Radiology Business Journal June-July 2010 by imagingBiz

FOR LEADERS IN MEDICAL IMAGING SERVICES

June/July 2010

CCTA

for Chest Pain in the ED:

Road to Acceptance

Featured in this issue Doing More With Less: Improving Productivity | page 16 The Captive Radiologist: Employment Versus Private Practice | page 26 Health-care Reform: Why Radiology Should Take Part | page 34

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FOR LEADERS IN MEDICAL IMAGING SERVICES

June/July 2010

CCTA

for Chest Pain in the ED:

Road to Acceptance

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CONTENTS

JUNE/JULY 2010 | Volume 3, Number 3

Features

CCTA for Chest Pain in the ED: The Road to Acceptance

By Cat Vasko The case for coronary CT angiography in the emergency department grows stronger every day, offering radiology practices that can deliver 24/7 interpretations a foothold in the exclusive field of cardiac imaging.

From Partner to Employee: The Captive Radiology Practice

By George Wiley The hospital-employed model and the proliferation of corporate teleradiology providers are causing more radiologists to choose employment over partnership.

4 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

A Health-reform Primer for Providers

By Cheryl Proval Tie your laces and get into the game, because reform, as viewed by the president of Kaiser Permanente Southern California, will initiate a period of great experimentation in health-care delivery.

Subspecialty Radiology: Beyond the Debate

By Julie Ritzer Ross While debate continues to swirl around the future of general radiology, the marketplace is clearly moving toward subspecialization and the real-world challenges that it presents.

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CONTENTS

JUNE/JULY 2010 | Volume 3, Number 3 Publisher Curtis Kauffman-Pickelle ckp@imagingbiz.com

EDitor Cheryl Proval cproval@imagingbiz.com Art Director Patrick R. Walling pwalling@imagingbiz.com Technical Editor Kris Kyes Associate Editor Cat Vasko cvasko@imagingbiz.com Contributing Writers David A. Dierolf; Christie James, MS; Julie Ritzer Ross; George Wiley Advertising Director Sharon Fitzgerald sfitzgerald@imagingbiz.com Production Coordinator Jean Lavich jlavich@imagingbiz.com

Departments

AdView

Finger in the Wind By Cheryl Proval

The Bottom Line

VP, Publishing Cheryl Proval VP, Administration Mary Kauffman

By Christie James, MS

Priors 12 Administration | Mindful Cost Cutting 14 Operations | Operating an Imaging-center Chain

in the Postapocalyptic Era Productivity | Dissecting a Mantra: Doing More With Less By David A. Dierolf

Leadership | Pat Basu, MD, MBA: The Radiologist in the White House

Advertiser Index

Final Read

PResident/CEO Curtis Kauffman-Pickelle

Can Decision Support Supplant Precertification?

Corporate Office imagingBiz 17291 Irvine Blvd., Suite 406, Tustin, CA 92780 (714) 832-6400 www.imagingbiz.com

The Message Is the Medium By Curtis Kauffman-Pickelle

6 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

Radiology Business Journal is published bimonthly by imagingBiz, 17291 Irvine Blvd., Suite 406, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. June/July 2010, Vol 3, No 3 ÂŠ 2010 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 406, 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.

AdView Finger

in the Wind MedPAC’s report to Congress takes on self-referral, but roughs up radiology

hysicians are in a real bind as feef o r- s e r v i c e reimbursement falls under attack and alternative payment methods (such as bundling and capitation) gain traction in Washington, DC. As of June 18, Medicare Part B claims were being processed with the 21.3% cut mandated by the sustainable growth rate’s formula, and House Democrats demanded legislation on jobs before they would pass the Senate bill to reverse the cut. This is not a transitory issue. There is no better finger in the wind for assessing sentiment inside the Beltway than the semiannual June report1 of the Medicare Payment Advisory Commission (MedPAC) to Congress. The report focuses entirely on ways to align the incentives of health-care providers and payors through changes in payment policy. The final chapter focuses exclusively on ways to address growth in ancillary services in physicians’ offices. My recommendation: Read it now. Previous MedPAC reports sowed the seeds of the imaging cuts seen in the DRA and in the Patient Protection and Affordable Care Act of 2010. This year’s report contains proposals that could have even more dramatic consequences for imaging, and they are not entirely negative.

The Upside The good news is that for the first time, MedPAC clearly distinguishes between imaging performed in physicians’ offices and imaging performed by radiologists. Noting that nonradiologists accounted for 69% of imaging services performed outside hospitals, while radiologists and IDTFs accounted for 31%, MedPAC recognizes selfreferral as a significant factor in the growth of imaging services over the past decade. One of the prevailing arguments for the provision of imaging and other in-office ancillary services (IOAS) by self-referring physicians is that it enables physicians to

make rapid diagnoses, therefore improving patient care. Using Medicare claims data to examine how often IOAS were provided on the day of an office visit, MedPAC looked into the mouth of that gift horse and found that IOAS are not performed on the same day as a related office visit most of the time. Just 10% of advanced imaging procedures were performed on the same day. Several ideas were proposed to address the growth of ancillary services. First, limit the types of services or physician groups covered by the IOAS exception (Stark law) to exclude outpatient therapy and radiation therapy, to limit the exception to physician practices that are clinically integrated, and to exclude diagnostic tests that are not usually provided during an office visit (such as advanced imaging). Second, implement payment tools to mitigate self-interest incentives by reducing payment rates for diagnostic tests performed by self-referring physicians and by imposing discounts that reflect the efficiencies of providing IOAS during the visit. MedPAC proposes using both empirical and clinical approaches to determine which studies should be covered by the IOAS exception. With the empirical approach, CMS would set a threshold for the percentage of certain tests provided on the same day and would refuse to pay for any test that is not provided at least that often; for example, if the threshold is 50%, tests would not be paid for if performed on the same day only 40% of the time. MedPAC suggests resetting the threshold every few years to allow for changes in practice patterns. Using a clinical approach, experts would determine which tests required patient preparation (prior fasting, for instance). Those tests could not be performed under the IOAS exception. MedPAC also suggests swinging the hatchet for across-the-board reductions in payment for studies billed under the IOAS exception (a kind of DRA for self-referrers). The amount of the reimbursement cuts

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would be determined by the average percentage of the increase in imaging utilization associated with physicians who own imaging technology. MedPAC cites its own analysis, which found that spending for imaging by self-referring physicians was 68% higher than spending by physicians who do not own imaging equipment. Other suggestions include making cuts based on the evaluation/management efficiencies obtained when the ordering physician is the interpreting physician and requiring self-referring physicians to participate in a prior-authorization program for advanced diagnostic imaging.

The Red Flag The most troubling aspect of the report is the suggestion that CMS review the professional component because “many procedures have never been reexamined to check whether the average time and intensity of effort to perform them has decreased due to advances in technology, technique, or other factors.”1 MedPAC plans to return to this subject in future missives. The temptation is to applaud the attack on self-referral, condemn the unfair call for a review of the radiology professional component, and fight tooth and nail for the preservation of the fee-for-service model. With state budgets in crisis and a rising federal deficit, however, it is time for radiology to take a longer view. As part of a health-care system that is headed toward insolvency, radiology has an opportunity to be a part of the solution, but vision and innovation will have to replace myopia and the status quo.

Cheryl Proval, Editor cproval@imagingbiz.com Reference 1. Medicare Payment Advisory Commission. Report to the Congress: Aligning Incentives in Medicare. Washington, DC: MedPAC; 2010.

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The Bottom Line

Can Decision Support

Supplant Precertification? Radiology decision support could qualify as meaningful use

ealth-care reform is here, and it’s the DRA all over again (but on steroids). Adjustments to the RVU for equipment utilization have increased from 50% to 62.5% for 2010 and will be capped at 75% for 2011 (for MRI and CT only). On July 1, the reduction in CT, MRI, and ultrasound technical-component reimbursement for contiguous imaging increased from 25% to 50%. Many commercial payors have already adopted the contiguousprocedure reduction or will do so soon. Some commercial payors are now applying this reduction to the professional component within the global payment, and a few have started to apply it to the professional component alone. Blue Cross Blue Shield of Massachusetts, for example, has announced that it will implement a 50% reduction to the global and professional components in August 2010. The radiology professional societies are fighting hard to prevent this, but they don’t seem to be making much headway. Payors are implementing higher deductibles and copayments, and radiology benefit management (RBM) companies are steering patients to providers of less-expensive (but not necessarily better-quality) imaging. About 70% of all covered lives in the United States are affected by the RBM process. According to one RBM, the overall denial rate (including orders withdrawn, ignored, or changed) is about 4%, but other RBMs report denial rates as high as 10%.1 Is the physician actually being educated by RBMs on the appropriateness of ordering high-tech imaging? Imaging centers and hospitals are finding ways around the RBMs to obtain precertifications for their referral bases, thereby creating a competitive edge for themselves. Is this all defeating the purpose of RBMs?

Decision Support An alternative to the RBM model is clinical decision support, which is gaining broad interest. Hospitals, in particular, seem eager to find a method that will let

by Christie James, MS

them reduce the effects of preauthorization and precertification on their costs. One of the three leading decisionsupport systems in use today was developed by physicians at Massachusetts General Hospital (MGH) in Boston.2,3 For the MGH system, clinical information provided at the time of ordering is combined with the patient’s age to produce a utility score for the examination requested. The scores are derived from ACR® appropriateness criteria and from evidence-based medicine, and the scoring criteria are frequently reviewed by imaging and clinical experts. A high utility score indicates that the clinical information provided strongly supports the use of the imaging test requested. A low score indicates that the information provided does not support the use of that test. The ordering physician will be asked to review the indications and to change, drop, or provide a reason to proceed with the order. Beyond educating referring physicians on the appropriateness of high-tech exams, the system lets them see prior procedures ordered, preventing procedure duplication. Another anticipated feature of this system is physician notification, at the time of exam ordering, of radiation-dose concerns. Most important, the imaging-appropriateness criteria remain under the influence of the radiologists who are the clinical experts. Decision support’s recommendations are made using a transparent algorithm (this is not the case for RBM recommendations). Decision support offers imaging alternatives, while RBMs do not. In addition, decision support can easily be integrated into major electronic medical record (EMR) systems. Payors substituting decision support for RBMs will obviously save the RBM fee. In addition, hospitals can negotiate payfor-performance contracts with payors in which the hospital assumes some risk, making decision support a more attractive proposition for payors.

Promoting Adoption It would be highly detrimental to radiology if CMS were eventually to adopt an RBM model. Administrative costs would continue

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to increase for the radiology provider and the referring physician. Many radiology professional societies are on board in favor of decision support, and several of them have issued position papers indicating this. So far, decision support has gained payors’ acceptance slowly, perhaps because payors are unwilling to make changes to an RBM model that often works in their favor. This could change, however, as incentives for the meaningful use of health IT (and penalties for failure to show meaningful use) take effect. Decision support could qualify as meaningful use, leading more hospitals to adopt it; as they do so, they add to the reasons for payors to accept it, since dealing with two models for utilization management simultaneously would be expensive. In June 2009, the Imaging e-Ordering Coalition was founded to promote decision support over the RBM model, as well as to promote the inclusion of decision support in EMRs and in public policy. Nonetheless, we want to continue to open channels to all RBMs, and we invite them to the table. Christie James, MS, is lead radiology billing manager for the professional billing office of Massachusetts General Physicians Organization in Boston and is chair of the Payor Relations Committee of the RBMA. This article has been adapted from “Decision Support: Is It an Alternative to RBMs?” (which she presented to the Northeast Chapter of the RBMA on April 16, 2010, in Tarrytown, New York). Massachusetts General Hospital’s decision-support experience will be covered in a future article. References 1. Pratt S. Imaging Ordering Decision Support. Washington, DC: Advisory Board Co; 2010. 2. Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH. Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: seven year time series analysis. Radiology. 2009;251(1):147-155. 3. Rosenthal DI, Weilburg JB, Schultz T, et al. Radiology order entry with decision support: initial clinical experience. J Am Coll Radiol. 2006;3(10):799-806.

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{priors} a d m i n i st r at i o n

Mindful Cost Cutting

onsider this scenario: You have exercised your duties as a manager over the past several years by cutting costs where possible, but now, you have been ordered to make further administrative cost reductions of 10%, 20%, or even 30%, and you cannot fathom how it will be done. Does this sound familiar? Dealing with a new wave of reimbursement cuts, imaging executives now face the daunting challenge of finding further ways to reduce overhead without impairing quality. An article1 published in a recent issue of Harvard Business Review distills 30 years of consulting, across multiple industries, into three distinct patterns of administrative cost-reduction opportunities at the 10%, 20%, and 30% mandated-cut levels. Principals in an executive consulting company, the authors forewarn that there is no silver bullet; no single idea can solve your problem. Rather, expect to reach your goal through a minimum of 10 actions. Opportunities to cut costs 10% are referred to as incremental ideas, and they include consolidating incidentals, taking overdue personnel actions, reducing spending on department management, getting control of expenses categorized as miscellaneous, holding down pay raises, and resurrecting rejected cost-cutting proposals. To get to a 20% reduction, it is necessary to remove a significant portion of the work content from the department. The authors call these redesign ideas, and the best way to begin uncovering such opportunities is to talk to counterparts in other departments about ways to eliminate or modify your service to them. Possibilities include eliminating liaisons and coordinators; reducing excessive service levels; changing processes through adopting automation, altering timing, and eliminating exceptions; and moving away from excessive contingency planning (which the authors call the belt-andsuspenders mindset). While redundancies and contingency planning may be essential to the clinical side of health care, opportunities may exist in radiology to

reduce, for instance, the amount of data kept online, as opposed to in storage.

