adopted similar measures. Many third-party insurance systems

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RCM | Denials and Collections

have editing capabilities that weed out incompatible diagnosis and procedure codes. A simple example would be a claim for an abdominal exam when the patient’s chief complaint is headache. Many carriers will deny such a claim, unless there is an established history of such an association (as seen in a patient with a history of metastatic cancer). Another example is a claim submitted for a male patient with a diagnosis limited to females, such as endometriosis. Such a claim is likely to be denied for incompatibility of diagnosis codes and procedure code. Similarly, a diagnosis of scrotal pain for a female patient will probably be denied. It is incumbent on imaging practices to obtain as much pertinent information as possible from patients or referring physicians’ offices to aid exam coding and subsequent payment. Another area of denial closely associated with incompatible diagnosis and procedure codes is the area of exam bundling. Bundling of exams occurs when an exam that could be billed using a single procedure code is billed using multiple codes. Claims for such exams are likely to be denied for bundling. An example would be a claim for a bilateral hip exam with a minimum of two views of each hip, including an anteroposterior view of the pelvis, submitted using the CPT® codes 73510LT (XR hip complete minimum of two views left), 73510RT (XR hip complete minimum of two views right), and 72170 (XR pelvis, one or two views). This is a classic example of bundling because the same exam can be billed using a single code, 73520. Another example would be billing a CT exam of the abdomen and pelvis, with and without contrast, using the old CPT codes 74170 (CT abdomen with/without contrast) and 72194 (CT pelvis with/ without contrast), when a single CPT code of 74178 (CT abdomen/pelvis with/ without contrast) would be sufficient for both exams. Begin at the Beginning It should be clear that the task of maximizing collections must start with the initial contact between a patient and an imaging practice. The appointment

schedulers, who are usually the first point of contact, must be educated to request additional information for signs and symptoms when the presenting diagnosis is not payable. The registration staff must be trained in accurately registering the patient’s demographic and insurance information. The staff members verifying insurance and preauthorization must be diligent in their duties, and coders must be careful to avoid submitting claims with incompatible diagnosis codes. In addition, an imaging practice could adopt other strategies to maximize collections; a policy of collecting copayments, coinsurance, and deductibles at the time of service is one such strategy. Since it is generally understood that Medicare pays 80% of the Medicare Physician Fee Schedule, a practice should calculate the 20% coinsurance for each category of exam for Medicare patients without secondary insurance and inform them that the 20% coinsurance is expected at the time of service. The same method can be adopted for other carriers. Another avenue for maximizing collections is aggressively addressing claim edits from clearinghouses and denials from insurance carriers. Edits from clearinghouses—which usually fall into the areas of missing subscriber numbers, wrong dates of birth, mismatched gender, and similar errors—can be easily rectified and turned around within 24 to 48 hours. Denials from insurance carriers should be monitored for patterns; if there is a pattern, the practice should find the root causes of the denials and correct them, so that future claims will not be denied for the same reasons. Practices should make every effort to make it easy for patients to pay by accepting all forms of payment, including credit cards, debit cards, checks, cash, and online payments. A practice should never be in the position of not collecting payment at the time of service because it lacks a mechanism to do so. Felix Okhiria, MPA, MA, CCPO, CMPE, CPC, CHC, is director of business services, NYU Langone Medical Center, New York, New York.

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advertiser index ACR (800) 770-0145 www.acr.org................................................................. 67 Affiliated Professional Services (800) 841-5200 www.affilprof.net......................................................... 63 Agfa (864) 421-1600 www.agfahealthcare.com....................................... 59–60 CompONE (800) 300-6717 www.componeltd.com................................................ 69 eRAD (864) 234-7430 www.erad.com............................................................ 35 Fujifilm Medical Systems (800) 431-1850 www.fujimed.com.................................................... 5, 25 GE www.gehealthcare.com/Imaging/RSNA/2011............. 17 GE Healthcare (800) 886-0815 www.gehealthcare.com............................................... 70 Hitachi Medical Systems America (800) 800-3106 www.hitachimed.com.................................................... 2 iCRCo Inc (310) 921-9559 www.icrcompany.com................................................. 23 Imaging On Call (888) 647-5979 www.imagingoncall.net............................................... 47 imagingBiz (714) 832-6400 www.imagingbiz.com.................................................. 51 Integrated Medical Partners (877) 816-1467 www.integratedmp.com.............................................. 27 Intelerad (514) 931-6222 www.intelerad.com................................................ 38, 44 Microsoft amalga@microsoft.com www.whatsnextinhealth.com/connectedimaging............. 3 MMP (800) 895-0002 www.cbizmmp.com....................................................... 7 ProScan Imaging (877) PROSCAN www.proscan.com...................................................... 61 Radisphere (866) 437-7237 www.radisphere.net.................................................... 29 RamSoft (888) 343-9146 option 2 www.ramsoft.com.................................................. 53–54 Regents Health Resources, Inc (800) 423-4935 www.regentshealth.com......................................... 18–20 Sectra (203) 925-0899 www.sectra.com.......................................................... 33 Virtual Radiologic (vRad) (800) 737-0610 www.virtualrad.com..................................................... 11 Visage Imaging (703) 858-5758 www.visageimaging.com............................................ 57 Vital www.vitalimages.com................................................. 31 VMG Health (214) 369-4888 www.vmghealth.com..................................................... 9 Watchtower Consultants (802) 871-5810 www.watchtowerconsultants.com.............................. 65 Zotec Partners (317) 705-5050 www.zotec.com........................................................... 13

