Radiology Business Journal October/November 2011

Charting the

October/November 2011

Leadership Course: Tales From the High Seas

Featured in this issue Measuring Performance in Radiology | page 30 The Tricky Art of Succession: Who Wants the Ball? | page 44 ACOs: Prototype, Rule, Capabilities, and Opportunities | page 54

www.imagingBiz.com

Charting the

October/November 2011

Leadership Course: Tales From the High Seas

Featured in this issue Measuring Performance in Radiology | page 30 The Tricky Art of Succession: Who Wants the Ball? | page 44 ACOs: Prototype, Rule, Capabilities, and Opportunities | page 54

www.imagingBiz.com

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CONTENTS

October/November 2011 | Volume 4, Number 5

18

Features

18 Charting the Leadership Course: Tales From the High Seas

30

By Julie Ritzer Ross Four leaders in radiology hold forth on the challenges of leadership and the way ahead for the specialty.

30

Measuring Performance in Radiology

By Greg Thompson In the era of growing accountability in health care, radiology departments and practices attempt to refine their metrics beyond the blunt tools of government mandates.

39

Pay and Partnership in Radiology Practices

By Joseph A. Serio, FRMBA, FACMPE, CPA, MBA Radiology practices are looking beyond traditional compensation models to build the modern practice.

44

The Tricky Art of Leadership Succession: Who Wants the Ball?

By George Wiley One New Jersey practice successfully navigates a leadership transition that straddles two centuries and several generations.

54

ACOs: A Concept in Motion

By Cheryl Proval An RBMA panel presentation suggests that the accountable-care movement is well underway, despite the absence of a final ACO rule.

4 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

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CONTENTS

October/November 2011 | Volume 4, Number 5 Publisher Curtis Kauffman-Pickelle · ckp@imagingbiz.com

Departments

8

AdView

Magical Thinking About Imaging

10

The Bottom Line

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

By Cheryl Proval

The Rise of the Physician Leader

12

Priors 12 Quality | Joint Commission Sentinel Alert: A Dose of Reality

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

By Timothy F. Signorelli, MHFM, FACMPE

Contributing Writers Julie RItzer Ross; Joseph A. Serio, FRMBA, FACMPE, CPA, MBA; Timothy F. Signorelli, MHFM, FACMPE; Matthew Skoufalos; Greg Thompson; George Wiley

By Matthew Skoufalos

15 15 16

Process Improvement | The Radiology Report, Refined Letters | Mail Call Numeric | Analytics Requirements for Accountable Care: Survey

62

Advertiser Index

64

Final Read

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

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Radiology Business Journal is published bimonthly by imagingBiz, 17291 Irvine Blvd., Suite 105, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. October/November 2011, Vol 4, No 5 © 2011 imagingBiz. All rights reserved. No part of this publication may be reproduced in any form without written permission from the publisher. POSTMASTER: Send address changes to imagingBiz, 17291 Irvine Blvd., Suite 105, Tustin, CA 92780. While the publishers have made every effort to ensure the accuracy of the materials presented in Radiology Business Journal, they are not responsible for the correctness of the information and/or opinions expressed.

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Magical Thinking About Imaging Six years out from the DRA, the continued targeting of imaging as a spending-reduction opportunity looks increasingly far-fetched

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understand that the government does not want to spend money on an imaging examination that is unnecessary. As a fiscal conservative, I have an inherent distaste for waste and actively resent the idea of my tax dollars being spent on anything that isn’t necessary. When it comes to finding opportunities to reduce healthcare spending, however, it is clear that the needle is skipping on the government’s record—because imaging cuts keep playing over and over and over again.

Most recently, imaging cuts and containment found their way onto the White House’s recommended hit list for balancing the budget. As part of its deficit-reduction proposal, the Obama administration suggests raising the equipment-utilization– rate assumption (already at 75%). It also recommends implementation of a priorauthorization program for high-tech imaging in the Medicare program.

For a summary of the major cuts that imaging has experienced and some of the results through 2010, take a look at the Imaging Market File on page 37. Thinking that imaging cuts are going to solve the Medicare expenditure problem is not only increasingly wishful; it is downright magical.

First, the growth of imaging has slowed dramatically, and in some settings, has veered into negative territory.

Second, although it sometimes is necessary to spend money to make money, what is the wisdom of adding another administrative layer (to a system already bloated with administrative costs) in the form of a radiology benefit management program? Aside from the per-member, permonth cost, CMS would be liable to monitor the program to ensure that policies were consistent and necessary care not denied, in a further investment of resources.

We now are spending more than $18 billion in tax dollars on the Health Information Technology for Economic and Clinical Health Act’s incentives to modernize health care

through IT. The Obama administration could compound its investment payback by making computerized provider order entry for radiology, with clinical decision support, a part of stage 2 meaningful-use requirements: clear and simple guidance at the time of ordering.

We need a health-care controller who can look at the system holistically and recognize that the unintended consequence of cuts to the imaging technical component could be the wide-scale shuttering of a low-cost, community-based provider.

Third, there is lower-hanging fruit that might not be as sexy as those big, sophisticated imaging machines, but that packs a much bigger wallop when it comes to savings potential.

Lower-hanging Fruit Recently, Kale et al1 did an analysis of work

by The Good Stewardship Working Group,2 which published, in May 2011, its list of the top five overused clinical activities across three primary-care specialties (pediatrics, internal medicine, and family medicine), as determined by physician-panel consensus.

That list included MRI for lower-back pain, head-injury imaging for children, and dualenergy x-ray absorptiometry for women under 65 and men under 70.

Kale et al performed a cross-sectional analysis using data from the 2009 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, limiting its sample to visits by patients to their primary-care physicians.

The most prevalent activity was ordering of a complete blood count for a general

8 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

medical examination, associated with a cost of $32.7 million. The activity associated with the highest cost ($5.8 billion) was the prescribing of brand-name statins instead of generic statins. The least prevalent activity was bone-density testing in women younger than 65, but it did account for $527 million in costs. MRI for lower-back pain had a $175 million price tag. Head-injury imaging in children and bone-density exams in men under 70 were too infrequent to report.

Kale et al conclude that most primary-care activities identified by the working group are not major contributors to health-care costs.

What we need now is an efficiency expert in Washington—someone who is aware of all health-care programs and initiatives and how they affect each other, so that we can begin truly economizing our health system.

We need a health-care controller who can look at the system holistically and recognize that the unintended consequence of cuts to the imaging technical component could be the wide-scale shuttering of a low-cost, community-based provider.

We need to begin making some of the tough choices that will result in real savings, such as raising the Medicare eligibility age (as recently proposed by the Healthcare Leadership Council) to 67, gradually, at a rate of two months annually. What we don’t need now is yet another round of cuts to the imaging technical component and another layer of bureaucracy that will increase the administrative cost of imaging delivery.

Cheryl Proval cproval@imagingbiz.com References 1. Kale MS, Bishop TF, Federman AD, Keyhani S. Top 5 lists top $5 billion; research letter. Arch Intern Med. http:// archinte.ama-assn.org/cgi/content/full/ archinternmed.2011.501. Published October 1, 2011. Accessed October 10, 2011.

2. The Good Stewardship Working Group.

The “top 5” lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011;171(15):1385-1390.

The Bottom Line

The Rise of the Physician Leader The new realities of health care present challenges and opportunities for physicians willing to invest in their leadership development—

By Timothy F. Signorelli, MHFM, FACMPE and for nonphysicians willing to act as guides

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he roles of the physician leader and the administrative leader are evolving in new ways. Historically, the physician leader devoted extra time to committees, to being the spokesperson for the medical group, and to chairing meetings. With complexity increasing and change rampant throughout health care, organizational leadership needs are growing. What does it take to be an effective physician leader today?

To provide effective, timely care in an increasingly transparent and resourceconstrained environment, vast systems of care must be coordinated and linked with communication, teamwork, efficient transmission of information, and effective utilization of resources. Understanding how the system produces outcomes and how to affect those outcomes (both clinical and financial) is a new challenge.

The need is growing for leadership rooted in clinical expertise. Physicians are best suited to evaluating or developing quality measures, and they have the clinical knowledge to detect which measures really affect patient health.

At the same time, leadership requires broader and deeper knowledge and skills.

If we are to achieve true coordination at all stages of health-care delivery, then we need the perspective that experienced clinicians provide. At the same time, physician leaders need to adapt to an enterprise view (as opposed to a onepatient-at-a-time view) and translate that to practicing physicians and caregivers.

Integrating physicians’ clinical competence with financial, business, and systems competence is a key imperative.

There are currently around 65 joint MD– MBA degree programs in the country, compared with only a handful in the 1990s. This reflects recognition of the need for broader skill sets.

What It Takes

Effective leadership requires an understanding of the enterprise that includes its governance, regulatory/riskmanagement, operations, planning, marketing, financial, human-resources, and IT domains. It also requires interpreting the outside world to the organization and representing the organization to the outside world—including patients,

hospitals, other health-care providers, payors, government agencies, the business community, and the public.

According to physician leaders with whom I have worked, the challenges are many; preserving collegial relationships— while making sure that the hard calls are made—is one. While patient-care decisions are often made on the spot, practice leadership requires more time to flesh out issues, get others’ input, and wait for other entities to respond. One learns to be patient, to avoid reaching a conclusion too quickly, and to be sure that all the right stakeholders are involved in major decisions.

An accomplished physician leader (who moved from private practice to hospital leadership and then to an integrated-care system) notes that simple, common-sense approaches to running a private practice do not translate to large, complex organizations.

Moving past telling employees what to do and developing the ability to influence others’ behavior in the correct direction involves learning a new language, although common sense is still valuable.

While reimbursement challenges are cited as the top concern in a survey1 of CEOs at the Top 100 Hospitals, the next priority is physician alignment (engaging highquality physicians to accomplish goals).

This invariably gives rise to the need for physician leaders who can hold relationships while meeting the strategic needs of the organization.

Business writer/lecturer Ram Charan, MBA, PhD, has observed that while knowledge in the domain areas is fundamental, the basic unit of work, for leaders, is dialogue in which the leader engenders intellectual honesty and trust in the connection between people. Put another way, the effectiveness of a physician leader shows up as authentic conversation with individuals and teams. It also is captured in the deep-democracy concept of psychotherapist Arnold Mindell, PhD, in which making decisions involves ensuring that every voice is heard—including voices outside the meeting room.