The 30% Solutions Managers charged with eliminating 30% of their departments’ overhead are unlikely to succeed if they think entirely within departmental walls. Noting that organizations can be inefficient even when each department operates efficiently, the authors urge readers to think more broadly. One opportunity that may resonate with health-care administrators is the coordination of parallel activities or purchases with other departments. Many departments in an organization frequently purchase from the same suppliers, and health care is no different. The authors cite office supplies as an example, but similar opportunities exist for medical equipment and supplies. A recent article2 in Medical Imaging Review described an initiative underway at Fairview Health Services, Minneapolis, Minnesota, to funnel imaging capitalequipment purchases from all departments through one person or department to leverage purchasing opportunities. The authors identify six other categories of opportunity. First, shift responsibilities to the most efficient location. If there are multiple people, across multiple departments, who have the same responsibility (for example, checking data accuracy or handling quality assurance), perhaps the best solution is consolidating that responsibility in the location that is most efficient, or in the location with the highest investment in success. Outsourcing is another potential opportunity across departments; candidate activities include payroll, billing, benefits management, recruiting, and media planning. Second, eliminate duplicative analysis. If multiple departments are looking at the same thing (the impact of health-care reform on the department, for instance), perhaps it is time to consolidate the review into a single coordinated effort, which is what the most efficient companies do. Otherwise,

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you risk wasting resources. Third, eliminate low-value meetings. Freeing top executives from unproductive meetings can increase the time that they spend on productive activities. Fourth, restructure or cut crossdepartmental activities. Be ready to take on even the sacred cows here: One company that prided itself on hiring the best talent revised its hiring practices to eliminate all but three interviews for each candidate. Fifth, eliminate low-value programs. If you can’t reach your goal with wellconsidered cuts, you may have to eliminate entire programs, but be sure to consider unintended consequences. Recall that many health-care providers reduced or eliminated mammography services in the early part of the decade only to reinstate them later, recognizing both the importance of the patient group (women) and the potential downstream revenue. Sixth, reduce your burden footprint. Since you are thinking globally, pursue opportunities to tell other departments how they might be overserving you. In conclusion, the authors propose this question: What is the right level of overhead? Their belief is that overhead should be incurred for just three reasons: to make your direct activities possible, to increase their effectiveness, and to lay the groundwork for growth. —Staff References 1. Coyne KP, Coyne ST, Coyne EJ. When you’ve got to cut costs—now. Harv Bus Rev. 2010;88(5):74-82. 2. Proval C. Leading an HCO in an era of scarce resources. Medical Imaging Review. http://www.imagingbiz.com/articles/ view/leading-an-hco-in-an-era-of-scarceresources-implications-for-radiolog. Published April 16, 2010. Accessed June 17, 2010.

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o p e r at i o n s

Operating an Imaging-center Chain in the Postapocalyptic Era

t began with the DRA, and ever since, CMS and Congress have set upon outpatient imaging like dogs on a bone, culminating in a new round of cuts to the technical component contained in the health-reform law. As a result, operations at many outpatient-imaging organizations came into acute focus in 2005, and they continue to be scrutinized. Radiology Business Journal talked with Clete Madden, COO of Touchstone Medical Imaging (Brentwood, Tennessee), an OIC company with 18 locations, but this was no pity party. Madden is downright upbeat about the future of outpatient imaging. RBJ: After DRA implementation, cuts to the technical component of outpatient imaging resulted in a significant blow to revenue for outpatient-imaging providers. Have you done the math on how the changes to the equipment-utilization rate and multipleprocedure discounts will affect revenue in 2011? Madden: We’ve done certain calculations on that, and the impact depends upon your payor mix, obviously. We’re well under 20% for Medicare in our payor mix, so it’s not as severe for us as it might be for others. We’ve definitely done the math and have a feel for what the impact could be, and we continue to monitor it. It will have a noticeable impact, but it is not something we can’t overcome, just as we did with respect to the DRA. RBJ: If it is like many other imagingcenter companies, Touchstone tightened operations considerably after the DRA. As COO, where will you look for cost-cutting opportunities? Madden: Anybody still in the will-look stage has got some scrambling to do. We’ve been looking at this for quite a while now, knowing that something was coming down the road. We’ve looked at every expense line item and prioritized the highest-cost line items first. We looked at payroll, radiology reading-fee contracts, equipmentmaintenance arrangements, facility leases, and billing/collections, and we are pretty deeply into several initiatives that involve cost cutting in all of those areas. RBJ: As the COO of an IDTF, you have been in a good position to test the quality and

the prices in the teleradiology marketplace. Have you been able to achieve any savings here in cost or turnaround time? Madden: We’ve looked at that, and Clete Madden we’ve had some people approach us. At present, we are not too deeply into teleradiology, with a couple of exceptions. Our focus has been making sure that radiologists are on-site at our centers, for a number of reasons (including covering contrast administration and being available for consultation with referring physicians). A couple of things that we have done in teleradiology have been more payor driven. In one part of the country, we have an initiative where the payor has reduced its network and let in fewer radiology imaging centers. You have to meet certain quality metrics and technology metrics before the payor will let you in, and as part of that, we have a backup teleradiology arrangement in place. If there is not a neuroradiologist with a certificate of added qualification available, the backup is through this teleradiology provider. We have a couple of instances where we have carveouts on the radiologist contracts we have, because a particular referring physician wants a particular national group to read his or her studies. Aside from that, though, we have not done a whole lot with that. RBJ: Are there opportunities to increase volume to offset reimbursement reductions? Where are the short-term referral opportunities? Madden: For us, the first and foremost concerns are continuing to provide highquality care to patients and timely reports to referring physicians (and not compromising on that), holding hard and fast to our bread and butter. Payors are getting more astute with respect to quality requirements, which is the reason for one of the teleradiology arrangements I mentioned earlier. Showing that we can get into those arrangements is helping our volumes and keeping out competitors that can’t meet those metrics.

14 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

We’re still talking about our pricing because we are definitely a better option than many hospitals and hospital/IDTF joint ventures, and much more convenient, and the consumers are getting more savvy every day. That’s creating opportunities for us with some of the payors. We have a couple of arrangements in which the referringphysician pool is actually incentivized, through a bonus pool, to steer imaging out of hospitals. We’ve become part of those. We’re also seeing competitors in certain service areas that don’t have the secure financial characteristics and balance sheet that we have, resulting in the closure of their operations. We see some opportunities through technology, especially with potential physician portals (to referring physicians) that would let us become more connected to them. We’ve also been approached by some hospitals to do some joint ventures. We’re looking into those. It sounds good on paper, and there have been some successful arrangements in the past few years that we are aware of, but the payors are starting to get savvy with respect to those as well. We are being very flexible in our hours of operation at the centers. We have extended hours and are open on Saturday, and that has done well for us. We also are somewhat encouraged by the so-called sunshine provision in the health-reform law: If physicians use the in-house ancillary exception to the Stark law for MRI or CT, they are required to tell patients, in writing, that they have a financial interest in that imaging equipment, and to provide a list of alternative sites. It’s baby steps on the self-referral issue, but better than nothing. We’ve seen a handful of physicians who have provided the list, and some who have stopped taking Medicare patients (who then are sent to us), but it’s not a significant number yet. RBJ: What do you expect from health-care reform and its 32 million new covered lives? What are your projections for impact on volume, and how are you preparing for this eventuality? Madden: In general, we hope that it has a positive impact, but we are still studying it. The 32 million won’t come onto the market until 2014, but we certainly hope that there

will be an uptick in our markets; how much, I don’t know. The area of the country you are located in is a factor. I would expect it will have a greater impact along our southern borders . We’re trying to look at growth areas that are contiguous to our existing markets: We are in Dallas/Fort Worth, Texas; Denver, Colorado; and a handful of others where there is a lot of projected growth, so we are trying to focus on those areas. Obviously, it is not rocket-science strategy. We think that if we can overlay our model on less-robust centers in some of these growth areas and apply our processes, we should do pretty well. We are going to be selective, but (we hope) also opportunistic. RBJ: The health-reform law appears to be stacked in favor of integrated delivery systems, bundled payments, and medical homes. Where do you see the IDTF fitting into the new order? Madden: I’ll try not to sound cynical here. Integrated delivery systems have been around since 1990. Even back then, there were a lot of consultants making a lot of money telling hospitals’ administrators they had to be a part of integrated delivery systems and helping them set up those systems; a few years later, those hospitals wrote off a lot of physician-practice acquisition goodwill. I was engaged with an integrated delivery system in the past few months, helping a close family member through a health-care issue, and they took this person’s medical history four times, took blood and vital signs three times, filled out a forest’s worth of forms, and billed the person incorrectly a few times. I was thinking, “Is this integrated delivery system really working?” Having said that, we’ve had numerous discussions with hospitals about joint ventures and fitting into an integrated delivery system, and even with some large physician groups and independent practice associations. If the physicians are willing and able, they (as opposed to just the hospitals) can really drive this thing. We are still exploring it. I guess I am naive, in some respects, to think that if you continue to provide high-quality service, with high-quality equipment, at an affordable price, in a setting that is

accessible and convenient for the patient, you might end up doing OK. RBJ: To paraphrase Samuel Clemens, then, are the reports of the demise of the IDTF industry premature?

Madden: I think so. Look at the big boys: RadNet and Alliance Imaging. They are raising more money to buy underperforming centers, and I think there is an opportunity there for us to do the same. —Staff

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priors

productivity

Dissecting a Mantra: Doing More With Less Improving productivity in the imaging workplace begins with measurement By David A. Dierolf

henever the economic aspects of business get tough, do more with less is a phrase heard everywhere. Of course, doing more with less just means becoming more productive. There is no scarcity of literature on productivity, and some authors claim to have identified more than 20 definitions for productivity. Economists use the term to measure the capacity of nations to use their human and physical resources to produce economic growth. A simpler definition, though, is that productivity equals output divided by input. The output is the product or service delivered, and the input is what was consumed in creating the output. Many different inputs are consumed in producing a product or delivering a service, but itâ&#x20AC;&#x2122;s simplest to consider one at a time. The output of an imaging operation could include procedures performed, patients served, reports signed, revenue generated, or even something more abstract, such as RVUs generated. Input is most often expressed as some measure of labor; this could be hours, FTEs, or labor dollars. Even for this simple definition, there are still many analysis options. Which outputs and inputs should be used depends on your reasons for measuring productivity, as well as on

who will be using the measurement.

M e as u r i n g Productivity Why measure productivity? If the goal is to do more with less, you wonâ&#x20AC;&#x2122;t David A. Dierolf know whether you have achieved the goal without a measurement. When you consider declining reimbursements and rising salaries/benefits, maintaining profitability becomes a concern. Imaging operations are characterized by large fixed costs that are not easily lowered. One quickly realizes that the salaries/benefits area is one where there is a possibility of improvement. Probably the best reason for measuring productivity is to substantiate your success at improving it. This idea highlights an important aspect of measuring productivity: You need to take multiple measurements over time. The absolute value of the productivity measurement is less important than how the measurements are trending. Consider a few examples. The first example takes a high-level financial view. Two readily available numbers, for many

operations, are the revenue generated and the total dollars spent for salaries/benefits. Revenue is the output, and salaries/benefits dollars are the input, so our high-level productivity measure is revenue divided by salaries/benefits. If your revenue for the month was $500,000, and you spent $100,000 on salaries/benefits, the productivity measurement would be five: For every dollar spent on salaries/benefits, you generated $5 in revenue. This single measure is not all that useful, but if you checked it every month, you could identify the trend in labor productivity. This financial measurement really does not tell you why productivity is trending the way it is, nor does it say much about how hard your people are working. Financial productivity could be trending downward because reimbursement for the service offered is decreasing, for example, or because the cost of benefits for your employees is going up (and both are likely scenarios for imaging operations today). The next example yields another highlevel performance measurement that is not monetary. This example employs RVUs as the output and FTEs as the input. RVUs are very useful in considering multiple

Productivity improvement

Increase volume

Increase referrals

Increase throughput

Reduce labor hours

Add capacity

Larger market

Process improvement

Longer hours

Larger market share

Technical aides

More equipment

Crosstraining

Figure. Drivers of improved productivity in the imaging workforce.

16 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

More part-time/ as-needed workers

Reduced operating hours

Efficient shift strategies

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modalities at the same time because they account for the differences in complexity of the exams. One FTE equals 40 hours of labor, but when I calculate FTEs, I usually exclude paid time off (since as-needed staffing and overtime are used to cover the person on vacation, who is not producing any output). The formula, then, is RVUs divided by FTEs. If your center produced 1,000 RVUs in a week, with 20 FTEs, your productivity number would be 50 RVUs per FTE. By watching this number from week to week, you get a feel for the natural variation in the measurement and can determine the trend. This measurement focuses on the performance of people and removes (or, as some might say, hides) the effects of declining reimbursement and the rising cost of salaries/benefits. It is still a highlevel measurement, and it does not provide much insight into what is causing changes in productivity. An obvious refinement would be to group the FTEs into functional areas. In this example, FTEs are broken into groupings of those performing clinical work (technologists and nurses) and those working in business-office functions (scheduling and registration staff ). Clinical work can then be broken down by modality. As the measurement looks at smaller and smaller groups of workers, what is causing productivity changes should become clear. The measurement becomes

easier to understand as well. If we are just considering a single modality, exams can be substituted for RVUs, and the productivity measurement becomes exams per technologist FTE. For the business office, one might want to use patients instead of exams, creating a productivity measurement of patients per scheduling FTE. The main requirement of this type of productivity measurement is the ability to track labor hours and outputs (RVUs, patients, or exams) over common time periods (weeks, months, or pay periods). You might find this requirement somewhat challenging.