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FinalREAD

Leadership

As Performance Art Tomorrow’s successful imaging leaders will be those who fully comprehend their roles By Curtis Kauffman-Pickelle

am sure that many of you have read the great 2004 book by Fred Lee, If Disney Ran Your Hospital.1 I have often used the material in this definitive treatise on customer service in my strategic-planning retreats, as the ideas and concepts about which Lee writes are timeless and apply to virtually any service organization. The book’s key takeaway is essentially that people judge organizations based on the total experience of their encounter with the enterprise. They compare this experience not necessarily with experiences at other, similar providers (in this particular example), but with what they know as the best customer-service experiences that they have had anywhere. It’s not surprising that Disney always tops the list of organizations seen as the best of the best. While this might not have been much of a concern in times past, when consumer choice was not a significant part of the referral equation in health care, the emergence of consumer-directed health care (as well as increased competition in virtually every market) has made the building of brand loyalty among patient populations increasingly important to all providers—and especially to medical-imaging services. When it comes to the marketing of outpatient imaging services, the freestanding community has had a bit of a historical advantage over the garden-variety hospital in the minds of patients and referral sources. That has been changing recently, as many hospitals have embraced the models developed over the past several years by many of the country’s top-tier imaging centers. Convenience, ambience, attentiveness, and friendliness, among other things, are elements now being expected in the hospital setting, and many hospitals are investing in

creating environments that rival those of their freestanding competitors.

Acting the Part This brings us to the performance-art part of the discussion. In my view, the successful imaging leaders of tomorrow will be those who truly understand that the roles that they are playing within their

All eyes will be on tomorrow’s leaders and they—you—will be expected to perform and act the part that corresponds with audience perceptions about what leaders do, how they act, and the confidence that they can instill. enterprises are those related to creating platinum levels of positive experiences for all of their audiences—referral sources, patients, employees, and so on. All eyes will be on tomorrow’s leaders and they—you— will be expected to perform and act the part that corresponds with audience perceptions about what leaders do, how they act, and the confidence that they can instill. Building loyalty among customers and employees will be the biggest challenge of tomorrow’s imaging leader. The degree to which you can rise to the challenge and make sure that your organization is among those that thrive (while all most certainly will not do so) will depend on how you choreograph and stage your performance.

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Can you inspire your staff to reach for new levels of productivity and quality? Can you communicate effectively the complex changes facing your hospital, practice, or center in a way that will not depress and demotivate? Can you clearly articulate your organization’s branding proposition to the referral community in a way that will make referrers feel good about sending their patients to you? Tomorrow’s successful health-care leaders will be those who understand that this mandate for superior communication and motivation will be an essential part of the leader’s portfolio. It will not simply be a part of the package that’s nice if you have it; rather, it will be the core of a well-rounded executive. We are entering an age in medical imaging in which the reimbursements will continue to decline; demand for services will remain very high, as baby boomers age; competition will become increasingly fierce, as providers seek to grow through gaining market share; and payors will demand a new balance in the cost/quality/outcomes equation. Added to this is the fact that consumers (patients) will become increasingly involved in the referral decision. This all adds up to a profession that is driven more and more by the laws of business, and those laws start with assumptions based on the perceived customer experience. Can you play the part of a next-generation health-care leader? Rehearsals start today.

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. Lee F. If Disney Ran Your Hospital: 9 1/2 Things You Would Do Differently. Bozeman, MT: Second River Healthcare; 2004.

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