The Nonphysician Leader

The advancement of the physician leader’s role in practice settings presents a question that some practices have already answered in the affirmative: Has

10 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

the traditional role of the administrative practice CEO become obsolete? While this is occurring in practices, there is an opportunity for administrative leaders to play a key role in partnering with physician leaders.

The 10,000-hour rule that Malcolm Gladwell popularized (in his book Outliers2) reflects the reality that for physicians to make this transition effectively, there is a lot of learning (and unlearning) that needs to be accomplished. The physician who continues to maintain clinical responsibilities will find that learning to be a long road.

Administratively trained leaders can be invaluable in partnering with physician leaders (sometimes as reflectors, coaches, and guides) as they navigate new territory.

This requires administrative leaders to examine and hone their leadership competencies as well.

As a leader, whether physician or administrator, you must maintain awareness in three key areas. First, be self-aware; know your patterns of thinking, communicating, and problem solving. Invest in the additional learning that will provide a foundation for your leadership, and be aware of what is going on in you when you are having highstakes conversations with others.

Second, be other aware by being truly open to listening, engaging, and communicating. I once heard it said that people don’t care what you know until they know you care. Third, be sky aware, as a meteorologist would put it. Be open to the environment that the organization lives in and serves. This is critical to recognizing patterns—and synergistic opportunities to further the mission, vision, and performance of the organization.

Timothy F. Signorelli, MHFM, FACMPE, is the president of Balancia, LLC, Minneapolis, Minnesota, a health-care executive coaching and development company.

References 1. 100 Top Hospitals Center for Healthcare Improvement. Research paper: 100 Top Hospitals CEO insights: keys to success and future challenges. Thomson Reuters. http://www.100tophospitals.com/assets/ CeoInsightsResearchPaper.pdf. Published August 2011. Accessed October 3, 2011.

2. Gladwell M. Outliers: The Story of Success.

New York, NY; Little, Brown: 2008.

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Joint Commission Sentinel Alert: A Dose of Reality

By Matthew Skoufalos he most recent Sentinel Event Alert1 issued by the Joint Commission formally put the medical world on notice that the expanding use of diagnostic imaging will require more stringent oversight to ensure patient safety. Whether that oversight will be self-imposed or enforced from without, the Joint Commission recommends that practitioners be held to more clearly defined standards concerning the overall radiation body burden of their patients, and it lays out 21 specific recommendations.

When the ACR® gently chided the Joint Commission for some of the wording in its alert, including mixing up the names of its registries, there was clearly a bit of bristle in the response.2 This is an issue on which the college has been proactive, both in launching the Image Gently campaigns and in adding a Dose Index Registry (DIR) to the other active registries that compose the National Radiology Data Registry (NRDR), launched in 2008.

The DIR was officially launched on March 14, 2011, as the newest component of the NRDR. In addition to the DIR, the NRDR warehouses seven other specific registries—covering oncologic PET, CT colonography, mammography, IV contrast extravasation, night coverage, pediatric CT quality improvement, and

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general radiology improvement—that help facilities benchmark outcomes and process-of-care measures and develop quality-improvement programs, according to the ACR. Despite the fact that the DIR has been in operation for just seven months, its chair, Richard Morin, PhD, says that the seeds for the registry were planted years ago, when he chaired the ACR Commission on Medical Physics. The commission came up with the idea of a database that would capture dose information, and the ACR funded the development of software that would automatically extract the amount of radiation associated with a study from the scanner and produce a structured dose report.

A pilot involving one vendor resulted in proof of the concept, so other CT manufacturers were invited to participate.

“We repeated the pilot with a much larger audience and demonstrated that this was a viable idea,” Morin recalls.

Registry Underway Already, the DIR has gathered information from 214 participating institutions, representing more than 150,000 exams and 250,000 individual series of CT studies. The largest single group participant contributes reports from 30 CT devices. Eschewing manual data entry, the DIR software automatically extracts imaging information from DICOM headers using the Integrating the Healthcare Enterprise Radiation Exposure Monitoring profile. By compiling those data, it can help institutions establish guidance on their dose indices for specific exams, relative to national benchmarks.

“It’s a way for the institution to see where it stands compared to everybody else,” Morin says. “We designed it, from the beginning, to be operator independent— no human interaction necessary.”

12 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

Of course, reports generated by the system are only as good as the data that have been entered. There’s no selection bias, Morin says, because every exam performed, on every participating machine, is logged in the system. The democracy of this process leaves its mark in two of the biggest challenges involved with DIR trending: nonstandardized naming conventions for CT studies and differences in patient size.

“Sometimes, it can be very difficult to try to match up your exam with someone else’s,” Morin says, particularly when seeking apples-to-apples comparisons of studies of the chest, abdomen, and pelvis.

Likewise, body-habitus differences can cloud the accuracy of registry values because CT-beam modulation means that “big, thick people have higher values than small, thin people,” Morin says.

“In our pilot, we saw some rather large variances—in some exams, a factor of four to six median values.”

Some larger institutions also have shown great internal variances among common studies because their protocols haven’t been harmonized across different devices and software iterations. “We hope, over time, that people will begin to home in on the optimal radiation for an exam.

The community has responded very well; the staff is talking to people daily who want to sign up,” Morin says.

George Segall, MD, president of the Society of Nuclear Medicine, says that the DIR represents a natural evolution of medical informatics and can be a helpful tool for physicians, but that it should not serve as a standard of judgment—or the basis upon which a determination to perform or avoid a scan should be made for individual patients.

“It would not be advisable not to have a test using ionizing radiation due to a fear that a single test is going to have a

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detrimental effect,” Segall cautions. “Not having an appropriate test is much worse.

If patients need these types of tests, they need them, regardless of the cumulative amount of radiation they’ve had in their lifetimes.”

He continues, “You could have the same issue if you substitute a national pharmacy or drug registry for a radiation registry. It’s not addressing safety in any particular patient; it’s a qualityimprovement initiative.”

A Feedback Tool Morin emphasizes that the registry is primarily a tool to benchmark and distribute radiation-dose data. “There certainly are many different aspects of the way people will use the data,” Morin says.

“Our biggest goal, here, is to put the tool in the hands of the users.”

The DIR is already gaining traction in health-care quality-improvement circles.

According to Morin, his committee is working very closely with Image Gently, which is using the registry as a mechanism to capture pediatric data, and the National Quality Forum, which endorsed participation in a systematic national dose-index registry as a quality measure on September 19, 2011.

To gain access to all of the NRDR registries (including the DIR), providers pay a one-time registration fee of $500 and an annual fee ranging from $500 to $10,000, depending on the number of radiologists and sites involved. Once enrolled, participants receive access to their own individual institutional data, as well as to aggregate reports released at regular intervals.

“One of the biggest challenges we’ve seen, particularly at large places, is that they have to sign a business agreement and provide a PC to run the ACR software,” Morin says. “Sometimes, depending upon the relationship with the IT folks, it can take some time to do.”

Morin hopes that participating institutions will begin to evaluate their imaging protocols internally, undertaking periodic reviews of their practices using the national registry data to provide a basis for judgment. Those facilities that already make use of in-house physics support teams “know quite well where their doses are,”

Morin says; they need to know whether those doses are too high or too low.

Furthermore, he envisions that the impact of the DIR could extend beyond practitioners to device manufacturers as well. “The values now used started with the literature,” Morin says. “These doses are changing, as new equipment comes out; new scanners do the same scan at a lower dose, with better detectors, different reconstruction techniques, and algorithms that take the noise out of the image.”

In as little as two years, Morin expects to see trends emerge across various device Joint Commission Dose-mitigation Recommendations

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mong the 21 measures suggested in the Sentinel Event Alert1 issued by Joint Commission were: • use of modalities other than CT (such as ultrasound or MRI); • collaboration between radiologists and referring physicians in the appropriate use of imaging; • adherence to relevant guidelines from the Nuclear Regulatory Commission, the Society for Pediatric Radiology, the ACR, and the RSNA; • use of proper imaging protocols, with annual or biennial reviews of evidence concerning those protocols; • expansion of the radiation safety officer’s role to include patient safety, in addition to education on proper dose and equipment use for all involved physicians and technologists; and • implementation of centralized monitoring of quality and safety performance for all imaging equipment that might emit high amounts of radiation.

Reference 1. Radiation risks of diagnostic imaging. Sentinel Event Alert. http:// www.jointcommission.org/sea_issue_ 47/. Published September 1, 2011.

Accessed October 10, 2011.

14 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

brands and models. “What I hope we’ll see, in certain exams, is that the median will trend downward, and the variance will become less,” he says.

The Sentinel Event Alert reflects a deeper need for the establishment of a common safety culture, in the imaging world, that “represents dedication to a process,” Segall says. Heightened public awareness of the potential risks of radiation made it timely for the Joint Commission to formalize its policy regarding medical-safety protocols surrounding the use of ionizing radiation, but none of the information in the alert qualifies as news, he adds.

“There’s really nothing new in this discussion; there’s really nothing unreasonable about the recommendations,” Segall says. “It’s very helpful to have them collected in one place and advocated by an organization as respected as the Joint Commission, but all of these recommendations have existed and have been supported by numerous agencies, including the government and professional societies, for a number of years.”

Nonetheless, the ACR announced, at the end of September, that it would host the First Annual ACR Imaging Informatics Summit and Dose Monitoring Forum, to be held November 3–4 in Washington, DC. The first day will bring together policymakers, vendors, consumers, and providers. The second will provide guidance to practice leaders, radiologists, and medical physicists, giving them a full picture of how a facility can proactively monitor dose indices and communicate relative risks and benefits to patients and referrers.

Matthew Skoufalos is a contributing writer for Radiology Business Journal.

References 1. Radiation risks of diagnostic imaging.

Sentinel Event Alert. http://www. jointcommission.org/sea_issue_47/.

Published September 1, 2011. Accessed October 10, 2011.

2.