Improving Productivity Once productivity is being measured, how to improve it can be considered. There are two different ways to improve productivity. You can increase the output (using the same amount of input), or you can produce the same output with less input. In more operational terms, this means adding volume without increasing labor hours or maintaining volume while reducing labor hours (see figure). The figure is loosely based on a slide from the Advisory Board Co (Washington, DC). It shows how the drivers of productivity can be grouped either as factors that increase volume or as factors that reduce labor hours. If you have equipment that is idle during operating hours, you can increase your marketing efforts to add to your

volume, or you can reduce operating hours and subsequently reduce labor hours. If your equipment is in full use, you can look into throughput enhancements or adding capacity. A key point: Productivity improvement is not just making people work harder. Along the same lines, you cannot just assume that increasing throughput will increase productivity. If your center is open for eight hours, but the current volume can be handled in five hours, increasing throughput so that the same volume can be managed in four hours will add capacity, but it will not increase productivity. Remember to watch the trends, not single data points. High-level productivity measures are good, but you need to drill down to understand how you can make improvements. Consider what drives productivity and your operational situation when developing an improvement strategy. A word of caution: productivity improvement must always be done within the guardrails of customer and employee satisfaction. Having a highly productive organization full of unhappy employees, who then provide lousy service to patients and referring physicians, is a recipe for disaster. As with many things in life, the trick is to find the right balance. David A. Dierolf is vice president of performance improvement, Outpatient Imaging Affiliates, Nashville, Tennessee.

leadership

Pat Basu, MD, MBA: The Radiologist in the White House

hile radiologists have served in prominent positions in Washington, DC, in the past, none have ever served as White House fellow and special assistant to the president before the recent appointment of Pat Basu, MD, MBA, as one of 13 men and women to serve in the 2010–2011 class of fellows. An attending radiologist at Stanford University and the VA Palo Alto Health Care System in California, Basu is course director of health policy, finance, and economics and a former Rutherford fellow in the Washington ACR® office. White House fellows usually spend a paid year working with senior White House staff, Cabinet secretaries, and other top-ranking officials, and their responsibilities include chairing interagency meetings, designing

and implementing federal policy, and drafting speeches for Cabinet secretaries. Radiology Business Journal spoke with Basu to find out why he would leave Pat Basu, MD, MBA the faculty of one of the most prestigious teaching institutions in the country (and take a 70% to 80% pay cut) to spend a year in the White House. RBJ: Why now? What led you to Washington at this time? Basu: I am a first-generation American. My parents had come to this country well over 40 years ago; my older brother (who happens to be a radiologist), my younger

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sister, and I were not born yet, but they came for the American dream. I still very much believe in the American dream and in the ideals and freedoms this country offers. I look back at all of the people who have believed in me: teachers, coaches, parents, family, and friends. With my energy, background, and training in medicine and business, I feel that there is something I owe and that I have to offer. Many people told me the same thing: If you get this appointment, that would be incredible, but it is a bad time. We are in two wars, the economy is in a shambles, the health-care system is broken, the education system is broken; it’s tough, but that’s the nature of the work. If I can make a difference in the lives of people, that would be very fulfilling for me.

RBJ: As course director at Stanford of health policy, finance, and economics, you have a great vantage point from which to comment on how The Patient Protection and Affordable Care Act of 2010 could affect radiology. With so many references to accountability and bundling in the legislation, what are the dangers for radiology? Basu: The biggest danger for radiology is not to be a part of the solution—not to be at the table. Radiologists are uniquely positioned to understand so many elements of the health-care system. We are in one

conversation. Sit down with legislators and administrators and begin a conversation. Here’s a story I share in a leadership class that I do: People on one side of the class are given a sheet of paper that says they need a bunch of oranges to make orange juice, and those on the other side are given a sheet of paper saying they need a bunch of oranges to use the peel to make lotion. They argue back and forth without realizing there is a win–win solution for both sides. If one side gets the peels and the other side gets the juice, they can both win.

All too often, all of the parties in medicine— radiologists, physicians in general, administrators, and legislators—are not seeing the overall picture as a potential win–win situation; they are seeing it as a zero-sum game. —Pat Basu, MD, MBA, Stanford University, Stanford, CA of the few specialties that sees patients in the outpatient setting, the emergency department, and the inpatient setting. We are in one of the few specialties that sees patients for ailments from the brain to the lungs, the abdomen, and all the way down to the legs and toes. We also deal with a lot of high–capital-expenditure equipment that we have a great amount of control over; we are very uniquely positioned. My biggest fear is that radiologists and physicians at large will not participate in the process. If you don’t participate in the process, you leave yourself open to not having a voice. I’ve seen that many times, in the past, in various physician capacities, and in people who are not members of the ACR. If you are not active directly, then you should be active indirectly. That is what they need to think about: the long-term future of health care. RBJ: Are there specific opportunities for radiology to participate in meaningful reform? Basu: Specifically, it would be in contributing to how we can maximize appropriate imaging. How can we decrease inappropriate imaging? More generally, a lot of people get fixated on the details of the conversation, and the devil is in the details. What it really takes is an initial

All too often, all of the parties in medicine—radiologists, physicians in general, administrators, and legislators— are not seeing the overall picture as a potential win–win situation; they are seeing it as a zero-sum game. More of those conversations involving radiologists, other physicians, and CMS administrators are what need to happen. Quite frankly, I think there are solutions that we haven’t even thought of yet. RBJ: What unique value will the perspective of a radiologist bring to health-care policymakers in the White House? Basu: We are some of the best-positioned physicians to see patients across horizontal integrations: We see them in every level of care, from chronic care to acute care, across subspecialties. If you make an axis vertically of all of the subspecialties, and then horizontally for the different settings in which you see patients, we are in one of

the few specialties that sees virtually every single box. To the vertical and horizontal axes, add 3D: We also deal with procedures, hightech equipment, diagnosis, and treatment. We have a very broad perspective, and that perspective is what I hope to bring. RBJ: What advice would you offer to radiology departments and private practices that are seeking to prepare for health-care reform? Basu: Take the first step: Engage in that conversation. I don’t want to tell people what to say before they have started that conversation. RBJ: Do you know what you are going to be doing in Washington? Basu: I do not. I have to interview with the different secretaries over the next month or so. My appointment doesn’t officially start until August 30. I have a general idea of the overall position, but what I will be working on is still to be determined. RBJ: How much time are you spending in the reading room these days, and how will you continue to practice your skills in Washington? Basu: Currently, I am spending more than 70% to 80% of the time in the reading room. In Washington, my primary responsibility is going to be the federal-government job. RBJ: What are the three most important things that you will pack in your suitcase? Basu: I am going to get existential. The most important thing I can bring is the versatile personal and professional background that makes me who I am. I’ve had a lot of different experiences in different jobs, and I am a very outgoing person in talking with people and hearing their ideas. That conglomeration of education and experience is number one. Number two is the high energy and positive outlook that I bring to the table. Those two won’t fit in a suitcase, but they are the main things I need to bring. Is there something that can go in a suitcase? Being in Stanford and living in California, I very rarely wear a tie at the office, but working at the White House is going to be a little different. A nice collection of new ties is probably going to be necessary. —Staff

www.imagingbiz.com | June/July 2010 | Radiology Business Journal 19

Cover Story | Emergency CCTA

The Road to Acceptance: CCTA for Chest Pain in the ED The case for coronary CT angiography in the emergency department grows stronger every day, offering radiology practices that can deliver 24/7 interpretations a foothold in the exclusive field of cardiac imaging By Cat Vasko

oronary CT angiography (CCTA) could be radiology’s most notorious underperformer. As the number of CT detectors increased from one to 256 and beyond, as the resulting images showed ever more exquisite detail of the chambers and vessels of the heart, CCTA nonetheless failed to overcome politics, sluggish reimbursement, and entrenched practice patterns to achieve the acceptance so widely anticipated. The future of that most underappreciated of radiologic studies, however, appears destined to improve: Multiple recent studies have validated CCTA as an effective method for ruling out acute coronary-artery disease in emergencydepartment patients presenting with nonspecific chest pain. In addition, CCTA requires less time than a traditional workup does, and it has a lower associated cost and radiation dose. As the most congested department of almost any hospital, the emergency department is an ideal proving ground for CCTA, which offers the rapid throughput so desperately needed to reduce patients’ waiting times and to decrease unnecessary hospital admissions.

William Shuman, MD, is professor and vice chair of the Department of Radiology at the University of Washington School of Medicine in Seattle. He says, “All emergency departments are suffering from overcongestion. They want to increase throughput and decrease turnaround time. Our research indicates that if you apply cardiac CT to the right population, it will get them in and out of the emergency department in under five hours, whereas the standard work-up can take 20 to 23 hours.” A Population in Need As Shuman indicates, the first issue tackled by clinicians aiming to prove cardiac CT’s worth as a triage tool is, of course, determining which group of patients will benefit most from its use. Like all diagnostic technologies, cardiac CT is hardly a onesize-fits-all method, according to Charles White, MD, professor of radiology and medicine and chief of thoracic radiology in the Department of Diagnostic Radiology at University of Maryland Medical Center in Baltimore. In May, at the 2010 Annual Meeting

20 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

of the American Roentgen Ray Society, Lu et al1 presented the results of research evaluating 256-slice CT’s diagnostic efficacy in patients with indeterminate chest pain. White, a coauthor, notes, “Our criterion was that patients were at low to intermediate risk for acute coronary syndrome. These were not patients the emergency department was worried about, but they weren’t unworried about them, either. They would still have been stuck possibly admitting these patients unless they went and got the CT.” White says that patients in what he calls this in-between group can be selected according to the nature of their chest pain and whether they fall into a highrisk category. “They’re patients who don’t have classic angina chest pain or classic nonangina chest pain,” he says. “The other piece is risk factors. If a 20–yearold patient presents with chest pain, it’s almost certainly not cardiac. It’s older patients, smokers, and diabetics; these are all patients who might be dealing with coronary syndrome.” White estimates that this group constitutes around 30% to 50% of patients presenting with chest pain.

Shuman et al2 and May et al3 used similar criteria for research evaluating the use of 64-slice CT. Shuman (also a coauthor of the May et al study) notes that a hospital’s population at low-tointermediate risk can vary, depending on its location and on demographic factors in its area. “Depending on the population the hospital serves, in some emergency departments, up to 20% of the patients who come in the door are presenting with chest pain,” he explains. “Patients at lowto-moderate risk for acute coronary-artery disease could represent up to 85% of that group. We use thrombolysis in myocardial infarction (TIMI) criteria to identify these patients; those with a TIMI score of four or lower, we consider at low-to-moderate risk for coronary-artery disease.” Judd Hollander, MD, professor and clinical research director in the Department of Emergency Medicine at University of Pennsylvania in Philadelphia, has investigated the issue from the perspective of the emergency-department clinician, and the criteria for CT evaluation of chest pain used in a study by Hollander et al4 were similar. “We looked at patients who were admitted to the hospital, but were still on the low-to-intermediate risk scale: patients who needed some kind of testing, but we suspected the tests would be negative,” he says. “Our normal protocol would involve admitting them to the hospital, where they would get a series of cardiac markers or a stress test, requiring an overnight admission.” Hollander estimates that these patients account for 40% to 60% of those presenting with chest pain. The Work-up Doesn’t Work A standard work-up for an emergencydepartment patient with indeterminate chest pain includes admission to the hospital, where a number of tests are performed; these range from nuclear stress tests to ECGs to cardiac-enzyme analyses. “Patients who have three sets of negative enzymes, three sets of negative ECGs, and a negative stress test have a very low prevalence of experiencing an adverse cardiac event within the next three months,” Shuman explains. It is this extensive work-up, aimed at ruling out the possibility of acute coronary-artery disease

Our research indicates that if you apply cardiac CT to the right population, it will get them in and out of the emergency department in under five hours, whereas the standard work-up can take 20 to 23 hours. —William Shuman, MD, University of Washington School of Medicine, Seattle, WA

as completely as possible, that results in the 20 to 23 hours typically needed before the patient can be discharged. Shuman points out that the standard work-up for chest pain is not without its flaws (not just when it comes to time and costs, but clinically as well). “About a quarter of the time, stress-test results are equivocal due to artifacts, false positives from attenuation in large breasts, or false negatives if there’s equally bad disease in all three vessels, which makes the stress test look normal,” he says. “It’s less than perfect.” Hollander adds that the results of a stress test are not necessarily conclusive over the long term. “The stress test doesn’t tell you whether there’s no disease,” he notes. “It just tells you that there’s no critical disease right now. Recurrent chest pain in people with a prior stress test most often results in readmission, whereas with a CT, it results in discharge. If you have a CT, you can also prevent readmissions over the next several months, or even one to two years, if you’ve ruled out disease.” Ruled out is the critical term: The goal of both methods (perhaps heightened by the threat of malpractice suits filed by litigious patients) is to determine, as definitively as possible, whether the patient is at risk for an adverse event in the near future. “Often, these patients may be admitted to the hospital just to make sure nothing’s going on,” White notes. “Even if they aren’t admitted, rule-out in the emergency department can take at least 24 hours. CT is how we short-circuit that process. If we view the results of the CT as definitive, we can just send the patient home.” Protocol and Pace Shuman’s research studied the use of 64-slice CT in the triple–rule-out (TRO)

protocol, which looks at the whole chest (instead of just the heart) in order to rule out the most common causes of chest pain. He explains, “Our entry criterion was nonspecific chest pain, so we had other causes of chest pain in the differential diagnoses: chest-wall disease, rib fracture, lung disease, and so on. We tended toward TRO for the whole chest.” White, whose research with Lu et al also used the TRO protocol, offers a historical perspective on the use of this method. “We’re not necessarily strongly in the TRO camp; it’s more that that’s how we started the program, when we were using 16-slice CT, and it’s what our clinicians are most comfortable with,” he says. “There is some literature to suggest that about 5% to 10% of the time, it finds things you might miss with dedicated cardiac CT, such as pulmonary embolism or pneumonia.” Although dedicated cardiac CT has traditionally been viewed as exposing patients to lower radiation doses than TRO does, White notes that this issue can be solved using newer scanners’ prospective gating. “You can mitigate the dose with prospective gating,” he says. “In our study, it’s not so much that every patient merited TRO; it’s more that in general, when radiologists read here, they may want a more comprehensive look.” Shuman also reports incidental findings at a rate of about 10%. “You do occasionally encounter a lung nodule, esophageal disease, or a findings in the spine or chest wall,” he says. “We report those to the emergency-department physician, who can make arrangements for subsequent workup.” He adds, however, that “anything that causes chest pain is not an incidental finding,” which is further argument for the use of TRO protocol. “All of our patients were scanned with prospective gating,

www.imagingbiz.com | June/July 2010 | Radiology Business Journal 21

Cover Story | Emergency CCTA

The negative predictive value of CT for coronary disease is very high; most studies, ours included, suggest it’s above 95%. —Charles White, MD, University of Maryland Medical Center, Baltimore, MD

which has a dose about 80% lower than that of retrospective gating,” he notes. “At that rate, we felt it was reasonable to scan the larger area.” Whichever protocol was used, CT was found1-4 to be a much more rapid method for patient triage than a standard workup was. “Being able to discharge more patients benefits everyone,” Hollander says, “because emergency-department crowding is just a function of too many patients being admitted.” Hollander notes that according to his research, using CT for triage in patients at low-to-intermediate risk takes 12 to 15 hours off of an average patient’s hospitalization time. Because his facility is large enough to support several CT scanners, “there’s no adverse impact on time spent waiting to scan. Even if you get a little delay going into the scanner, it’s a minority of patients in the emergency department who wind up going there.” Shuman notes that triage with CT resulted in improved workflow for both the radiology department and the emergency department. “The emergencydepartment physicians really like getting definitive information quickly, choosing a course of action, and then sending the patients home or admitting them,” he says. “We do a cardiac CT now in about 7 to

10 minutes of room time. Reading time for a normal case is about 10 minutes. We can wheel the patients across the hall, scan them, have them back in 15 minutes, and have their results 10 minutes later.” White, however, strikes a more conservative note. “There’s no question that your CT volume will go up if you implement this as the standard,” he says. “Workflow is a very real consideration, and people should go into this kind of program with their eyes wide open and do whatever they can to ease the transition: Work with their emergency-department physicians and set up guidelines so there are as few unnecessary studies done as possible.” The Economic Case In all three physicians’ research, most patients are discharged and sent home, with the possibility of an acute coronary event ruled out through the use of CCTA. “The strength of this technique is highlighted in the negative because if a patient is shown to have coronary-artery disease, his or her work-up doesn’t change,” White says. “The negative predictive value of CT for coronary disease is very high; most studies, ours included, suggest it’s above 95%.” Hollander notes that a CT exam is significantly less expensive than a nuclear stress test, observing, “It’s not just that it’s cheaper in a test-by-test comparison. When you consider the fact that the other test comes with a hospital admission, it’s a ton cheaper.” White adds that in spite of the potential for increased CT volume if CCTA is adopted on a wide scale for chest-pain triage, “It becomes a scale: On one hand, you have the cost of all these additional CTs, and on the other, you have all the tests you were doing that might be eliminated: stress tests, cardiac catheterizations, and ECGs. There’s very preliminary evidence that suggests that CTA results in cost savings because of the high negative rate of

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studies and the elimination of downstream studies and hospital admissions,” he says. Shuman’s hospital analyzed the costs associated with both types of work-up and was able to assign a dollar value to each. “When we really dissected out every charge we could find with each,” he says, “we were looking at about $8,000 for a traditional work-up versus $4,200 for a CT-based work-up. That’s nearly a 50% savings in cost.” Barriers to Adoption Early experiences indicate, fairly unanimously, that CCTA is an effective, efficient, safe, and low-cost method of performing triage for a significant portion of patients presenting with indeterminate chest pain. What’s preventing the method’s use from becoming more widespread? With CT radiation dose currently residing dead center in the regulatory crosshairs, patients are more aware than ever of the risks associated with CT radiation. The alternatives, cardiac catheterization and thallium stress testing, entail even greater exposure to ionizing radiation, however. “The dose for a thallium stress test is about five times greater than that for a properly performed, prospectively triggered cardiac CT,” Shuman notes. “In all my clinical work, and in the full courses of our clinical protocols, I can only recall one patient who declined a cardiac CT due to concerns about dose. There is a heightened awareness of dose related to CT in the laity and lay press right now, but I have not seen it as an issue in the evaluation of chest pain in emergency-department patients, all of whom are older.” He adds that CCTA is a relatively lowdose technique, especially when performed using prospective gating. “We’re seeing a lot of publications now about sub–1-mSv cardiac CT, and when you think about it, a typical CT exam of the abdomen and pelvis runs in the 12- to 18-mSv range, and we don’t think a thing about doing that exam.” He says that doses for most cardiac CTs are now under 4 mSv. “On the scale of CT exams, it’s pretty low dose,” he notes. “I think it’s less a barrier now than it used to be.” Shuman adds that the technique has historically been met with skepticism from

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Cover Story | Emergency CCTA

the emergency-medicine community, although the tide is rapidly turning in CCTA’s favor as more and more studies emerge validating its use. “A number of good articles have appeared in the emergency-medicine literature; every subspecialty sees its literature as being the most valid, so publishing in that literature has a big impact,” he says. “I’m seeing that skepticism diminish fairly rapidly.”

He can count at least one emergencymedicine physician as a strong proponent. Hollander doesn’t mince words on the topic. “Being able to take 12 to 15 hours off a patient’s hospitalization time means that any positive benefits far outweigh the negatives,” he says. White agrees. “I think the evidence suggests pretty strongly that there’s going to be a lot of time saved by conducting triage

this way, and the consequences of that are more free emergency-department space and better throughput,” he says. “That’s the exciting feature of this: We may be able to avoid many unnecessary admissions and do it more quickly than with the current standard work-up.” Cat Vasko is associate editor of Radiology Business Journal.

Setting Up a CCTA Service

our hospital just installed a new multidetector CT (MDCT) scanner of 64 slices or more, and your emergency-department physicians are clamoring for a 24/7 coronary CT angiography (CCTA) service; now what? According to David Dowe, MD, a privatepractice radiologist with Atlantic Medical Imaging, Atlantic City, New Jersey, and a passionate teacher and advocate of the study, a practice interested in launching a CCTA service must focus on three things: image quality/diagnostic superiority, service, and marketing. On May 3, Dowe (who describes the study as beautiful, quick, and easy to administer) told radiologists at the annual American Roentgen Ray Society meeting in San Diego, California, that CCTA’s time has come, and not just in the emergency department. Dowe asserts that the literature is replete with comparisons of CCTA with catheterization and stress tests in asymptomatic and symptomatic patients. Universally, he says, that work shows not only that CCTA is superior to stress testing as a first-line test, but also that it saves money, no matter where it is used. “Why should half of US catheterizations show 50% or less stenosis?” Dowe asks. “There should never be another elective, negative diagnostic catheterization here. We have CCTA available in all 50 states.”

Diagnostic Superiority Image quality is a function of proper patient selection and preparation (and excellent equipment), Dowe says. The minimum equipment required is 64-detector MDCT system with prospective gating capabilities. Many courses are available covering the correct CT-imaging variables. Proper patient selection: There are few patients for whom Dowe will not do CCTA. His list of absolute contraindications consists of

five circumstances: uncontrolled atrial fibrillation, bigeminy, trigeminy, or highgrade heart block; severe, uncontrolled asthma; renal insufficiency; a prior allergic reaction to David Dowe, MD contrast while on steroids; and patient weight exceeding the 500-pound limit of his CT table. There are some patients for whom CCTA will fail, Dowe says, but educating your schedulers on proper patient selection can minimize those events and save time. “Don’t be your own worst enemy; educate your schedulers,” he advises. Patient preparation: Dowe advocates getting the preparatory packet to the patient in advance. The packet includes all of the necessary cardiac/medical-history forms, a brief description of what to expect during CCTA, and a beta-blocker.

Service In the interest of delivering excellent service, Dowe has two ways to administer the beta-blocker. In the first method, a day in advance, at one of Atlantic Medical Imaging’s sites, the patient’s resting heart rate is checked to make sure that it is above 60 beats per minute (bpm); if it’s lower, a beta-blocker is not needed (and could be harmful, Dowe says). The alternative is to ask the patient to arrive an hour early for the exam (an option recommended for patients already on betablockers). The drug is then given only if necessary. Dowe never faxes a prescription to a patient, nor does he ask the ordering physician to take care of it. “Those are not friendly possibilities,” he says. Before the exam, patients’ vital signs are obtained in a quiet room, and if their heart rates are greater than 72 bpm during breath

24 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

holding, they are remedicated. Dowe uses oral beta-blockers exclusively, eliminating the need for preinjection/postinjection monitoring by a nurse and reducing the drug’s postexam effects. IV access is obtained, in another room, before the exam, and no one gets on the CT table without prior verification that his or her heart rate is where it needs to be. Dowe describes the exam itself as very brief, taking 10 minutes or less. He shows patients their images before they leave the building (a key service element in his practice). He acknowledges that this is where the radiologist interested in launching a CCTA service could run into trouble. “Your partners may not support that activity; they may say, ‘What are you doing? We don’t bill for that visit.’” Dowe suggests that early in the endeavor, when processing takes extra time, patients should come back later in the day. Whether immediate or postponed, that patient contact is not optional, Dowe notes. “You are not going to be involved in CCTA if you are as invisible as you are in a routine CT. There are too many other people who want to do this exam for you,” he says. After the patient leaves, the interpretation is dictated, the technologist creates a 3D volume-rendered image for the referrer, and the report is mailed.

Marketing Dowe identifies five primary referral sources for building a CCTA practice: cardiologists, primary-care physicians, internists, surgeons and anesthesiologists, and nurse practitioners and physician assistants. Your mix will vary greatly, depending on your market location. Cardiologists inclined to order CCTA probably will do so after a stress test and before a diagnostic catheterization, and there is a strong likelihood that such a study will be precertified by an insurer. “They are slowly starting to learn that they can

References 1. Lu M, Chen J, Jeudy J, White C. Initial evaluation of 256-slice cardiac CTA for acute chest pain in the emergency department. Paper presented at: ARRS 2010 Annual Meeting; May 4, 2010; San Diego, CA. 2. Shuman WP, Branch KR, May JM, et al. Whole-chest 64-MDCT of emergency department patients with nonspecific

chest pain: radiation dose and coronary artery image quality with prospective ECG triggering versus retrospective ECG gating. AJR Am J Roentgenol. 2009;192(6):16621667. 3. May JM, Shuman WP, Strote JN, et al. Low-risk patients with chest pain in the emergency department: negative 64MDCT coronary angiography may reduce length of stay and hospital charges. AJR

Am J Roentgenol. 2009;193(1):150-154. 4. Hollander JE, Chang AM, Shofer FS, et al. One-year outcomes following coronary computerized tomographic angiography for evaluation of emergency department patients with potential acute coronary syndrome. Acad Emerg Med. 2009;16(8):693-698.

prevent a lot of negative catheterizations,” Dowe notes. Primary-care physicians and internists are another potential source of referrals, but they run into precertification difficulties in New Jersey, Dowe says. They do order a significant number of CCTAs under plans that don’t require precertification. Preoperative clearance is an active source of referrals: Surgeons, anesthesiologists, nurse practitioners, and physician assistants are all potential referrers for CCTA. “Patients in their 70s and older who are getting total hip and total knee replacements are going to come to you for CCTA. They also get echocardiograms,” Dowe reports, “but CCTA is the driver in preoperative clearance.” Dowe reports that there now are four CPT® codes (see table) used for CCTA: 75571, basically the calcium-scoring code

that replaces the 0114T code; 72272, used for cardiac structure and morphology, left atrium, and pulmonary venous mapping; 75573, used for cardiac structure and morphology in the presence of congenital heart disease; and 75574 (the code most commonly used for CCTA), which replaces the 0146-0149T codes. For a TRO cardiac CT, also bill 72175, chest CTA. Dowe emphasizes that there is no ICD9 code for the work-up of an asymptomatic patient with risk factors; he also warns providers never to bill for calcium scoring (75572) in addition to 75574, as this will result in immediate claim rejection.