ACR statement on TJC sentinel alert. http://www.acr.org/ SecondaryMainMenuCategories/ NewsPublications/FeaturedCategories/ CurrentACRNews/ACR-Statement-onTJC-Sentinel-Alert.aspx. Published August 27, 2011. Accessed October 10, 2011.

process improvement

The Radiology Report, Refined

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t’s often said that radiology’s product is the report. It’s the crucible where referring physicians judge the effectiveness of their subspecialist colleagues, it’s a primary source document for coding and billing, and it’s riskmanagement documentation in the event of a malpractice suit.

In addition, according to Patricia Kroken, FACMPE, FRBMA, CRA, a principal with Healthcare Resource Providers, LLC (Albuquerque, New Mexico), it’s a vital tool for establishing imaging appropriateness. “The radiologist can’t change the order,” she notes, “but if the study was inappropriate, that ought to be documented in the report.”

In “Improving Radiology Reports: A Change Management Case Study,” which she presented in Grapevine, Texas, on August 14, 2011, at the annual conference of AHRA: The Association for Medical Imaging Management, Kroken shared the results of a process-improvement project for the radiology report conducted for a hospital-based practice in an urban area.

Kroken explains that the project began as part of an overall denials-management program: In looking over coding denials, her team discovered that denials were due largely to a lack of information in reports— and that they were associated with a significant loss of revenue. “This practice has good, ethical coders, and they would not do assumption coding,” she says, “but if it isn’t documented, it didn’t happen.”

Straight to the Source As Kroken points out, there is a limit to the amount of responsibility that can be assigned to a practice’s coders; to improve reports, practices must engage their radiologists. This, she warns, can be controversial, and it requires the full commitment of the practice’s leadership. “If you don’t have their support, it will be very difficult to drive this through,” she says.

“The meeting where you present this idea will be one hot meeting. It’s very volatile.”

When the project began, in 2004, Kroken and her team first established a baseline for comparison: At that time,

4.26% of the practice’s procedures billed were being denied for coding reasons. Once it had been established that physician dictation was a key cause of inaccurate coding or undercoding, Kroken’s team reviewed dictation patterns and compared them with ACR® communication guidelines1 to establish a set of dictation points that are critical, in terms of billing. These include the exam performed, the number of views, the clinical indication for the study, findings, limitations, and more.

“The ACR does you a great favor by outlining all of this, and that’s why we used it,” Kroken says. “What you don’t want to do is go in criticizing reports, because if you’re a nonphysician, they will ask, ‘Where did you go to medical school?’

Anecdotally, the better the medical school is, the worse the report is.”

After analyzing how frequently physicians hit the benchmarks established by the ACR communication guidelines, Kroken and her team developed custom workbooks for each physician; the workbooks indicated how their reports stacked up against best practices and gave samples of their problem reports.

Blinded samples of ideal reports were also included. “If we don’t show them what we do want,” Kroken notes, “we’re just assuming they will get it. You have to reinforce what you want to see.”

Enforcement and Reinforcement Physicians were educated on coding basics, and an administrative employee was assigned to return for redictation any reports that were missing critical elements. Any patterns of incomplete dictation were brought up in monthly board meetings for further enforcement of the new order.

“They hated this,” Kroken notes. “It was not a popular program. You’ll see one or two great offenders in a group of 20, and those who are chronic offenders go kicking and screaming through this program. This is absolutely where you need physician leaders reinforcing this for you.”

letters

MailCall

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ne of my colleagues recently sent to me the article “2011’s Top 20 Imaging-center Chains.” I thought it was great! He did, however, point out to me that the number of centers the article says RadNet has is materially incorrect.

As of September 4, 2011 (the date of the article), RadNet had 206 facilities.

For reference, at December 31, 2010, our public filings stated we had 201 facilities. The article suggests we contracted in 2011, which is actually incorrect. We’ve been an aggressive consolidator and acquirer over the last several years in our markets.

Also, for reference, at December 31, 2009, we had 180 facilities. At December 31, 2008, we had 134 centers.

I’ve enjoyed reading the articles on your website.

Thanks, Mark Stolper Executive vice president and CFO RadNet, Inc Los Angeles, California SDI reports that the data for the survey are compiled from providers’ materials and that hospital-based joint ventures are not included in the totals, which might account for some of the discrepancies that you noted. In addition, the compilations take place at the end of the first quarter of each calendar year, so they would not necessarily match year-end figures.

Thank you for your compliments and for bringing these differences to our attention.

Cheryl Proval Vice president, publishing imagingBiz Tustin, California

www.imagingbiz.com | October/November 2011 | Radiology Business Journal 15

priors

Positive reinforcement, however, was right around the corner. Before long, denial rates improved; in 2007, fewer than 1% of procedures were denied for coding, and in 2009, that number hit 0.41%, demonstrating that the change had been effectively sustained. Practices can still expect to be affected by annual changes in payor rules; “We’ll never get perfect on coding,” Kroken notes.

Eliminating denials that originated in reports, however, enabled the practice to focus on other causes of denials, and Kroken says that the practice’s overall culture of quality was enhanced as well.

Today, established physicians in the practice provide monitoring and feedback for new physicians. “They now police each other,” she says. “They’ve done a really good job of maintaining the numbers.”

For practices that want to implement a similar process-improvement project,

Kroken advises that they get the buyin of physician leaders; that they use an unimpeachable source of best practices, such as the ACR’s communication guidelines; that they provide concrete information in a blinded format; and that they provide continual feedback. “You want to be looking back at the same criteria you did on the front end and be monitoring it and refining it to improve your results,” she concludes.

“When you’re doing process improvement, you’re never really done.”

—Cat Vasko Reference 1. ACR practice guideline for communication of diagnostic imaging findings. http://www.acr.org/ SecondaryMainMenuCategories/quality_ safety/guidelines/dx/comm_diag_rad. aspx. Updated 2010. Accessed October 10, 2011.

numeric

Analytics Requirements for Accountable Care: Survey

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nalytics technology is the number-one IT requirement for implementing an accountablecare organization (ACO), according to 197 providers (at 187 organizations) interviewed by KLAS

(Orem, Utah) to get an early picture of what ACOs mean for the health-care IT market (see figure). Health information exchanges, data warehouses, and patient portals also figure prominently in the must-have list of IT solutions for ACOs.

Considering the enormous amount of data processing and reporting required to manage a patient population effectively in an ACO setting, a surprising 13% of respondents feel that they have everything that they need.

Analytics Health information exchange None Data warehouse Patient portal Patient health record Home care Care management Bundled payment Claims processing Enterprise master patient index/record locator Interface engine Skilled nursing/long-term care Single sign-on Physician portal Unsure

Figure. Adapted, with permission, from “Accountable Care: Providers Forge the ACO Trail,” August 2011, figure 3, © KLAS Enterprises, LLC. All rights reserved; www.KLASresearch.com.

16 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

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COVER | Leadership and Radiology

Charting the Leadership Course: Tales From the High Seas Four leaders in radiology hold forth on the challenges of leadership and the way ahead for the specialty By Julie Ritzer Ross

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hat qualities make a radiology leader? What experiences best prepare leaders to assume their roles?

How do leaders know whether they are performing to the best of their abilities?

These were among the questions that Radiology Business Journal recently asked four undisputed industry leaders: a radiologydepartment chair, a practice president, a practice CEO, and a hospital radiology executive. All four shared a wealth of perspectives and philosophies, using anecdotes and other glimpses into the workings of their organizations to illustrate their points.

The Radiology Chair: Putting Creativity to the Test

Four years ago, Steven Seltzer, MD, FACS, and his colleagues determined that the department of radiology at Brigham and Women’s Hospital in Boston, Massachusetts, needed a cyclotron to support molecular-imaging research and other endeavors. Seltzer knew that the acquisition would present obstacles, from budgetary and logistics standpoints, but he was determined to succeed in his endeavor—and he didn’t mind spending time coming up with a solution.

The solution: A consortium of Brigham and Women’s Hospital, Harvard Medical School, the Dana-Farber Cancer Institute (Boston), and faculty and corporate sponsors was formed to finance what Seltzer calls the 50-ton monster, while a crane was used to hoist it above nearby buildings and to its destination.

Seltzer has served, since 1997, as chair of the Brigham and Women’s Hospital radiology department and as the Philip H. Cook professor, department of radiology, at Harvard Medical School. He says, “Dealing

18 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

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COVER | Leadership and Radiology

with seemingly ubiquitous people problems is my least favorite part of being a radiology leader, but applying creativity and thinking out of the box to handle bigger challenges (such as this one) are what I like best. They keep me on my toes.”

RBJ: As the leader of a large and prestigious academic department, you have responsibilities for teaching, research, and patient care. How do you balance their varying leadership needs?

Seltzer: I position myself as a convener who sets the overall strategic direction of the department. Beneath this layer is a very capable, very effective management team, and each of its members concentrates on one aspect of our mission, be it clinical/ medical, educational, or financial.

RBJ: What have you done to ensure that after you move on, the organization will continue to thrive?

Seltzer: I keep it an open topic of discussion among members of the department and the leadership of the health-care system. I believe in being as transparent as possible in identifying the specific individuals who should be groomed for positions of leadership.

Some hospitals and academic institutions are sheepish about the fact that they have CEOs because they think it smacks of the corporate realm. The management of a $2 billion organization, however, has to take on the characteristics of the management of a corporation, when it comes to carrying out the mission and handling succession.

RBJ: How do you assess the job that you are doing as a leader?

Seltzer: We have reasonably robust IT tools to track performance through performance metrics. I review this information with hospital leaders and others at least once a year—and often, more frequently than that.

I also conduct informal 360° evaluations of myself as part of my annual performance review, inviting comments and feedback from subordinates and supervisors. We look at subjective issues, such as whether the physicians and technicians believe I am going in the right direction with the department and all of its initiatives, as well as quantitative issues—for example, the number of research grants procured.

RBJ: What are the most important reports that you need (weekly, monthly, and annually) to do your job?

Seltzer: The most important weekly report—really, the most important daily report—isn’t an in-house one, but rather, news of what is happening on Boston’s Beacon Hill and on Capitol Hill. This is because so much short-term direction is shaped by politics and what is going to happen, or probably going to happen, with health-care reform.