opportunity, though a somewhat onerous one, due to its around-the-clock service requirements. “Cardiologists are not set up to offer CCTA 24/7,” Dowe notes. “In general, good luck finding a radiology group that wants to read CCTA 24/7. It’s a very difficult proposition.” Nonetheless, there are benefits for all stakeholders. For hospitals, the advantages include decreased lengths of stay, decreased costs of care, and tremendous throughput enhancement in the emergency department. “What they don’t want is a nonpaying patient sitting in a bed for eight hours, waiting to have a stress test the next day,” Dowe says. “They want to turn over those beds.” Both hospitals and payors are interested in decreasing liability risks in the emergency department. “The biggest cause of malpractice in the emergency department is management of chest pain,” Dowe notes. “In the future, there may be better contracts (or novel contracts) from-third-party payors that insist upon having CCTA 24/7. It may be futuristic right now, but I think that day will come.” Patients also benefit from more accurate triage, from spending less time in the emergency department, and from getting into the hands of the correct specialist sooner. Dowe says that only about a quarter of emergency-department chest-pain patients have coronary-artery disease, with the overwhelming majority of patients suffering from gastrointestinal disorders instead. Dowe urges forging ahead, despite resistance, because radiologists are the ideal physicians to do CCTA. “You can read the whole exam, you understand CT, and you understand radiation protection,” he says. “I will tell you this: I am seeing it in New Jersey, with precertification companies forbidding specialists from having high-tech CT, MRI, and PET in their offices. It is slowly coming our way.” —Cheryl Proval

Radiology’s Trump Card If anything works in favor of the radiologist performing CCTA, it is the emergency department. This is a bona fide

Table. CPT® Codes for Cardiac CT and Coronary CT Angiography

2010 CPT Code

Description

Comments

75571

CT, heart, without contrast material, with quantitative evaluation of coronary calcium (calcium score)

Replaces 0144T; do not bill with 75572-4

72272

CT, heart, with contrast material, for evaluation of cardiac structure/ morphology; includes function

Replaces 0145T

75573

CT, heart, with contrast material, for evaluation of cardiac structure/ morphology in the setting of congenital heart disease; includes function

Replaces 0150T

75574

CT angiography, heart, coronary arteries and bypass grafts (when present), with contrast material; includes structure/morphology and function, evaluation of veins

Replaces 0146T– 0149T

www.imagingbiz.com | June/July 2010 | Radiology Business Journal 25

Practice Models | The Employed Radiologist

From Partner to Employee: The Captive Radiology Practice The hospital-employed model and the proliferation of corporate teleradiology providers are causing more radiologists to choose employment over partnership By George Wiley

erry Owen is senior vice president of Florida Hospital in Orlando. He says, “We think the old days of fee for service, the high-water mark, are behind us.” What’s coming is some permutation of the accountablecare organization (ACO), with bundling of payment for services and outcomesdriven treatment. “If we get bundled pay for disease groups, then obviously, we will need radiology services for those disease groups,” Owen says. In June 2008, Florida Hospital put radiologists across the country on alert when it announced that it was not renewing its contract with a radiology group that had served it for 40 years. Instead, the hospital offered to take that group’s radiologists on as employees. Two-thirds of the physicians accepted. Those who stayed were organized under a new administrative entity, Radiology Specialists of Florida, which was placed under the hospital’s subsidiary, Florida Physicians Medical Group. One of the issues that prompted the hospital to employ the radiologists was a failed negotiation with the predecessor group over subsidies for unpaid indigent care. The old group claimed that without subsidization for unpaid indigent care, it could not compete in recruiting radiologists. Owen said in 2008 (and still says) that Florida Hospital’s intent was never to employ radiologists. That was simply the option the hospital chose after the breakdown of negotiations with the old group. “One of the tools we have is an employment model,” Owen says. Some analysts count employed radiologists as less than 10% of those working in nonacademic settings. 26 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

Radiologists might want to plan to prevent becoming employees (or, given the current vagaries of reimbursement, they might want to become employees for their own financial health). Employment Trends Owen believes that employment is becoming an increasingly attractive option for new radiologists coming out of residency. “What I see is an interest in more predictable shifts and a more scheduled work life, along with some concern with more stability of income,” he says. “There are changing expectations, and starting a practice can be very costly.” Larger trends also might be pushing the employment model. Corporate teleradiology companies that can leverage technology to undercut standard hospital contracts for interpretation, especially in rural settings, are paying radiologists (either through salaries or per study) to read remotely. The consolidation of health systems into megaproviders that can adapt to insurance initiatives to drive down costs also is adding shine to the employment model. Florida Hospital is a case in point: It is growing. While Florida Hospital in Orlando is the entity’s flagship, the system is actually composed of eight hospitals and four OICs. It treats nearly a million patients per year and is part of the even larger Adventist Health System. Florida Hospital has mounted a task force to study evolving health-care scenarios. “I think every responsible organization is doing pilots of the ACO, the medical-home model, or some other way of delivering the product differently,” Owen says. “We strongly feel that in this country, we have a costly model without the outcomes to justify that cost. There are a number of ACO-type models or bundledpay models on the radar screen. Earlier this year, the Florida government talked about moving all Medicaid to managed care, including provider-sponsored networks. In some parts of the country, people are a lot further along than we are here.” With a new focus on quality and outcomes, hospitals must come up with solutions that align the incentives of physicians and the hospital. Owen says, “We all have been focused on productivity or volume, not on outcomes. How do you

What I see is an interest in more predictable shifts and a more scheduled work life, along with some concern with more stability of income. —Terry Owen, senior vice president, Florida Hospital, Orlando, FL

transition to an outcomes-driven model? That’s something we’ve got to do.” Methods of aligning the physician and hospital, including risk sharing, are being explored. Employing radiologists or other specialists can be part of that solution, he says, although it’s a minor part now. “Our number of physician employees is significant, but it’s nowhere near the majority of the medical staff,” Owen says. As for Florida Hospital’s in-house, employed-radiologist makeover, Owen says that the transition has been seamless. Radiology Specialists of Florida is running the department, using teleradiologists to handle overflow. “They don’t use locum tenens anymore,” he reports. The salaries of radiologists, Owen thinks, have been unchanged in the two years of employment. “It has gone well,” he says. “On the finance side, we still have opportunity for improvement, but where we are is a very good place to be. I think the radiologists are happy to be at the hospital. We are pleased with the service and the quality of work.” Events in Toledo What happened in 2009 at the Mercy Health Partners hospitals in Toledo, Ohio, is a second example of how a radiology group with a long-standing relationship can run afoul of a major client. In this case, the hospitals did not opt for a directemployment model. Instead, they asked a corporate entity to take over radiology services and run the imaging departments (using a combination of locum tenens, inhouse staff, and teleradiology providers). Consulting Radiologists Corp (CRC) had covered the Mercy Health Partners hospitals in Toledo (Mercy St Vincent Medical Center, Mercy St Anne Hospital, Mercy St Charles Hospital, and Mercy Children’s Hospital) for decades when it was suddenly replaced by Imaging

Advantage LLC (Santa Monica, California), a corporate provider of imaging services. David R. Cervantes, MD, an interventional radiologist, is president of CRC. Cervantes reported in 2009 that CRC had been in negotiations with Mercy Health Partners over benchmarks (particularly for report turnaround) that the group felt were unobtainable without more flexibility on the part of Mercy Health Partners. The hospitals would not agree to 24-hour transcription or provide transporters for radiology patients, for instance. CRC was unusual in that it was operating under an old handshake agreement forged decades earlier. There was no contract between CRC and Mercy Health Partners. The system was demanding one, however, and negotiations had been ongoing when they stalled. After being told by the system that the contract was no longer a priority, CRC radiologists were offered jobs by Imaging Advantage, which had been given the Toledo contract for Mercy Health Partners beginning in June 2009. The conditions of the offer were that CRC would give up reading for St Luke’s Hospital in Maumee and close an imaging center that it ran. Instead, the group kept its contract with St Luke’s Hospital and its imaging center, and it said goodbye to Mercy Health Partners. Cervantes says, “We never told anybody in our group they couldn’t go there, but nobody went.” A year later, Cervantes says, the decision not to work for Mercy Health Partners definitely changed CRC. The group has downsized from 19 to 11 radiologists; it still reads for St Luke’s Hospital, has contracted with another outlying hospital, and still has the CRC imaging center, which has gotten busier. Radiology groups should be extremely wary, since something like the Imaging

www.imagingbiz.com | June/July 2010 | Radiology Business Journal 27

Practice Models | The Employed Radiologist

We have three components: The radiologists on-site, the radiologists reading remotely (who are still our radiologists), and commercial teleradiology for Mercy St Vincent Medical Center only. —S. Mark Ellis, vice president, operations, Mercy St Vincent Medical Center, Toledo, OH

Advantage takeover could happen to them, Cervantes says. He advises radiologists to strengthen their relationships with hospitals and tells new radiologists to align themselves with established practices, not teleradiology companies. As a specialty, he says, “We have to get our medical staffs to realize that you can’t turn radiology into a commodity.” Learning Partnership At Mercy St Vincent Medical Center, S. Mark Ellis, vice president of operations, says that the changeover resulted in a 1269_Rad_Sprd_RBJ_BOT.qxd:Layout 1 5/7/10 tough year for the Mercy Health Partners

radiology departments, but he attributes that to learning a different system. “It’s like any other marriage: If you make the separation, you’ve got to learn the new partner,” he says. Ellis says that Mercy Health Partners is now poised to give better service and to move with clinicians into new areas of specialized care in oncology, stroke, and vascular intervention that Mercy St Vincent Medical Center and the other hospitals didn’t offer previously. “We refer to Imaging Advantage as our radiology department,” he says. our 1physician customers, it’s 3:06 PM“To Page just part of the infrastructure.”

Mercy Health Partners supplies the radiology suites and modalities, technologists, and support staff, and it handles billing, with the exception of professional fees. “Imaging Advantage provides the professional services and bills for those. Mercy Health Partners manages and controls the overall outcomes and the scheduling of patients,” Ellis says. This frees the radiologists to focus on patient care, he says, while the hospital handles management, although a radiology CMO is contracted to Imaging Advantage. In the beginning, Imaging Advantage did rely on locum tenens heavily, but that has changed, Ellis adds. “We have three components: The radiologists on-site, the radiologists reading remotely (who are still our radiologists), and commercial teleradiology for Mercy St Vincent Medical Center only,” he says. There are 14 radiologists now on-site, Ellis says, with another six to eight Imaging Advantage remote readers dedicated to Mercy Health Partners, in addition to

MAKING

Clarian Health has gone down a path where it determined, several years ago, to align as many physicians as it can with the hospitals’ interests and support the best patient care. —Richard Helsper, MBA, FACHE, COO, Ball Memorial Hospital, Muncie, IN

the teleradiology company’s radiologists. Preferred readers are selected from the commercial teleradiology pool and assigned to read Mercy Health Partners cases so that familiarity develops with referrers. Remote readers contracted to Imaging Advantage are brought to Mercy St Vincent Medical Center to train and to get face-to-face contact with the medical staff. According to Sarah Bednarski, media spokesperson for Mercy Health Partners, the combined hospitals are now conducting about 800 imaging exams daily, with 90% of those read by Imaging Advantage contracted radiologists. Ellis says that both

the Ohio Department of Health and the ACR® have assessed the radiology operation at Mercy Health Partners and have given it passing grades. Clarian Health What started in 1997 as the merger of three Indianapolis, Indiana, hospitals to form Clarian Health has now grown into a network of more than 20 owned or affiliated hospitals throughout Indiana. As Clarian Health has expanded, it has focused on bringing physicians on as employees through an entity called the Indiana Clinic. Today, there is a mix of

private-practice and employee physicians in the hospitals, but the direction of change is toward employment. Richard Helsper, MBA, FACHE, is COO of Ball Memorial Hospital, Muncie, part of the Clarian Health group. “Clarian Health has gone down a path where it determined, several years ago, to align as many physicians as it can with the hospitals’ interests and support the best patient care,” he says. “Through the Indiana Clinic, as well as direct hospital employment and lease models, there are hundreds of physicians, hospitalists, primary-care physicians, and radiologists already aligned, sometimes to specific locations and sometimes as part of the larger pool.” Helsper, who most recently held the corporate position of vice president of operations for Clarian Health, says that employing physicians is becoming more common for hospitals as they consolidate and position themselves to respond as ACOs. Size equals clout in negotiating contracts, he says.

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Practice Models | The Employed Radiologist

Aggregate RVUs set the salary. . . . If we manage costs, we have the opportunity to control salary or adjust vacation time. That gives us a lot of flexibility. —Kenneth A. Buckwalter, MD, FACR, clinical director, Indiana Radiology Partners, Indianapolis, IN

The squeeze on physicians’ pay due to falling reimbursement is opening the door to more of these arrangements. “Physicians are seeing this, and it’s frightening to them: There is no one who hasn’t had to work harder this year than last year to make the same money,” he says. Many specialties, radiology included, will migrate away from freestanding physicianowned clinics and back to employment models, he predicts. “Medicare is putting more scrutiny on in-office coverage,” Helsper says. “Clarian Health has taken over imaging centers just so the providers could rid themselves of them, because they could barely cover the costs.” Indiana Radiology Partners The radiology practice at Clarian Health provides a clear look at how the employee model for physicians can take shape as health systems consolidate. Kenneth A. Buckwalter, MD, FACR, is clinical director of Indiana Radiology Partners (IRP), a group of close to 100 radiologists who work for the Clarian Health hospitals. IRP is owned by Clarian Health and acts as the clinical arm of radiology services. IRP is soon to be part of the Indiana Clinic, a multispecialty group formed to oversee all the specialties engaged in the employee model. The Indiana Clinic is co-owned by Clarian Health and the affiliated Indiana University School of Medicine, Buckwalter says. Clarian Health formed IRP following the merger of two radiology groups in 1997. IRP radiologists are guaranteed salaries benchmarked to Medical Group Management Association (MGMA) standards. “If we do a million work RVUs, that’s the total money we’ll have to distribute to the radiologists. Aggregate RVUs set the salary. Instead of being a fixed salary, as it is now, salary will float based on work available. If we manage costs, we have the opportunity to control salary or

adjust vacation time. That gives us a lot of flexibility,” he says. “It gives us lots of control,” he adds. “If you were on a fixed salary, the hospital could take over another hospital, and you’d have more work and the same fixed pay. The downside is if the hospital loses business, then the salary will drop.” In that case, radiology could cut jobs or move people internally to balance the income and lifestyle desires of various physicians. No production incentives are imposed, but radiologists are expected to meet demand and stay busy. “In the aggregate, we produce at about the 50th percentile for MGMA standards for private practice, and that’s with the large residency program that we run. It’s much simpler for the hospital system to pay a fixed amount per RVU; the radiologists don’t have to worry about the hospitals’ payor mix. We don’t have to worry about the uncompensated emergency department night visits that kill some radiology practices,” Buckwalter says.

30 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

Radiologists don’t have to worry about malpractice insurance, which is paid for by the Indiana Clinic. “I think it’s a hugely beneficial model,” Buckwalter says, “and better than a fixed-salary model.” Nonetheless, radiologists are worried about income, and one of the issues in negotiation between IRP and the Indiana Clinic is the benchmark to be used to set reimbursement per RVU. Data for the Midwest indicate higher RVU benchmarks for radiologists than for other regions, and radiologists want those benchmarks used, whereas the clinic wants the same aggregate national benchmarks applied for all specialties, not just radiology, Buckwalter says. “They want one standard, and our point is that for the Midwest, radiology is a higher number,” he explains. “We’ve had a number of conversations, and we’ll have to come to a reckoning. Our goal is to have the best-run department in the clinic. We have no desire to be contentious. There is a limited pot of money, and radiology is at the high end. There’s not too much sympathy from nonradiologists if our perRVU reimbursement is $52 versus $54.” IRP is unusual in that its salary structure is flat, with no additional pay for rank or seniority. New radiologists are brought in at 80% of the salary standard and move to 90% the next year. After that, they become partners in IRP. Buckwalter says, “We pay more the first year or two, and then new employees discover that they like being here, and they don’t want to leave. These junior people do a ton of work, typically. I don’t begrudge paying them that amount to start.” By keeping salaries more or less equal, IRP avoids another phenomenon that plagues the recruits in many privatepractice settings: churn. “Lots of folks turn over the junior people they pay at 40% to 50% of the senior-staff level. Then, they take that excess revenue and redistribute it to the senior partners. It’s a very common strategy. They just bring in more new people. We treat our juniors much better than most people do,” Buckwalter says. Decreased Income Many radiologists fear that if they move to employee status, their incomes

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Practice Models | The Employed Radiologist

I see far more to be concerned with on the corporatization road than in the hospital employment model. I think the corporations are far more formidable competitors than radiologists have ever faced before. —Lawrence R. Muroff, MD, FACR, CEO and president, Imaging Consultants Inc, Tampa, FL

will inevitably decline. Buckwalter views this as a real possibility. For now, hospitals must approximate in salary what their radiologists might make in private practice, but if more and more radiologists become employees, then hospitals won’t worry as much about mirroring private practice, and salaries could fall, Buckwalter says. “Right now, we’re benchmarked against private practice, and that allows us to enjoy our high salaries,” he says. “The downside is if all private-practice groups evaporate, then hospitals will set the salaries. Radiology may experience across-the-board cuts when hospitals seek to cut expenses. I know that has happened in other hospital systems.” The way out of this scenario is for radiologists constantly to prove their worth to referring clinicians and hospitals. Buckwalter says, “The bottom line, for those of us who are hospital-based physicians: We are joined at the hip, like Siamese twins, to the hospital. We need to do everything in our power to make sure the hospital is a success.” Helsper agrees. He notes that there are now many variations in the way that radiologists in the Clarian Health system are compensated. Some remain in privatepractice models. About 100 are currently salaried members of IRP, which is looking at rolling into the Indiana Clinic. Eventually, most (if not all) radiologists will be employees in system-owned groups like IRP, he says. To retain their importance, radiologists have to make an added effort to demonstrate their value. “Pick up that phone,” he advises, in urgent cases, adding, “Call and tell that referrer what the finding is, when it’s unusual or critical. In radiology, you have no patient contact (except, perhaps, for interventional radiologists). If you make your referring clinicians look good, they

will send you business; if you make them look bad, they won’t.” It is also important to leverage radiology expertise, Helsper says. IRP radiologists provide night coverage to many Clarian Health hospitals, and they are beginning to offer these services commercially. “IRP is conscious of not appearing predatory,” Helsper says, “but it’s happy to help, when asked. It will do night-coverage service, but it’s not knocking on doors.” Many commercial teleradiology companies are knocking on doors, however. Commoditization Fear Lawrence R. Muroff, MD, FACR, is CEO and president of Imaging Consultants, Inc, in Tampa, Florida. He is a nuclear-medicine specialist who now devotes his time to consulting with radiology practices and hospitals on a range of issues. Muroff says that he sees more to fear from teleradiology companies and the commoditization of radiology than he does from hospitals turning radiologists into employees. “The salary model is not common at this time,” he says. “I think it’s probably close to 6% to 8% of those in practice.” When hospitals do employ radiologists, he adds, it’s not to save money, it’s to have greater control over hours, assignments, subspecialization, and keeping radiologists on-site. “The secondary factor is that the hospitals don’t like the radiologists to compete with them,” he says. “They want the radiologists’ incentives aligned with those of the hospital. The easiest way to do that is if they are employees.” Muroff says that the nonpredation philosophies of the early teleradiology companies have been dispensed with; the corporate teleradiology companies are doing more to disrupt existing contracts with

32 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

hospitals than any move by hospitals to turn radiologists into employees has done. “I see far more to be concerned with on the corporatization road than in the hospital employment model. I think the corporations are far more formidable competitors than radiologists have ever faced before,” Muroff says. “Teleradiology teaches peer physicians and hospital administrators that relationships don’t matter and that studies can be read at any time and in any place. Commodities are basically traded on price, and that makes it very dangerous for radiologists.” Practicing Decommoditization Muroff says radiologists must counter the trend by decommoditizing radiology. That means involvement in the governance, politics, and clinical practices of the hospitals for which they read. Radiologists must involve themselves in their communities, too, Muroff says. “It’s very rare that a group has been fired while a member of that group sat on the medical staff of the hospital, and I’ve never heard of one being fired when a member sits on the hospital’s board,” he notes. Doug Smith is president of Barrington Lakes Group (Barrington, Illinois), a Chicago-area radiology consultancy. He works with radiology groups and hospitals on contract negotiations, joint ventures, and what he calls other weird arrangements. Smith says that there is built-in tension between hospitals and radiology groups. “Hospitals are like a medical mall: They’re dependent on the kindness of the medical staff to do anything,” he says. When there are discrepancies between radiologyservice expectation and delivery in that setting, hospitals might see bringing the radiologists on as employees as the best way to gain control. He adds that after some consideration, hospitals might say, “‘We’re not really good at managing physicians.’ On a good day, most hospitals never want to employ these people.” Smith agrees that corporate teleradiology companies are changing relationships between hospitals and radiology groups, but he says that the full hands haven’t yet been dealt to let us see who will win that game. “The teleradiology companies that are really self-professed virtual national

radiology groups say they’ll put certain bodies on the ground and read the rest from a distance,” he notes. “It’s still too early to see the holes in those relationships and to see if that’s a true emerging model that really has legs.” Making Hay At the Clarian Health hospitals, there is no fear of teleradiology providers taking over a practice; the hospitals have a team of emergency radiologists at their hospitals 24/7 through IRP. Buckwalter believes that it sends a bad message if independent radiology groups have teleradiology night coverage when other clinicians at the hospitals they serve must cope with night call. Helsper, in fact, says that teleradiology groups are only “making hay while the sun shines,” and he thinks that they might be a short-lived phenomenon. When large systems form ACOs, they will take the night-call piece for themselves, as part of their service model (just as IRP has done within Clarian Health), Helsper suggests. “Teleradiology is a cottage industry,” he says. “It fulfills a need today, but as systems

‘We’re not really good at managing physicians,’ hospitals might say. On a good day, most hospitals never want to employ these people. —Doug Smith, president and CEO, Barrington Lakes Group, Barrington, IL

get bigger, we won’t need those external groups, just as Ball Memorial Hospital’s joining Clarian Health gave it access to 24/7 radiology through IRP.” Helsper says that having more large hospital systems will probably lead to more radiologists becoming hospital employees (or having their services leased) in a true integratedcare model. “I think the employment model is becoming more common, and you will see it more on the national level,” Helsper says. “Radiology will be one of many specialties doing the same thing. For more and more clinicians, employment will be a comfortable place for them to be. They’ll have flexibility, infrastructure, and backup; I think it will ultimately depend on income

stabilization.” Radiologists on hospital salaries might be a small percentage of all radiologists now. How long will that be true, though? For those not wishing to be radiologist employees, the advice is uniform: Involve yourself more with your clients. Make your referrers look good, as Helsper says. Smith adds, “Hospitals are actively putting together ACOs to be part of the early test models. Get a seat at the table today, and be a contributor. If you aren’t at the table, somebody’s going to be making a decision about your service, and it isn’t going to be you.” George Wiley is a contributing writer for Radiology Business Journal.

Health Care | Reform Primer

A Health-reform Primer for Providers Tie your laces and get into the game, because reform, as viewed by the president of Kaiser Permanente Southern California, will initiate a period of great experimentation in health-care delivery By Cheryl Proval

buoyant tour of health-care reform greeted radiologists who gathered at the annual American Roentgen Ray Society meeting for the Caldwell Lecture, delivered by Benjamin K. Chu, MD, on May 3, 2010, in San Diego, California. If Chu seemed unusually upbeat, for a physician, about health-care reform, it might have been because the internist also is president of the Southern California region of Kaiser Permanente (Pasadena), a system that embodies many of the goals of the Patient Protection and Affordable Care Act. During his talk, “Health Care Reform: Implications for the Health Care Delivery System,” Chu focused on three essential elements of reform: health-insurance market reform and coverage expansion, financing of reform, and payment/delivery reform and cost containment. Characterizing the reform law as unprecedented in its potential to allow swift payment-policy changes without congressional action, Chu concluded his talk with a strong caveat for radiologists: If you prefer that the new Independent Payment Advisory Board (IPAB) not dictate rates, get involved now in devising new ideas for sharing the health-care dollar. Insurance Reform Begins Now Without cost containment, health care is on track to account for nearly 50% of the gross domestic product by 2082, Chu notes, underscoring the case for change with data from a 2007 Government Accountability Office report. In moving the insurance market toward guaranteedissue policies, rating bands, and standard packages with ranges, reform aims to broaden the risk pool.

“A lot of these insurance-market reforms are actually contrived to level the playing field, to make sure that we get as many people in the pool Benjamin K. Chu, MD as possible and then share the overall cost, as opposed to trying to risk-segment the population and target products toward certain people,” he says. Health-insurance exchanges (debuting in 2014), the individual mandate to buy health insurance, and employer incentives in the form of tax credits are key tools that will be used to leverage participation, but Chu questions whether the penalties for nonparticipation are high enough. “With the typical family plan costing $12,000 or $13,000 a year, some employers might elect to drop coverage and pay the penalty to let their employees go through the exchange,” he notes, “but that hasn’t happened in Massachusetts. In fact, the percentage of employers covering employees in Massachusetts has actually risen.” Further insurance regulatory changes, such as rate review and minimum loss ratios (the percentage of the insurance premium that goes to health care) are expected to provide a greater level of transparency in the insurance marketplace. Insurers in the large-group market will be required, in 2011, to use 85% of premium dollars for health care; in small markets, where the cost to market the products is greater, the minimum loss ratio will be 80%. Insurers must publish their minimum loss ratios this year (Figure 1), page 36. “UnitedHealth just reported that its loss ratio was 79%,” Chu notes. “It’s a way

34 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

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Health Care | Reform Primer

2010

2013

2014

National high-risk pool

Nonprofit member-run cooperatives

Individual mandate

No preexisting-condition exclusion for kids Dependents covered to age 26 No lifetime dollar cap on coverage

Tax penalties for failure to obtain coverage

Administrative simplification: • eligibility verification • claim status, and • enrollment (2014)

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State-based exchanges; by 2016, cross-state compacts Guranteed issue and renewal; no preexistingcondition exclusions Community/age rating only Standard benefits package

Publish minimum loss ratios in 2011

Figure 1. Major insurance reforms contained in the health-care law will be phased in through 2014.

to dampen health-premium rises, going forward.” Of the 32 million newly covered people, half will come from Medicaid expansion (to include everyone with an income of up to 133% of the federal poverty level), and the other half will come from individuals heeding the mandate, leaving approximately 16 to 18 million uninsured. “It’s a complicated piece of legislation that phases in over a three-year period,” Chu says. “Some things happened almost immediately, like a lot of the insurancemarket reform, but the big bang is going to happen in 2014.” Transforming Care Delivery The Congressional Budget Office estimates that the new law will cost $940 billion over 10 years. In addition to measures that will broaden coverage, the law includes significant funding for community wellness programs, preventive health care, and health-workforce development. The funding package includes a series of taxes and new fees (see table) and an equivalent amount of cuts to Medicare and Medicaid funding (Figure 2), page 38. Chu reports surprise at seeing specific care-delivery demonstration projects actually named in the legislation. He notes a prevailing interest in encouraging the health-care system to develop into more integrated models, as well as in finding ways to get the payment system to drive that change.