Monthly, it is very detailed reports of procedure volumes, performance efficiencies, and our financial status. On a yearly cycle, the most critical reports have to do with research and teaching—the number of federal individual grants we have received to support research, the number of peer-reviewed publications in which work has appeared, and teaching accomplishments.

RBJ: What experiences, in your life and education, best prepared you for leadership?

Seltzer: I’ve had the good fortune to have worked with a series of amazing role models and mentors, including Herbert Abrams, MD, who was chair of our radiology department when I was a resident, and the late B. Leonard Holman, MD, whom I succeeded. Len took me under his wing and helped me to assimilate leadership and management skills and provided invaluable guidance as to how to approach operational improvements within the

20 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

department. He freely shared his thinking about how to tackle global issues that affect the department, not just issues that affect the department alone. For a leader, this last ability is critical.

RBJ: Why is leadership in radiology so important today?

Seltzer: Radiology is at a challenging and pivotal point. After years of uninterrupted growth and development connected to clinical-service expansion, technology introductions, and a supportive economic environment, radiology is coming up against external forces—like the congressional 12member supercommittee—that want to tip the scales in the other direction, with cuts and other measures. Without good radiology-department leadership, and strong leadership in general, those scales will tip way too far.

RBJ: What are the one or two most important lessons that you have learned as a leader?

Seltzer: Be patient, be open-minded, accept criticism of your ideas, and don’t act impulsively. Some leaders, especially new ones, have trouble resisting the temptation to implement change or come up with a strategy for handling an external threat without first obtaining colleagues’ buy-in.

Getting that buy-in is much easier when you’ve developed a culture that prioritizes open communication and serious consideration of other peoples’ ideas.

RBJ: Are you optimistic or pessimistic about the future of the specialty?

Seltzer: I’m highly optimistic. Many of the contributions radiology makes to ensure firm diagnoses for patients—for example, image-guided intervention— are indispensible to 21st-century medical practice.

I’m not so much of a Pollyanna as to say the federal government won’t take measures to cut back sharply on payments for clinical care and funding for National Institutes of Health research, but considering the importance of the specialty, unless we’re overcome by a tsunami of bad economic and political news, I would remain optimistic about the future of radiology (in general) and academic radiology (in particular).

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COVER | Leadership and Radiology

The Practice President: Continuing Education

Eric Mansell, MD, PhD, president of Greensboro Radiology in North Carolina, learned a lot about leadership while a medical student at the University of Florida College of Medicine–Gainesville and during his residency at Wake Forest Baptist Health (Winston–Salem, North Carolina). He believes, however, that ongoing education is critical to effective leadership performance in any discipline, medical or otherwise. Accordingly, he continues to read as much as he can about organizational culture, change, and leadership, in addition to attending conferences that cover these topics.

Mansell and other Greensboro Radiology principals work with a leadership coach on best practices.

They also participate in the Greensboro Leadership Academy, a small, rotating group of radiologists who meet regularly to discuss leadership issues and strategies.

“All radiologists, not just the designated leaders, are included in the academy, but we rotate so that the group, at any one time, remains small,” Mansell explains.

“We want every radiologist becoming a more effective physician leader and member of the medical community by learning communication skills and behaviors. The more open to learning leaders remain, the better—not just for their careers, but for the practices they head.”

RBJ: With the advent of accountable care and the renewed interest of hospitals in physician ownership, what are the greatest challenges for practice leadership and in the practice setting?

Mansell: The big all-around challenges remain how to position the practice as part of a larger health-care enterprise and how to ensure it delivers high-value services at a sustainable cost.

It’s also difficult, now, to know how to build a plan for fostering practice growth in the environment we’re in: The facts that the landscape is changing— and we will have to change, too—only complicate matters. Still, we’re moving ahead, because if we wait, it may be too late to take advantage of alliances and opportunities.

RBJ: As the person with the primary responsibility for setting a strategic path for the practice, how do you approach the challenge of leading so many independent thinkers?

Mansell: I welcome input from each and every one of these thinkers because they are all highly intelligent and have much to contribute to the practice. If I waited for each of them to weigh in on every possible issue or change, though, nothing would ever be accomplished.

For this reason, I work with a very small executive committee on strategic planning and direction, taking into consideration what constituents have to say, but not

22 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

involving them in the actual nitty-gritty of it all. I try to keep the executive committee thinking strategically, so dayto-day and managerial issues are handled by other committees.

RBJ: Why did you choose the leadership path?

Mansell: I like strategizing—helping to find solutions, instead of being part of the problem. One of my most gratifying projects had to do with the procurement of our own PACS. We had contracted with a new hospital and were at the mercy of its PACS, which had a negative impact on service and left us no control of our brand. To take control of everything, from orders to final reports, we came up with the strategy of buying our own PACS, voice-recognition platform, and interface engine. The results were that report turnaround decreased from 24 to 36 hours to less than an hour, and we can offer more value to the partners we serve.

RBJ: What do you like most (and least) about leadership?

Mansell: For me, the best part is innovating within the organization, as happened with the PACS. I also very much enjoy coaching and teaching. With 44 radiologists and 200 staff members, there’s never a shortage of people to assist.

On the flip side, balancing being a leader with the needs of a family is difficult. I have two sons, ages 15 and 14, and both of them are very active in sports. I want and need to be involved in their lives, but much of the relationship building that comes with leadership doesn’t happen during regular business hours.

RBJ: What are the three most important reports that you need (weekly, monthly, and annually) to do your job?

Mansell: It’s easier for me to do my job when I can see the number of reports read, the number of work RVUs generated, and other group productivity measures by the day and by the week. Weekly, I like to look at scheduling waits and third available appointments booked per modality and individual center, so as to identify week-over-week trends. When looking at weekly trends, however, I am careful

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COVER | Leadership and Radiology

to take variances into consideration; for example, maybe productivity is down in one area because a big referrer is out on vacation. Once a month, I review our financial dashboard to understand where we are, in terms of our budget, and to ensure that we aren’t seeing any creep on the expense side.

RBJ: Why is leadership in radiology so important today?

Mansell: We know that health-care delivery is going to change, but nobody has a clear picture of how. Radiology leadership is important because those who are involved in the field need to get off the sidelines and frame the discussion of where radiology fits into the healthcare landscape. If we leave that task to those outside radiology, we don’t know what we’re going to get.

RBJ: Are there leadership qualities that you find to be most helpful in an uncertain, rapidly changing radiology environment?

Mansell: The abilities to get past the status quo, to be innovative, and to look for opportunities to grow the practice— rather than to continue to do what was done in the past, simply because that once worked—are very valuable.

RBJ: Are you optimistic or pessimistic about the future of the specialty?

Mansell: I’m optimistic; if I weren’t, I could not be doing what I’m doing.

Everyone in the discipline, especially leaders, needs to understand that we have opportunities to redefine radiology, in terms of value and service provided to patients and the medical community, but those opportunities aren’t going to be handed to us. We need to pursue them.

The Practice CEO: Preparation by Parenthood

Many adults credit their parents with helping them to become the individuals that they have grown up to be—and Marcia Flaherty’s four grown children are no exception. Flaherty, however, also believes that the experience of bringing up her offspring was instrumental in fostering her professional growth and preparing her to serve as CEO of Riverside Radiology & Interventional Associates (RRIA), Inc, and Premier Imaging Ventures (both of Columbus, Ohio).

Parenthood offers the highest volume and breadth of challenges, Flaherty says, “to provide an environment in which everyone can grow, be respected, enjoy what he or she does, and feel good about himself or herself.” She notes that she was also fortunate to have had several mentors who supported and guided her on the road to leadership and throughout her career; in particular, she cites Robert S. Chaloner, who now serves as president and CEO of Southampton Hospital in New York.

When Flaherty joined RRIA in 1999, it had 17 radiologists and three staff members. Today, the practice has more than 70 subspecialty radiologists.

RBJ: There are few women in practiceleadership positions; has being female been an asset or hindrance to your career? What advice would you give to women interested in following in your footsteps?

Flaherty: I can’t say that being female has been a factor, one way or the other.

24 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

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COVER | Leadership and Radiology

What has mattered is what RRIA has been able to accomplish as a team. We have physicians who trained at some of nation’s most respected medical centers, but you would never know it by the way they interact with and support their colleagues and staff, regardless of whether they are male or female. Trust, mutual respect, and recognition of what each of us brings to the table are the backbone of our success.

My advice for other female healthcare professionals would be to seek out an organization that is exciting, that provides you with an opportunity to do something you are passionate about, and that motivates you to go to work each day and be your best.

RBJ: On a day-to-day basis, what are the most important things that a practice CEO must do?

Flaherty: Make sure you have the right people in the right places in the organization; then, provide them with opportunities to maximize their talents and excel. At the end of the day, it all comes down to people.

It’s just as important to communicate the vision and stay focused. If people don’t have a clear vision of where the group is going, it’s hard to do that. Each person must understand the practice’s strategies and his or her role in contributing to its overall success.

RBJ: Why did you choose the leadership path?

Flaherty: I never remember seeking to be a leader; it was more of an evolution—a journey. I have always been a strategist, and I like to be challenged. I originally planned to become a college professor because I liked to see young people learn and excel, but while I was in graduate school, I worked in patient relations at a hospital, and my supervisor encouraged me to channel the sense of compassion he saw in me into a health-care career.

I still enjoy the gratification of watching people maximize their potential, and it’s a big part of what I do now. Seeing our physicians and staff mature and develop new skills, over time, is very rewarding.

RBJ: How do you assess the job that you are doing as a leader?

Flaherty: Leaders have to ask themselves: Is the organization growing (and not just in size)? Is it evolving to meet the challenges of the current environment?

Are we a disciplined organization, with well-defined governance and evaluation processes? Are we organized and coherent? Do we communicate effectively with one another and our customers?

Again, it goes back to the makeup of the people within the group. The right people in the right leadership positions will challenge and police themselves in many ways.

RBJ: Why is leadership in radiology so important today?

Flaherty: We have challenges, on all fronts, with reimbursement and increased regulation; there is also an inherent lack

26 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

of understanding of the importance of radiologists and the role they play in the health-care–delivery system. We need to take a leadership position and educate decision makers and patients about the value added to the system through appropriate imaging utilization.