“When I say integrated model, I mean having physicians, hospitals, nursing homes, and home health, the whole continuum, melded together to work more closely and in a much more coordinated way: something we do a little better at Kaiser Permanente,” he believes. Demonstration projects are planned in three areas. Accountable-care organizations: A great deal of flexibility is built into this project to include group practices, hospitals, or joint ventures, with partial capitation or some other form of payment. Participants must have at least 5,000 beneficiaries and must be responsible for quality, coordination, and cost of care. Bonus payments will be earned

if a participant cuts average expenditures. Chu thinks that multispecialty academic practices are well positioned to participate. This project begins in 2012. Medicare bundled payments: This fiveyear pilot will test bundled payments for episodes of care for up to 10 conditions. The bundled payments will include three days of care prior to admission, acute care (hospitals and physicians), and 30 days of postacute care. The pilot will be evaluated for improved quality, better access to care, and reduced spending. This project begins in 2013. Medicare value-based purchasing: This project is partially voluntary and is intended to be budget neutral: 1% of payments will be withheld in 2013, phasing to 2% in 2018. Hospitals delivering subpar care on hundreds of measures will be penalized up to 3% of payments, while hospitals that exceed care standards will receive bonus payments. Two sections of the project focus on 30day readmissions and on hospital-acquired conditions. This project begins in 2013. Chu advises health-care providers to pay close attention to communications from the secretary of HHS because the legislation gives the secretary wide discretion in defining project parameters, as well as in implementing three new centers to evaluate innovations and coordinate care: the Center for Medicare and Medicaid Innovation, the Patient-centered Outcomes Research Institute, and the Federal Coordinated Health Care Office. “These centers are created for the express intent of developing the evidence base for

Table. Health-reform Taxes and Penalties Contribute $597 Billion in Revenue Through 20192 Total Taxes: Raise Medicare hospital insurance tax and extend it to unearned income for high earners $210 billion Temporary increase in Part B premiums for high-income beneficiaries $25 billion Modify taxes related to medical expenses $39 billion Penalties for failure to obtain coverage: Employers $52 billion Individuals $17 billion Assessments and excise taxes: Health-insurance providers $64 billion High-premium plans $32 billion Manufacturers and importers of brand-name drugs $27 billion Manufacturers and importers of certain medical devices $20 billion Indoor-tanning services $3 billion Other

36 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

$597 billion $275 billion

$69 billion

$145 billion

$108 billion

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Health Care | Reform Primer $164 billion $135 billion

$129 billion

$65 billion

Hospitals

Medicare Advantage plans

Skilled nursing facilities and home care

Miscellaneous

$62 billion

Pharmacy

$16 billion

$15 billion

$13 billion

Independent Payment Advisory Board

Reforms

Other providers

Figure 2. Health-reform Medicare and Medicaid cuts add up to $597 billion in savings through 2019.2

better understanding of what the payment system should be, as well as for putting in pilots to test the efforts to get the system into a much more coordinated state,” Chu explains. Significantly, the legislation gives the HHS secretary the power to turn a pilot into policy. “As soon as there is any indication that it might work, the secretary has the authority to expand it and spread it very quickly,” Chu says. “It is really quite unprecedented for Congress to give that type of authority to the executive branch.” Congress does have the ability to amend a recommendation from the HHS secretary, and the president has veto power over Congress, but Congress must muster a three-fifths majority to overturn the veto. The Cost Ultimatum The reason that Chu is so insistent on encouraging provider participation in the demonstration projects is this: If they do not succeed in lowering the cost of care, the IPAB has been given the authority to cut reimbursement. “This is a 15-member board that will make decisions,” Chu says. “This is the most amazing thing, when you think about it.” The IPAB has been charged with making recommendations to reduce the difference between the consumer price index and the medical inflation rate, which has been trending 3% to 5% higher over the past several years. In its first year (2015), the IPAB must cut the difference by half a percentage point, bringing it down to 38 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

a 1.5% difference over a couple of years. Congress can dissolve the IPAB and, in fact, is supposed to do so by 2019, but it must do so with a three-fifths vote. In the final segment of his talk, Chu turned homeward, sharing a quote from President Obama that appeared in Time magazine: “ . . . if we could actually get our health-care system across the board to hit the efficiency levels of a Kaiser Permanente or a Cleveland Clinic or a Mayo or a Geisinger, we actually would have solved our problems.”1 He can’t vouch for that statement, but Chu does draw some parallels between the ambitions of the reform law and the results of Kaiser Permanente’s integratedcare approach, fueled by IT. “What they are driving at is the kind of integration we have,” Chu explains. “This is actually how we do things now, particularly since we put in IT that allows that coordination on a real-time basis. Not only is it coordination at the point of care, but we have tools that allow me to look at my 3.3 million people and tell you how they are doing, relative to some evidence-based care protocols.” He continues, “For example, I have 600,000 members who are diagnosed with hypertension. I can tell you, at this time, that 83% have their hypertension under control. I can actually drill down and tell you which ones don’t, where they are being taken care of, whether they are being seen on a regular basis, and whether they are compliant with their medications, based on their refill rates. If you can build those

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Health Care | Reform Primer 227.8

United States Luxembourg

176.9 167.7

Belgium 144.8

Iceland

Australia

88.6 75.1

Czech Republic

70.2

Spain United Kingdom

59.1

Hungary

58.8

France

Kaiser Permanente Southern California rate (2009) for members: 106.3

103.5

Canada

45.1

Figure 3. CT scans per 1,000 enrollees for Kaiser Permanente Southern California (KPSC) in 2009, compared with 2007 data from the Organisation for Economic Co-operation and Development (Paris). The KPSC Radiation Utilization Action Team brings diverse parties together to develop utilization guidelines for radiological services that are now embedded in the computerized provider order entry system. 91.2

United States Iceland

64.7 63.3

Luxembourg 49

Belgium 32.9

Spain Canada

31.2 28.8

United Kingdom

27.9

Hungary

24.5

Czech Republic France Australia

Kaiser Permanente Southern California rate (2009) for members: 43.7

21.8 20.2

Figure 4. MRI scans per 1,000 enrollees for Kaiser Permanente Southern California in 2009, compared with 2007 data from the Organisation for Economic Co-operation and Development (Paris).

tools, you can see how you can change the delivery system to be much more proactive, to get at better outcomes overall.” In working with Kaiser Permanente radiologists since 2006 to develop radiologyutilization actions and then embed them into the computerized provider order entry system, Kaiser Permanente Southern California has achieved utilization rates for CT (Figure 3) and MRI (Figure 4) that are less than half the US average. “We have less than half the rate of the rest of the country for CTs, and as you can see, the rest of the world actually uses it less as well,” Chu notes. “The key will be if the outcomes are just as good, if not better. Similarly for MRIs, we are at 43.7 per 1,000, and the rest of the country is at 91.2.” He adds, “Since we have patients who have been with us for 15 or 20 years, we can actually start to track outcomes, such as

a failure to diagnose something because we didn’t order a certain test. We actually can track and feed that back to the physicians: That is something that you don’t often have outside a system like Kaiser Permanente or Group Health.” In conclusion, Chu encourages radiologists to begin working with hospitals, physician groups, and other providers to improve care coordination, to use the evidence base to drive decision making, and to implement feedback loops. The door is open to accountable-care organizations willing to experiment with taking a fixed pot of health care dollars and redistributing it in better ways, Chu says. “Cost containment may come in the form of better coordination and evidence-based utilization of services,” Chu notes. “Let’s hope that’s true, or in the end, the IPAB will resort to price or rate regulations.”

40 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

Cheryl Proval is editor of Radiology Business Journal and vice president, publishing, ImagingBiz, Tustin, California. References 1. Tumulty K. Obama: We’ve provided more guidance than advertised. Time. http://www.time.com/time/politics/ article/0,8599,1913363,00. html#ixzz0pfYH7UTO. Published July 29, 2009. Accessed June 1, 2010. 2. Raske K, Wynn E. Federal health reform. Paper presented at: Health Insights Spring 2010 Conference; April 8, 2010; Atlanta, GA.

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Radiology | Subspecialization

Subspecialty Radiology: Beyond the Debate While debate continues to swirl around the future of general radiology, the marketplace is clearly moving toward subspecialization and the real-world challenges that it presents By Julie Ritzer Ross

he question of whether general radiology is on the path to obsolescence has sparked considerable debate in recent years, with much of the controversy centered on the contention that subspecialty radiologists are responsible for fewer errors than their generalist counterparts. Whether this contention is true or not, the trend toward subspecialization is undeniable. In fact, a recent article in the Journal of the American College of Radiology1 pegs 91.5% of residents and fellows surveyed as intending to pursue a subspecialty. Myriad factors continue to fuel the subspecialization fire. Demand from hospitals tops the list. Robert E. Epstein, MD, is president of East Brunswick, New Jersey-based University Radiology, which owns or operates 10 sites in the state’s central corridor, covers five hospitals, and interprets 950,000 procedures per year. University Radiology’s staff includes 84 radiologists; of these, 72 subspecialize: four in pediatric radiology; six in nuclear medicine; 10 in interventional radiology; nine in neuroradiology; six in musculoskeletal imaging; 14 in body imaging (CT, MRI, and ultrasound); 14 in women’s imaging; four in neurointerventional radiology; and five in cardiovascular imaging. Epstein says, “As technology and the subspecialties themselves have become increasingly sophisticated, hospitals are definitely demanding more and more radiology subspecialist services. Take PET/ CT: It involves complex equipment. In

regional hospitals’ view, it is unacceptable for a general radiologist to be reading exams conducted using such advanced equipment. Their reasoning is that if there is a subspecialist in the practice serving them, that is the person they want.” Epstein adds that in University Radiology’s case, provisos for certain types of subspecialist coverage are being incorporated into contracts. He cites mammography and interventional radiology as two areas of service that have been carved out in this way, attributing the trend, in part, to the fact that while cries for radiologists in both of these subspecialties are especially loud, demand far outstrips supply. In some cases, a need to maintain accreditation and/or attain specific business objectives spurs hospitals to push the subspecialty envelope. For example, University Radiology works with several New Jersey hospitals that must, in order to qualify as Joint Commission designated stroke centers, offer advanced neuroradiology services. Attending physicians generally demand that head CT and similar exams be read within 30 minutes, according to University Radiology’s CEO, S. Thomas Dunlap. On the business side, Dunlap notes, “Hospitals are saying that they want to work with a women’s imaging subspecialist who will

42 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

become the face of their mammography services, as this brings in more patients for cancer surgery and treatment.” Even if hospitals do not insist that contracts be written to guarantee specific subspecialist services, some assume that such services will be provided, in accordance with an unwritten general rule. That has been the experience of West County Radiology Group, headquartered in St Louis, Missouri. The practice is staffed by 35 radiologists, with five subspecializing in radiation oncology, five in neuroradiology, five in body imaging, three in pediatric radiology, three in musculoskeletal imaging, three in nuclear medicine, and three in vascular/ interventional radiology. Four radiologists are subspecialists in women’s imaging; of these, three spend about 98% of their time on breast MRI, but they also possess expertise in body imaging, and they assist in that area as needed. The remaining four radiologists handle some body imaging, as well as general radiology. West County Radiology Group serves two hospitals and six to eight freestanding imaging centers in the St Louis area. Jeffrey L. Thomasson, MD, is West County Radiology Group’s president and vice chair. He says, “Our contract with the hospitals reflects that we will provide radiology services, and subspecialty services

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Radiology | Subspecialization

As technology and the subspecialties themselves have become increasingly sophisticated, hospitals are definitely demanding more and more radiology subspecialist services.

Studies Support Error Theory

uch of the evidence said to support the theory that radiology subspecialists make fewer mistakes than their generalist colleagues is anecdotal. The content of some peer-reviewed papers, however, appears to lend more credence to the theory. The results of a 2002 study1 published in Radiology demonstrated a 76% higher cancer-detection rate for screening mammograms read by subspecialists than for those read by general radiologists. The study also showed, for screening mammography, that subspecialists’ early cancer-detection rate was approximately 77% higher than that of general radiologists. Moreover, in a 2007 article2 in Clinical Radiology that compared neuroradiologists’ second-opinion reports for CT and MRI exams with general radiologists’ original interpretations, the authors found a 34% discrepancy rate. They concluded, “There is a significant major discrepancy rate between specialist neuroradiology second opinion and general radiologists. The benefit of a specialist second-opinion service is clearly demonstrated.” In the typical practice setting, however, most subspecialists do not exclusively read in their subspecialties, posing the following question: Do subspecialists, when reading outside their subspecialties, make a smaller or greater number of mistakes than general radiologists make? References 1. Sickles EA, Wolverton, DE, Dee KE. Performance parameters for screening and diagnostic mammography: specialist and general radiologists. Radiology. 2002;224:861-869. 2. Briggs GM, Flynn PA, Worthington M, Rennie I, McKinstry CS. The role of specialist neuroradiology second opinion reporting: is there added value? Clin Radiol. 2008;63(7):791-795.

—Robert E. Epstein, MD, president, University Radiology, East Brunswick, NJ

Hospitals make it clear that if a radiology practice does not offer a desired subspecialty or is not willing to explore the possibility of doing so, they will go elsewhere to fulfill their patients’ needs. —Geoffrey D. Smith, MD, partner, Casper Medical Imaging, Casper, WY

are perceived and implied to be part and parcel of that because it is what we do anyway.” A similar perspective is shared by Geoffrey G. Smith, MD, FACR, a partner at Casper Medical Imaging in Casper, Wyoming. Casper Medical Imaging has seven FTE radiologists on its staff, serves 120 to 140 physician clients, and performs 110,000 exams per year. Its team comprises two general radiologists, two general radiologists who also subspecialize in interventional radiology, one nuclear-medicine subspecialist, one neuroradiologist, and one subspecialist in both musculoskeletal imaging and cardiothoracic radiology. Smith describes a buyer’s market in subspecialty radiology, noting that hospitals “make it clear that if a radiology practice does not offer a desired subspecialty or is not willing to explore the possibility of doing so, they will go elsewhere to fulfill their patients’ needs.” Clinician Expectations There are other catalysts at work on the hospital front. Indeed, requests from individual attending physicians and other referrers continue to spur the call for subspecialist services. Charles J. Gatt Jr, MD, is a partner in University Orthopaedic As-

44 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

sociates, LLC, which has offices in New Brunswick, Princeton, and Somerset, New Jersey. Gatt, who subspecializes in sports medicine, believes that the quality of care that his practice can provide is heavily affected by his ability to obtain interpretations from musculoskeletal-imaging subspecialists. “It’s not really data in the health-care literature, and certainly not marketing by teleradiology companies, that send me in this direction,” Gatt observes. “In my experience, getting rapid, subspecialist reading means a higher caliber of care, at least most of the time.” While demand for subspecialists in all areas clearly exists, some subspecialties are more sought after than others. There is markedly high demand for subspecialists in breast imaging and in interventional/ vascular radiology, with the trend stemming largely from technological advances and continued enhancement of image quality. “The advent of 3D ultrasound, breast MRI, and computer-aided detection in mammography has made breast imaging a foremost subspecialty,” Thomasson notes, adding that neither hospitals themselves nor referring physicians prefer that these exams be handled by generalists. “The same is true with vascular and interventional procedures. Diagnostic tools are better

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Radiology | Subspecialization

Multiple PACS and disparate systems form big roadblocks. The objective is for imaging information to flow freely into a robust, simple system, but with disparity, this does not happen. —S. Thomas Dunlap, CEO, University Radiology, East Brunswick, NJ

today than they were in the past,” he says; general radiologists, as a result, are not always seen as the ideal candidates for leveraging these technologies. Thomasson deems pediatric radiology an especially desirable subspecialty, most notably where attending physicians are concerned. “It is commonly accepted that there not only is a certain skill set needed for children’s imaging, but a distinctive ability to relate to both kids and their parents,” he explains. Subspecialty patterns, however, do not entirely jibe with demand. Liability concerns remain a force in discouraging many radiologists from subspecializing in breast imaging. Practicing interventional radiology necessitates leading a restrictive, pressure-laden life, preventing many radiologists from pursuing fellowships and board certification in that arena. Conversely, many aspiring subspecialists find neuroradiology, musculoskeletal imaging, and body imaging most attractive. “Here, there is less of a risk of malpractice litigation, and there are opportunities to use high-tech equipment and live a less frenetic professional life,” Epstein says. Facing Challenges While the appeal of individual radiology subspecialties varies, the

challenges presented by subspecialization as a whole do not. “Besides a blurring of the line between certain subspecialties, we see real-world limitations in the form of challenges,” Dunlap says. Cost ranks toward the top of the list. The volume of cases in any subspecialty must support the higher financial outlay for the IT support and equipment needed to route images to the appropriate reader. Some are compelled to pay higher salaries to subspecialists in areas in which there are more positions to fill than radiologists to fill them; interventional radiology and breast MRI are among these areas. Technical obstacles have emerged. For example, in some cases, there exists a lack of interconnectivity between a practice’s PACS and its other IT systems. Disparate hospital systems put forth a separate set of obstacles. “Multiple PACS and disparate systems form big roadblocks,” Dunlap says. “The objective is for imaging information to flow freely into a robust, simple system, but with disparity, this does not happen.” University Radiology mitigates many of the headaches caused by system disparities with the assistance of an in-house, 19person IT team. Recruitment roadblocks also exist. For example, while the consensus apparently holds that the increasing number of

46 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

fellowships, the formation of larger practice groups, and the general tendency among individuals to want to hone their radiology skills only in areas that interest them will lessen the role of general radiology over time, there will always be a need for radiologists who can move quickly from reading one type of study to reading another. Many subspecialists, however, are less willing to accept positions in which they cannot focus primarily on their area of expertise. “Of course, occasionally, this kind of challenge can work in one’s favor,” Dunlap observes. Recently, University Radiology was able to attract a highly qualified interventional radiologist, recruiting him away from another practice that had too much general work (and insufficient interventional work) for him to perform. Moreover, staffing needs do not always correlate with the available pool of subspecialists. “We need to recruit in line with what is warranted by the needs of the medical community, and to remedy the situation if we are not fulfilling its requirements in terms of areas of expertise,” Smith states. “Still, that is easier said than done.” Over the past few years, Casper Medical Imaging has been attempting, on and off, to fill a recognized need for a full-time musculoskeletal-imaging subspecialist. “Last year, we got serious about it and started to look actively,” Smith reports. “We had inquiries from 12 candidates; of these, eight to 10 came to visit. Not long before that, there were just a few. We haven’t filled a slot yet, and now, there are 26 residents who are interested in checking us out; recruitment has an ebb and flow.” For its part, West County Radiology Group has had fairly good luck on the recruitment front, but Thomasson chalks up a portion of the group’s good fortune to creativity and flexibility. “Candidates have been through the rigors of medical school and fellowship, and quality of life is a big issue for them,” he notes. “They don’t want to be locked into 50-, 60-, or 70-hour work weeks, so they want to be guaranteed some kind of night-coverage arrangement. They are not interested in waiting five years for a partnership. Even more important, they want reassurance, up front, as to how much time they will be spending in their defined practice areas.”

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Radiology | Subspecialization

We do have some subspecialists who want the extra hours, but teleradiology is here to stay, especially for body imaging. —Jeffrey L. Thomasson, MD, president, West County Radiology Group, St Louis, MO

In addition to the requisite reassurance and guarantees, Thomasson and his partners sweeten the pot with such perks as signing bonuses and reimbursement of relocation expenses. Wherever possible, they will agree to special arrangements such as the promise of time off for an already-scheduled future trip or a deferred starting date. Scheduling problems for subspecialists persist in many groups and departments. Epstein observes that the more a practice raises the subspecialty bar by adding staff with different areas of expertise, the greater the pressure becomes to ensure coverage in all subspecialties. This is not necessarily a problem for larger groups, but smaller groups with fewer resources might struggle with it. Scheduling Dilemmas Solutions to scheduling problems have been developed by trial and error. At West County Radiology Group, each subspecialty section does its own scheduling. Radiologists arrange their own schedule trades; Thomasson says that this increases their willingness to cover for each other when necessary. Meanwhile, Casper Medical Imaging leverages PACS to prevent scheduling complications from interfering with subspecialty care. “If we have a complex case that a referring physician only wants a particular radiologist to handle, but that radiologist isn’t scheduled, we will assign someone on call to render the report,” Smith explains. “Then, the radiologist specified by the referrer can weigh in later and communicate the findings to the referring physician.” It’s not surprising that practices of all sizes depend on teleradiology organizations to close at least some of their scheduling gaps. West County Radiology Group has

a hybrid system wherein a teleradiology provider handles evening call. The group’s radiologists, however, have the opportunity to make themselves available to read procedures from home, if needed, during the night. “We do have some subspecialists who want the extra hours, but teleradiology is here to stay, especially for body imaging, neuroradiology, MRI, and ultrasound,” Thomasson says. “It’s not for plain films, but truly, you can neither recruit nor schedule fairly without it.” As a large practice, University Radiology is able to offer its own teleradiology services (which it provides to hospitals, emergency departments, and private practices) to plug scheduling holes and ensure adequate subspecialty coverage around the clock. These services are provided via fully redundant, on-site, HIPAA-compliant servers using virtual private networks, HL7, and broadband Internet gateways. Casper Medical imaging uses a teleradiology provider to provide preliminary reading of bread-and-butter procedures from 10 pm until 6 am daily. “We use teleradiology companies only about 5% of the time, but we do what we must to support subspecialization,” Smith concludes. “There will always be a role for general radiology, but the subspecialty piece (whether practiced only partially or entirely, depending on the group and the needs of the community) is the way of the future.” Julie Ritzer Ross is a contributing writer for Radiology Business Journal. Reference 1. Smith GG, Thrall JH, Pentecost MJ, et al. Subspecialization in radiology and radiation oncology. J Am Coll Radiol. 2009;6(3):147-159.

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FinalREAD

The Message Is the Medium By print, portal, e-journal, or blog, ours is a message informed by a deep commitment to the specialty By Curtis Kauffman-Pickelle

s a journalism and media student in the early 1970s, I was exposed to what was just then emerging as an entirely new way of aligning the creators of information with those who were hungry to receive it. The selection and nurturing of the media outlets and conduits of critically important information into highly tailored segments were then brand new. Cable was the new kid on the block, and its potential was only beginning to rise to the surface in commercially viable outlets. Media philosopher Marshall McLuhan (1911–1980) coined the term global village, and he envisioned a day when media would truly divide along active and passive lines of communication. What he saw was true media/message convergence (hence his statement that the medium is the message), and it truly has arrived, bearing the distinctive signs of his vision from many years ago. Among the historical case studies that the media experts analyzed then was the development in the early 1950s of television. Prior to television, radio was king, and the pundits at the time not only extolled the virtues of this fascinating new medium that added pictures to the voices, but also predicted that radio was, in fact, dead. An interesting thing happened on the road to radio’s demise, though. Radio did more than fail to die with the advent of television; it thrived. Today, it is one of the hottest media alternatives available to marketers of goods and services all across the country. It is a very important part of the media mix because it offers a unique approach. The current debate among the media watchers who are predicting the death of print (while they extol the virtues of online media) is giving me a strange sense of déjà vu from nearly 40 years ago.

Make no mistake: We here at imagingBiz have bet on the online-media phenomenon in a big way. We have developed several online publications that have found their way into the hospital executive suites, private radiology practices, and imaging centers where all of you work. They are now part of the fabric of the profession, and they offer alternative content delivery to those who need in-depth, credible information with which to run the practice, center, or hospital. You can now receive imagingBiz/ RBJ content via portal, blog, Facebook, Twitter, or RSS feed. We believe strongly, however, in the value of print as a continuing medium that

It has also been gratifying to hear from you about the depth and breadth of our editorial content, which is the result of our very active participation in the profession on a number of levels. We are heavily invested in the industry, which allows us to showcase very real and relevant topics that reflect the essence of the issues that you deal with each day, providing guidance, an exchange of ideas, best practices, and leadership. Rest assured that we will continue to invest in bringing you these important topics and discussions in every media format available, including the all-important print version. Based on my nearly 40 years of

Media philosopher Marshall McLuhan (1911–1980) coined the term global village, and he envisioned a day when media would truly divide along active and passive lines of communication. is unique in its ability to add a certain tactile quality to the absorption of the content that we develop. We are writers and content developers with a very long track record of creating unique material based on our knowledge of, and involvement with, the profession of radiology. This distinguishes us in ways that make us much more interested in what we say than in how we deliver it. It is important for us to be able to develop both online and print content, and we look to the expansion of the media mix as part of a natural maturation of media and our true global village. You have told us how much you appreciate the fact that we bring you high-level content in a variety of formats, including the journal that you hold in your hands. You have noticed that we have invested in highly opaque, bright paper stock, and that we support the thoughtful articles with top-level graphics and design.

50 Radiology Business Journal | June/July 2010 | www.imagingbiz.com

experience as a student of media, I feel that it’s safe to say that print is more than here to stay: Readers will continue to rediscover its unique qualities and will hail its rightful place of influence in the pantheon of informationdelivery alternatives. We are thankful that our terrific sponsors agree with us, as you can see from our growing list of advertisers. Not only are we here to stay, but we have been working on turning the vision of media convergence into a reality that will bring you the information that you need in order to compete effectively, and win, in a new and complex arena. We are with you all the way, online and (not incidentally) prominently in print as well. Curtis Kauffman-Pickelle is publisher of imagingBiz.com and Radiology Business Journal, and is a 25-year veteran of the medical-imaging industry. He facilitates strategic-planning retreats for radiology groups.

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