RBJ: What are the greatest challenges in the practice setting today?

Flaherty: They are reimbursement challenges, particularly multipleprocedure codes and the sustainable growth rate. Health care is so complex, and decision makers seem to look for easy answers on what to cut. They choose to cut those items with increasing utilization, rather than look at the value that utilization brings to the patient.

I know of no industry where you might (or might not) get paid, and the payor decides whether it will pay you after the service is rendered. It is very challenging to make long-term plans when you don’t know what next year will bring.

RBJ: What are the most important lessons you have learned as a leader?

Flaherty: Be humble. Listen to what others have to say, and let them know you appreciate their support. Be accessible; engage your team in the challenges you’re trying to overcome.

RBJ: Are you optimistic or pessimistic about the future of the specialty?

Flaherty: I’m extremely optimistic. Any time you have an environment of rapid change (such as the one that we are in today), there is also opportunity. I am fortunate to be part of a group that is proactive, versus reactive—and very nimble as well.

For example, when we saw that the radiology marketplace was growing increasingly competitive, we expanded our base of radiology service from one hospital to a current total of 17 hospitals, and we developed additional subspecialties, such as cardiac radiology and neurointerventional radiology.

Although there will be challenges down the road, we have already anticipated many of them and are working on preparing for what might lie ahead of us.

The Hospital Imaging Executive: Staunch Support

Good leadership involves a fine balance between offering staff members the support that they require to fulfill their responsibilities and allowing them to get the job done without an unwarranted dose of micromanagement.

Such is the philosophy of Richard Guarino, vice president, hospital-based clinical services, at Lahey Clinic Medical Center (Burlington, Massachusetts).

In overseeing the hospital’s radiology service (as well as its laboratory, clinicalpathology, and pharmacy services, and part of the cardiac ICU), Guarino actively maintains open lines of communication with directors and other staff so that he can be readily informed of any assistance they require to execute tasks and initiatives. At the same time, however, he respects his constituents’ expertise—and his leadership style reflects it.

Guarino says, “You can give a person goals to attain, but if you’ve hired that person to do a certain job, he or she is the expert and should be treated that way.

Otherwise, you’ll undermine your whole relationship—and, quite possibly, your department.”

RBJ: As the leader of a hospital radiology department (with broader responsibilities throughout the institution), do you perceive opportunities for radiology to engage in a greater leadership role within the organization?

Guarino: Yes; when I first started in radiology, in 1979, radiologic

technologists were considered buttonpushers. As the technology has grown, however, radiology has assumed a much larger role in patient care. We’ve stepped up our game, making it more natural and creating opportunities for larger numbers of radiology-trained individuals to assume leadership roles.

RBJ: You were involved in a turnaround experience in your previous position, as director of radiology at Newton–Wellesley Hospital (Newton, Massachusetts). What attributes did you draw upon in that experience, and what did you learn about leadership?

Guarino: Honesty was one. Many times, I had to tell staff that while they could ask questions about what was going on, I might not know the answer. I think this helped to establish trust. Another was a sense of directness—the ability to say to people, “This is what we need to do next, and this is why.”

During this period, though, I learned the importance of keeping a balance between being honest regarding everything that is happening, including tense staff communications, and revealing too much. I learned the benefit of not showing all the cards in my hand because it’s impossible keep people motivated that way. In the end, the turnover rate dropped from 17.4% to 8%, and the patient experience improved dramatically.

RBJ: What do you like most (and least) about leadership?

Guarino: I like the strategic-planning aspect, especially now, with health-care reform happening. It seems that the job is changing every week, calling for different strategies to be developed and keeping things very interesting.

I don’t like the lack of instant gratification, though. It can take months, or even years, to realize your goals, because there are so many mitigating factors.

RBJ: How do you assess the job that you are doing as a leader?

Guarino: I take the same form I use to evaluate my directors, and I give it to them to evaluate me. They tell me whether I am providing the support they need and what I can do better to support them.

RBJ: What are the three most important reports that you need (weekly, monthly, and annually) to do your job?

Guarino: Every week, I take a close look at variances and whether they are being followed because it helps us to make cost corrections, adjust, and set a percentage or dollar-amount threshold.

Patient satisfaction scores are critical, too, as unhappy patients just don’t come back. I also go over the hospital’s Joint Commission-type tracer reports; often, some of the information will have relevance for my departments.

RBJ: What, in your life and education, best prepared you for leadership?

Guarino: I once had a boss who told me that he had hired me to be the CEO of MRI. He was clear in his expectations of me, and he gave me some guidelines, but then he stepped back. That became a leadership mold for me.

RBJ: What is the greatest challenge in the hospital setting today?

Guarino: Health-care reform: We’ve always been able to justify FTEs and advancement, and to use radiology money to take care of other departments.

It isn’t happening anymore. In 12 to 18 months, radiology could become a cost center as a result of health-care reform, and that alone will be a very difficult transition.

RBJ: Are there leadership qualities that are most helpful in an uncertain, rapidly changing environment?

Guarino: One is the ability to answer questions honestly—to tell people, straight out, that you will give them your opinion, but they may not like it. Knowing how to say no so as not to turn staff off is also key. I won’t say, for example, “We didn’t get it” or “You can’t have it,” but instead, “We didn’t get it because of this” or “Your case needs to be stronger.” I once had an employee tell me I have the nicest way of saying no. I take that as a great compliment.

Julie Ritzer Ross is a contributing writer for Radiology Business Journal and the editor of Radanalytics.com.

www.imagingbiz.com | October/November 2011 | Radiology Business Journal 29

Performance Assessment | Metrics and Measures

Measuring Performance in Radiology In the era of growing accountability in health care, radiology departments and practices attempt to refine their metrics beyond the blunt tools of government mandates

By Greg Thompson

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umber crunchers at radiology practices might occasionally lose sleep over the complex nature of performance assessment, but that’s nothing, compared with the sleepless nights experienced by women who learn of possible breast abnormalities. In his work as regional radiology department chief at Kaiser Permanente (KP) Colorado in Denver, Greg Mogel, MD, instinctively knows this, and he sets the tone accordingly.

It’s not that Mogel neglects the hardcore financial metrics—far from it.

It’s just that the 15-year radiology veteran is convinced that the organization can do it all (and do it well). The philosophy is embraced from the top down, thanks to a KP culture that puts sleepless nights on par with productivity-based metrics.

The sleepless-night indicator is no mere platitude. It is measured, refined, and reported to top leaders. The clock starts ticking the moment a woman is told her that mammogram is abnormal (or when a palpable abnormality is found), and it runs until the time of the biopsy. With so many moving parts, the sleepless-nights initiative is nothing less than a large interdisciplinary project that involves several populations within the radiology department.

To improve overall performance at KP, Alise Vanoyen, MD, mammography section chief; Rachel Biller, CPMG, radiology business manager at KP Colorado; and Mogel examined the situation and recommended behavior changes for radiologists, mammography technologists, schedulers, equipment purchasers, and even equipment

distributors. “This initiative has led to new jobs, such as breast coordinators and navigators,” Mogel says. “Sleepless nights is a highly studied metric. It is a number we calculate internally every two weeks and report to the top of the leadership chain.”

Reducing Sleepless Nights The potential for delays and long nights is enormous due to the numerous handoffs from discovery to diagnosis.

Many of these handoffs occur in the department—and, sometimes, across departments.

“We have reduced sleepless nights by about 30% within the department of radiology,” Mogel says. “Did that improve patient care? That is self-evident.

It is humane, and the highest value in medicine, to reduce suffering and uncertainty for women in that situation.

Does it improve the financial bottom line? Perhaps, but probably not; you could say that as we improve the process for patients, it will amount to good word of mouth for the facility.”

According to Biller, schedulers are given scripts with an eye toward reducing the amount of time for call-backs, and this speeds up the second round of imaging after an abnormality is discovered on a screening mammogram. Same-day biopsies are now a regular part of the workflow as a direct result of studying performance-assessment measures.

Quickly substantiating the abnormality through additional appropriate imaging is part of that workflow, as is carrying out all compliance work necessary to get orders (up to and including biopsy) from

30 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

physicians outside the department.

“In the past month, we have begun doing an increasing number of sameday or fast-track biopsies,” Mogel reports. “This is something that does not happen very frequently anywhere.

We are collecting the data, and we will have numbers to compare our August timing, for example, to our May timing.

We follow the numbers closely. Every fast-track biopsy means a woman is only waiting for the pathology report, which is literally out of the hands of the radiology department.”

Mogel points out that breast imaging, since it is largely based on a screening modality, is inherently different from other areas of radiology. He believes that much can be learned from mammography’s standardization of follow-up care, as outlined in the ACR BI-RADS® criteria.

The role of a mammographer ultimately represents a much more defined and repeatable task than that of a radiologist covering many modalities. “Generalizing performance assessment is difficult across specific tasks within the same radiology department, let alone across different radiology departments with different financial realities, pressures, payor mixes, and responsibilities to the ordering clinicians,” Mogel acknowledges.

He continues, “The ACR would like to reproduce the success it has had in the standardization of mammography in CT and MRI. I, too, dream of that day. There currently are no BI-RADS equivalents for chest CT. There is no widely agreed-upon protocol for cardiac MRI. These fields are much more in the formative stages.”

Nonetheless, Mogel is convinced

that the methods developed at KP are reproducible at other sites, and mammography is a good model to copy, if possible. It comes down to setting priorities.

The sleepless-nights measure affects everyone, from senior leaders to every technologist, staff member, and physician.

Incentives are applied at every point, and information is collected biweekly on mammogram acquisition to interpretation to call-back to biopsy. Changing individual behaviors allows each individual to see how his or her performance has decreased the overall number of sleepless nights.

The performance assessment ultimately shines a powerful light that improves care and seeps into the fabric of the culture.

Transforming the Culture Mogel and Biller are looking for ways to reproduce the mammography performance-assessment model in other areas of medical imaging. They don’t claim to have all the answers, but they relish a future that is likely to reveal final metrics that will fully realize the value proposition that radiology departments bring to each organization.

Governmental entities have tried to set the bar and establish consistent ways to assess performance, but the effort has its problems. “National approaches to assessing performance are doomed, at least in the current state, to fail,” Mogel says. “The reason is that an academic setting requires different measures. Private practice is different, and a multispecialty outpatient practice such as ours has different measures than an inpatient structure has.”

The value proposition of the modern radiology department also continues to change, as do external pressures on radiology as a cost center. Biller observes that not only is there a trend in reduced reimbursement per RVU, but there also is a downward trend in the number of RVUs associated with individual studies, requiring agility in all facets of maximizing reimbursement.

commodity-style productivity measures such as RVUs,” Mogel says. “There are no RVUs assigned to clinician interaction. No RVUs are assigned to helping technologists with patients who are anxious or having a tough time in the MRI scanner.”

He adds, “Using commodity-style, RVU-based productivity measures too broadly risks disincentivizing other behaviors that radiologists can do to add

National approaches to assessing performance are doomed, at least in the current state, to fail.

—Greg Mogel, MD Kaiser Permanente Colorado

Along with RVU-based productivity, Biller keeps track of a wide variety of measures, such as the positive predictive value of mammography, stage 0 and stage 1 breast cancers detected, turnaround times, and satisfaction-survey results for patients and ordering clinicians. Many of these standards have been highlighted by the ACR, but the key for success in day-to-day operations is to keep accurate records routinely and rigorously.

“We monitor and drive productivity by creating an environment to foster that productivity,” Mogel says. “We make sure that quality never suffers in the pursuit of productivity.”

Mogel says that straight productivity models tend to remove incentives for crucial behaviors such as clinician interaction. “There is danger in using

value. Ultimately, radiologists’ value is to serve as partners in shared decision making about diagnostics. RVUs don’t capture that.”

Because radiology is a serviceoriented specialty, Biller emphasizes the importance of identifying the value proposition. “In a capitated environment, reducing utilization of radiology services is obviously valuable,” she says. “In a fee-for-service environment, maximizing use of radiology services is valuable; however, assessing radiologists in those two environments would be different.”

Depending on Data As CMIO for Southwest Diagnostic Imaging (Phoenix, Arizona), James Whitfill, MD, provides IT services for Scottsdale Medical Imaging Ltd (SMIL).

www.imagingbiz.com | October/November 2011 | Radiology Business Journal 31

Performance Assessment | Metrics and Measures

It’s an enormous task, made all the more difficult by the sheer amount of data generated by SMIL, a busy radiology practice.

According to Whitfill, the key to good performance assessment is choosing data that truly influence the patient’s health experience. Do patients end up in the emergency department?

Can they get follow-up care from their physicians? “We have outstanding access to tremendous amounts of data,” Whitfill says. “These data are all related to the

outstanding groups. SMIL is a member of the entity, which encompasses about 1,000 radiologists (who read millions of examinations per year).

Without objective data, everyone thinks his or her patients get the best care, and everybody believes he or she is maximally efficient, really busy, and in need of more resources.

—James Whitfill, MD Southwest Diagnostic Imaging

patient’s radiology experience. Ideally, you would want to match those up with other external sources that tell you how the course of the disease is improving.”

Information can generally be found in the electronic health record (EHR), the paper chart, or the hospital information system. Amalgamating the data into a cohesive whole is no easy task, and Lisa Mead, RN, CPHQ, CAO at SMIL, is partially responsible for getting the data to Whitfill.

“Tracking the patient’s entire experience, within a closed system, is the only way really to know what is going on,” Mead says. “We all think performance assessment is difficult. It is complex because it is a large umbrella.

If you look at all the things that go into quality assessment, it gets back to the performance that you are assessing.”

Accurate benchmarking is one way to know whether a department or practice is on track. SMIL relies on Strategic Radiology (St Paul, Minnesota), a group of 16 private-practice, physician-owned radiology groups across the country, to gauge its performance against that of other

Benchmarking helps gauge the business side of the equation, while EHRs are increasingly interacting with the RIS and PACS to make data acquisition more convenient. “It is not enough just to create a report and say, ‘Here’s the truth,’” Whitfill says. “You get reports, you get data, and then you have to understand whether they make sense. Without objective data, everyone thinks his or her patients get the best care, and everybody believes he or she is maximally efficient, really busy, and in need of more resources.”

For Mead, more data created more questions and motivated her to look deeper into performance assessment to address new issues. “The first thing I think of is the phones, which encompasses the amount of time on hold and people who hang up,” she says. “Often, you hear that you need more people to answer the phones because people complain that you are not answering and/or they are on hold too long. You really need to look at the information and look at how many people are on the phone. How many calls do they take? What is the length of the call?”

32 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

She continues, “You can respond by staffing appropriately or reallocating shifts. Look at staffing hours. Look at individual performance. There is a lot you can do with the information to manage a service area of your company better.”

Expense management, productivity, throughput, and turnaround time all require complete assessment. With the help of Whitfill, SMIL has gotten a handle on its expenses by focusing on the basics.

“The equation, in any business, involves revenue and expense,” Mead says.

Priority data under the quality umbrella are gathered in a variety of places, such as the payroll system, the RIS, and the billing system. “We use two tools for most of these reports, to look at the metrics,” Mead says. “These are business-intelligence tools. We analyze the data and find benchmarks.”

Whitfill adds, “Without a robust performance-management system, you are making really critical decisions about staff and equipment without

Common Measures

G

reg Mogel, MD, regional radiology department chief at Kaiser Permanente (KP) Colorado in Denver, and Rachael Biller, CPMG, radiology business manager at KP Colorado, use a wide variety of indicators to assess performance. They include: • productivity per shift; • peer-review participation; • RVUs per shift, assessed every two weeks; • benchmarks for each modality; • turnaround time; • clinician-satisfaction surveys; • referring-physician satisfaction; and • patient satisfaction, which involves interaction with technologists and physicians.

TELE

Performance Assessment | Metrics and Measures

the proper data. You are making large decisions based on intuition. The larger your organization, the tougher it can be.

Organizations can really drift off track. It’s all about matching resources to demand, and data provide that opportunity in an objective way.”

Ongoing Monitoring At SMIL, indicators are tracked on a weekly, monthly, quarterly, and yearly basis. For employees, Mead looks at job

Patient satisfaction is always a concern, and Mead spends a lot of time poring over satisfaction surveys. Efficiency improved even more when SMIL surveys became automated, as well as outsourced. The outside firm sent out 1,000 surveys for feedback from referring providers, alleviating the burden on in-house staff and providing a wealth of information.

Meanwhile, physicians routinely review samples from each modality under the ACR’s RADPEER™ peer-review

The physician peer-review program is probably the most difficult to measure.

There is such a large exam volume in radiology. With so many exams, you must make sure that you are building a just culture that is not based on blame, and that can be difficult. You want to create an environment in which everyone can truly share and learn.

—Lisa Mead, RN, CPHQ Scottsdale Medical Imaging Ltd

satisfaction and performance, which are usually tied to a yearly merit bonus.

“We ask our supervisors and staff to meet during the year to give feedback on performance,” Mead explains. “From a clinical perspective, and under the quality umbrella, we look at the quality of images. We get this from feedback from referring physicians and/ or comments from our radiologists. They can let the supervisors know if there are any issues with image quality.”

program. Results are fed into the ACR database and used to review trends and boost learning opportunities.

Mead puts everything under the quality umbrella, with specific emphasis on image quality; satisfaction; risk management; compliance; physician quality, via peer review; and various projects through the accrediting bodies.

“The physician peer-review program is probably the most difficult to measure,”

34 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

Mead says. “There is such a large exam volume in radiology. With so many exams, you must make sure that you are building a just culture that is not based on blame, and that can be difficult. You want to create an environment in which everyone can truly share and learn.”

At KP, Mogel also uses RADPEER, which monitors participation by individual radiologists and determines how many colleagues’ cases are reviewed. Interpretations are graded on a scale of 1 to 4, and every month brings a quality-assessment meeting to discuss particular cases.

“Many radiology departments are not great at making sure everyone is reviewing enough,” Mogel says. “We make sure everyone is participating equally.”

Mogel says that a long-term patientcentered philosophy at KP has made teamwork and high performance entrenched parts of the culture. The standards of the team are high, and while performance-assessment numbers usually back that, the raw statistics don’t always tell the story.

“There are shifts and tasks that must be commoditized, but over-reliance on productivity as a measure is a big mistake and has significant unintended consequences,” he says. “Radiology involves shared decision making, utilization decisions, and decisions to reduce radiation exposure. If productivity is relied upon too much, it reduces the radiologist’s role to that of a commodity.

That does great damage to the whole specialty, and ultimately, to the people we serve.”

Greg Thompson is a contributing writer for Radiology Business Journal.

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Imaging Market File

Outpatient Imaging Utilization Trends

B

eginning with the DRA of 2005, a cascade of negative reimbursement pressures— including exam bundling, a weak economy, radiology benefit management programs, and the adoption of appropriateness criteria— has had an effect on historical outpatient imaging utilization trends.

This fourth installment of the Imaging Market File explores utilization trends,

by modality, for hospital outpatient and freestanding outpatient locations nationally, from 2007 to 2010, while identifying the regulatory and economic factors that are likely to have had an impact on these trends (using complementary timelines). The database includes volumes from 96 outpatient imaging providers and 24 hospitals in 14 states. Total outpatient exam volume is 13.7 million, from

Imaging Timeline Advanced imaging grows 16.1%, year over year DRA introduced

US Economic Timeline 1995 2005

Original implementation of Multiple Procedure Payment Reduction (MPPR) policy; 25% reduction for technical component (TC) for second and subsequent studies (same patient, same day) in same session on contiguous body area within family of codes February: Congress passes DRA

June: Consumer debt soars to new heights—129.3% of disposable income

2006

Stark II causes some imaging joint ventures to unwind DRA reductions fully implemented: Medicare Physician Fee Schedule (MPFS) TC paid at lower of MPFS or Hospital Outpatient Prospective Payment System rate; Congressional Budget Office estimates $8.1 billion in savings over 10 years; Government Accountability Office (GAO) finds decrease of $1.7 billion in 2007 Medicare imaging-utilization growth rate slows to 3.2%

Unemployment rate: 4.6%

October 9: The Dow Jones industrial average (DJIA) peaks at 14,164

2007

Mortgage defaults and provisions for future defaults cause profits at the 8,533 US depository institutions insured by the FDIC to decline 98%, from $35.2 billion in 2006, quarter four (Q4), to $646 million in Q4 2007 December: The National Bureau of Economic Research (NBER) declares the start of the recession Unemployment rate: 4.6%

Medicare Improvements for Patients and Providers Act passed by Congress; requires accreditation by 2012 for all providers of high-tech imaging services

President Obama is elected on a platform that includes health-care reform

Trade deficit widens to $763.3 billion

The subprime mortgage crisis hits: About 16% of subprime adjustable-rate mortgages are either 90 days delinquent or in foreclosure proceedings

RBM influence widens to 100 million covered lives

GAO recommends preauthorization to slow explosive Medicare imaging growth

The United States experiences two consecutive quarters of growth below 3% for the first time in three years Housing boom ends: The rate of home appreciation begins to decrease

CMS reports 22% increase in imaging spending, 2004–2005 Radiology benefit management (RBM) initiatives begin to affect volumes

2007 through 2010.

While the data represent almost 14 million exams across 14 states, the 96 outpatient and 24 hospital locations do not represent samemarket comparisons between hospitals and outpatient centers. The data set analyzed did not provide the ability to determine whether a drop in volume for one provider was picked up by other providers in the same market.

September 15: Lehman Brothers declares bankruptcy

2008

October 3: President Bush signs the Emergency Economic Stabilization Act of 2008, creating the $700 billion Troubled Asset Relief Program (TARP) October 6: The DJIA falls 1,874 points in one week, or 18.1% November 7: The US Treasury announces the restructuring of AIG’s debt with a $40 billion TARP purchase of senior debt

October: Dow Jones industrial average drops 1,874 points due to credit crisis

Job losses total 2.6 million, the greatest loss since 1945 Medicare Payment Advisory Commission recommends increase in equipment-utilization–rate assumption Year ends without sustainable growth rate (SGR) fix in place

Unemployment rate: 5.8%

2009

February: President Obama signs the American Recovery and Reinvestment Act of 2009 Underemployment jumps to 8 million, the highest since records were first kept, in 1955 June: The NBER announces the end of the recession

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New Physician Practice Information Survey data (criticized by the ACR) begin four-year phase-in, causing sharp reductions in practice-expense-per-hour rates Hospital acquisition of outpatient imaging centers is in full swing: Imaging centers affiliated with health networks double since 2005 MPFS cuts for 2011 include a 75% equipment-utilization–rate assumption; application of MPPR across families, regardless of body part; and application of bundled imaging codes for procedures performed together more than 75% of the time, such as CT of the abdomen and pelvis

Unemployment rate: 9.3%

2010

March: President Obama signs the Patient Protection and Affordable Care Act, expanding access to health insurance for more than 30 million people July: The Dodd–Frank Wall Street Reform and Consumer Protection Act is enacted Unemployment rate: 9.6%

October/November 2011

Imaging Market File

30%

15%

20%

10%

10%

5%

0%

0%

–10%

–5%

–20%

–10%

–30%

–15%

–40%

CT

Radiography

MRI

Nuclear Medicine

PET

Ultrasound

CT

Radiography

MRI

Nuclear Medicine

PET

2008

15.6%

–14.4%

9.2%

15.4%

20.8%

19.2%

2008

–1%

1%

1%

–4%

9%

1%

2009

2.5%

4.2%

–0.1%

–8.6%

1.1%

–2.6%

2009

4%

4%

0%

–12%

10%

–1%

2010

–1%

–2.6%

1%

–28.3%

11.9%

–4.4%

2010

–2%

3%

–1%

–11%

–1%

–1%

Figure 1. Combined hospital and freestanding outpatient imaging center volumes: This figure represents combined outpatient volumes of 13.7 million exams performed at 24 hospital and 96 freestanding imaging-center sites between 2007 and 2010. Over the four years of data capture, PET was the single modality that exhibited volume growth in each of the three comparison years.

Ultrasound and nuclear medicine both show declines in 2009 and 2010, reversing strong double-digit growth trends from 2007 to 2008.

Figure 2. Freestanding outpatient imaging center volumes: After exhibiting high–single-digit and double-digit growth in the early part of the decade, freestanding outpatient imaging-center volumes were flat or declined in 2008 in all modalities except PET, a modality for which CMS steadily broadened coverage throughout the second half of the decade. CT, radiography, and PET saw increases in 2009, but in 2010, volumes decreased in every modality except radiography.

60%

40%

40%

30%

20%

20%

0%

10%

–20%

0%

–40%

–10%

–60%

–20% CT

Radiography

MRI

Nuclear Medicine

PET

Ultrasound

2008

42%

–26%

46%

30%

32%

48%

2009

1%

5%

–2%

–7%

–6%

–4%

2010

0%

–5%

6%

–32%

25%

–6%

Figure 3. Hospital outpatient imaging volumes: After significant increases were logged in 2008-over-2007 volumes, declines were seen in all modalities except CT and MRI in 2009. In 2010, only PET volumes increased. Hospitals, however, generally display more positive trending than freestanding outpatient imaging centers in all modalities. Is this due to hospital acquisition of outpatient providers, or is the shift due to the closure of unsustainable outpatient imaging center locations?

Ultrasound

–30% 2007–2010 variance

CT

Radiography

MRI

Nuclear Medicine

PET

Ultrasound

17%

–24%

7%

–23%

41%

7%

Figure 4. Variance between hospital-based and freestanding outpatient imaging center volumes: The net sum total for the four-year change measurement can be misleading in some modalities. For example, CT demonstrates terrific growth overall when 2007 is used as a baseline. If the 2007 data are removed, total growth of 17% becomes 1.5% for the period 2008–2010.

Similar significant four-year MRI growth demonstrated in the data transforms into flat utilization when the 2007 baseline reference and associated growth in 2008 (over 2007) are removed.

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The Practice | New Compensation Models

Pay and Partnership in Radiology Practices Radiology practices are looking beyond traditional compensation models to build the modern practice By Joseph A. Serio, FRMBA, FACMPE, CPA, MBA

I

n the past, many radiology private practices used a fairly traditional (and extended) track leading to full partnership in the practice.

Now, however, many practices are exploring emerging compensation models—including accelerated partnership tracks and enhanced flexibility in balancing earnings and hours—to accommodate the needs and preferences of a new generation of radiologists. Making these changes without antagonizing established partners is particularly difficult in some practices, so considerable finesse, patience, and communication skills will often be required.

For practices seeking physicians, it really is a buyer’s market right now. Many physicians are coming out of training now and finding that there are fewer jobs to be had, partly because physicians have become more productive. In addition, advances in health IT (such as PACS) have made it possible for fewer physicians to cover a given geographic area.

A recent look at the ACR® Career Center (www.jobs.acr.org) gave me an indication of the subspecialties that are now in highest demand. The top four fields, based on the number of job openings, are breast imaging, neuroradiology, musculoskeletal radiology, and teleradiology. The only surprise here is teleradiology; its position as the fourth most requested subspecialty tells us not only about the growth of teleradiology itself, but about the ability of teleradiology companies to get radiologists to work for less compensation than they might once have expected.

Some of us will remember that in the early 1990s, practices were discussing

how they were going to raise the starting salary for radiologists from $120,000 per year to $144,000; there was a lot of heated debate. Today’s radiologists are typically seen starting at $250,000 to $300,000 per year and ramping up from there.

Under the traditional model of the partnership track, radiologists could expect fixed compensation and benefits for their first and second years of working with a practice. Partnership was usually offered after the second or third year, depending on the supply of available radiologists and the demand for their services.

The third year offered fixed base compensation plus a bonus that was based on a percentage of the practice’s earnings (but was not equal to the full

partners’ bonus). During the fourth year, the radiologist earned base compensation plus the full bonus distributed to partners.

Today’s partnership track in radiology looks quite different in its early phases, although it reaches the same point—base compensation plus the full partners’ bonus—during the fourth year. In effect, the first and second (bonus-free) years of the old model are being skipped, and the third year, under the traditional system, is being extended to last for the first three years of work.

The radiologist begins working with the practice in exchange for base compensation plus a percentage of the partners’ bonus. Based on the results of quarterly performance evaluations,

www.imagingbiz.com | October/November 2011 | Radiology Business Journal 39

The Practice | New Compensation Models

partnership is often offered at the end of the first year. During the second and third years, the bonus percentage is increased annually, reaching the full amount in the fourth year.

This is a way of spreading risk, since the fixed compensation is a smaller amount and the bonus percentage depends on the financial health of the practice. If there are revenue problems, the practice will be responsible for paying a lower amount than it would have paid under the traditional partnership model (which had larger fixed compensation and had smaller—and later—bonuses).

The risk borne by the senior shareholders is spread, in this way, to the newcomers as well.

In addition, the practice’s efficiency and income can benefit when making an earlier offer of partnership becomes the norm. If the practice knows, by the end of the first year, that it likes a new radiologist, offering that person partnership status can inspire greater effort on that physician’s part—by making him or her a stakeholder (as well as a shareholder).

The new partners in a practice are more willing to bring forward new ideas, and they are more likely to participate in the committees and governance activities of the group.

Evaluating New Radiologists The earlier a partnership in the practice is offered, however, the more certain the practice must be of the new radiologist’s abilities, qualifications, and general suitability for the position. Evaluating new radiologists becomes more critically important when they could become partners (or seek employment elsewhere) after only a year.

At Radiology of Huntsville, PC, in Alabama, we use an evaluation form (see figure) that is used at the end of three, six, and nine months of work; after 12 months, the practice members vote on whether a partnership will be offered to the new radiologist. Because this leaves little time for gradual adjustment to the expectations of the practice, new radiologists need the feedback (both early and ongoing) that the evaluation form provides.

After each round of evaluations, in which forms are completed by the new

radiologist’s colleagues, the executive committee and I meet with the radiologist to go over the results. For this reason, free-text comments can be even more important than the form’s checkboxes in providing specific, useful feedback that the radiologist can use to adapt to the expectations of the practice.

In some cases, these expectations are easily met, but might not have been apparent without the evaluation. One radiologist was stunned to find, at his first evaluation, that his habits of arriving late and leaving early were attracting the negative notice of his colleagues; it had simply never occurred to this high achiever that maintaining a fixed schedule would be expected of him. Frequent evaluation sessions allow misperceptions

of this kind to be corrected quickly and easily, before they can impair the new radiologist’s chances at partnership.

The group does a one-week orientation when a new person comes into the practice. A senior radiologist in the same subspecialty is assigned to sit down with the new radiologist and answer questions. Advice is also given concerning which referrers prefer certain reporting conventions, so the orientation is customized to prepare the newly hired person to make a solid start.

There is a chance that a referrer will refuse to have a particular radiologist perform interpretations in the future if the referrer’s preferences are not observed initially, so it is important both to the new radiologist and to the practice to

Figure. Example of an evaluation form used for quarterly assessment of newly hired radiologists.

40 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

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The Practice | New Compensation Models

All of the practice’s physicians should be on the same contract (shareholder employment agreement). That might seem obvious, but I have actually known groups in which the physicians all have different contracts—and that does not make for harmony.

—Joseph A. Serio, FRBMA, FACMPE, CPA, MBA Radiology of Huntsville, PC

ensure that the information needed to accommodate these preferences is communicated at the beginning.

In addition, a handbook for new associates is given to cover broader topics that will apply to all new physicians; it covers such mundane (but important) topics as where to find the restrooms and how to use the practice’s information systems.

Examining Contract Terms All of the practice’s physicians should be on the same contract (shareholder employment agreement). That might seem obvious, but I have actually known groups in which the physicians all have different contracts—and that does not make for harmony. If you give everyone the same contract, that makes things simple, especially when it is time to update contracts. If the new contracts offered to radiologists at that time are identical, there is an element of peer pressure that will encourage them all to sign the new agreements.

About 80% of any contract’s text concerns itself with how the physician and the practice are going to part ways, if that time comes. The termination portion of a contract should always have for-cause provisions that include loss of medical licensure or loss of medical-staff privileges.

It is important to add to these causes for termination any event that impairs the physician’s ability to generate charges or bill for services. An example might be loss of Medicare privileges, but there could be several other situations that affect charges, so inability to bill for services (not the reason for that inability) should be the focus of the contract’s clause.

The contract should also give the

practice the ability to end its relationship with a physician without showing any cause at all. Some hospitals, for example, reserve the right to terminate any physician, without cause, on 30 days’ notice. Contract clauses that permit termination without cause might lead some physicians to raise objections, but they are in the best interests of the practice and its shareholders.

For example, there might be a radiologist who continually does a number of small things poorly, leading to great frustration within the practice—but none of those small problems might be significant enough to be considered cause for termination. If there is a without-cause termination clause in the contract, it is possible to end this person’s employment without worrying about discrimination suits (or other legal action against the practice).

If the contract permits only for-cause termination, however, then the group will be forced to prove that some egregious failure on this radiologist’s part has taken place. That could be impossible, particularly in practices that require a high percentage of partners (rather than a simple majority) to vote out a radiologist.

Earning More According to a 2010 survey1 involving 15 medical associations and physiciansearch companies, the compensation range for radiologists is $377,300 to $478,000. Only five medical specialties showed pay increases, from 2009 to 2010, that exceeded the 2.7% inflation rate for the survey period. They were dermatology, pediatrics, neurology, pathology, and hospital medicine.

42 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

Nonetheless, the survey showed that few specialists made more money than radiologists did; cardiologists, neurosurgeons, and orthopedists were among them. Pediatricians’ average compensation was $193,135; for family practitioners, the average was $187,821.

This kind of information is reviewed at the legislative and regulatory levels of government, so it’s easy to see why radiology is a target for those who intend to reduce per-procedure physician compensation.

On the practice and individual scales, variations in compensation for radiologists are naturally a concern as well. There are always physicians who want to earn more by working longer, and there are always physicians who are willing to accept lower incomes in exchange for more time off work. The challenge, under traditional compensation models, has been to find a way to accommodate the preferences of both groups.

Where the income of the practice is shared equally among the partners, it will be difficult to keep everyone (or, perhaps, anyone) happy. At either end of the spectrum of preferences for free time versus income, some physicians will always blame those at the other end either for diminishing everyone’s compensation or for decreasing everyone’s available time off work. Although splitting practice profits equally has been a common compensation model, it is not a good fit unless the practice partners happen to be quite alike in their preferences for income and free time.

A good compensation model must answer one key question: How can radiologists who want to earn more do so within the practice? One solution to this problem has been to adjust radiologists’ individual compensation based on their productivity, either to determine their overall share of the practice’s profits or to award them additional income on top of a fixed share. In the model that is often employed in practices that are heavily involved in teleradiology, the radiologist is assigned a fee per study. In the hospitalemployee model, the radiologist’s income is based on work RVUs. An emerging hybrid model is likely to be better than either the traditional model or the productivity model at adjusting

radiologistsâ&#x20AC;&#x2122; compensation to match their added efforts. This modified equal-share model awards points for taking longer and/or less desirable shifts (for example) and equalizes the points at the end of the year to determine the amount of the radiologistâ&#x20AC;&#x2122;s bonus. Radiologists can trade shift point for days (or weeks) off if they want to work less, since the partners who have higher shift-point totals will earn larger bonuses.

Shift points are assigned to each work period in advance, based on the perceived desirability of working that shift. An index of shift desirability is constructed based on the hours of the shift (with higher points awarded for evening and night shifts) and the day of the week (with higher points awarded for weekend shifts).

When applicable, a holiday adjustment factor is also used to award extra points to radiologists who work holiday shifts that are considered mildly undesirable (Memorial Day, Independence Day, and Labor Day), moderately undesirable

(Thanksgiving and New Yearâ&#x20AC;&#x2122;s Day), or highly undesirable (Christmas).

A 10-hour weekday shift, for example, is worth the same number of points (10) as a five-hour weekend evening shift, and a shift worked on Labor Day is worth an additional 10 points beyond its basic day/night and weekday/weekend points. Radiologists who want extra compensation can work shifts with higher point countsâ&#x20AC;&#x201D;and when radiologists must cover undesirable shifts, they do so knowing that they will gain a larger yearend bonus for doing so.

The modified equal-share model also has mechanisms that let radiologists earn more outside the shift-point system. For a flat daily fee, a radiologist can act as an internal locum tenens. The practice also can become a broker for a partnerâ&#x20AC;&#x2122;s work, allowing that partner to accept outside opportunities that the group, as a whole, does not want. For external work that the group does want, such as site coverage, the group can handle billing and collections

for individual radiologists who want to take on these extra assignments.

This kind of flexibility is vital to keeping a practice running smoothly.

This evolving compensation model, by making it possible for each radiologist to achieve an individual balance between compensation and time off, makes the practice more harmonious, more efficient, and more productive.

Joseph A. Serio, FRBMA, FACMPE, CPA, MBA, is executive director of Radiology of Huntsville, PC, in Alabama. This article has been adapted from â&#x20AC;&#x153;Trends in Privatepractice Partnership and Compensation Models,â&#x20AC;? which he presented at the RBMA Executive Education Program in Scottsdale, Arizona, on July 23, 2011.

Reference 1. Robeznieks A. Slow growing. Modern Healthcareâ&#x20AC;&#x2122;s 17th annual physician compensation survey. Mod healthc.

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The Practice | Succession Planning

The Tricky Art of Leadership Succession: Who Wants the Ball?

One New Jersey practice successfully navigates a leadership transition that straddles two centuries and several generations By George Wiley

I

t is a well-accepted axiom in business that to be successful, a leader must want to lead. The truth, though, is that business entities often struggle to find leaders because no one really wants to put in the time or make the effort to push the organization up the hill.

This is particularly true for medical practices, where many physicians only want to treat patients, and they look askance at administrative duties.

Radiologists are no different from other physicians in this regard.

Edward J. Petrella, MD, recently stepped aside as president/CEO of South Jersey Radiology Associates (SJRA), PA, Camden, New Jersey. Petrella learned the lesson of the desire-to-lead vacuum early.

He found himself in a leadership role at SJRA by default.

“In many practices, leadership falls to whoever is willing to take the green banana,” Petrella says. “I volunteered to do the business side of it. I didn’t want to, but nobody else was stepping up to the plate.”

Long before he decided to step aside, at the beginning of 2011, Petrella began looking among SJRA’s younger partners for a successor. He fastened on William F. Muhr Jr, MD, an MRI subspecialist who showed interest in administration. For several years, Petrella says, he nurtured and mentored Muhr, bringing him along slowly.

In January, Muhr succeeded Petrella as SJRA’s president and CEO. The irony, Muhr says, is that he was the only one who wanted the job. The pattern of a desire

44 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

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The Practice | Succession Planning

I saw that unless somebody made sure we were collecting our money, we were going to be in a difficult position in keeping up with technology. I said, ‘OK I’ll take the leadership role.’

—Edward J. Petrella, MD South Jersey Radiology Associates

vacuum in leadership had continued for 20 years. “The job was open to anyone who was interested,” Muhr says, “and I was the only one. The partnership approved the change.”

Of course, by the time Muhr took over, he had been groomed and targeted for succession for years. Nonetheless, there weren’t many partners clamoring for the leadership role. “The world is run by those who show up,” Petrella says, quoting an anonymous aphorism.

Seeing a Better Way Petrella himself showed up as SJRA leader, he says, because he could no longer endure watching money go to waste in uncollected billings. If the practice could collect the additional money, Petrella says, it could expand its locations. It could hire subspecialists and purchase technology to stay abreast (or ahead) of competitors.

This is exactly what the practice did once he took over, Petrella says.

SJRA has deep roots. It began as a practice reading for a single Camden hospital nearly 80 years ago. When Petrella joined the practice, in the early 1970s, it had two outpatient centers and was reading for two hospitals. Today, the group has 45 radiologists (most are partners) and 10 centers, and it reads for three hospitals.

It also has become a highly subspecialized practice and a show site for a major modality manufacturer. SJRA was fifth in the nation to install its vendor’s dual-source CT and third to deploy its 256-channel MRI, Petrella says.

“I was with the practice for 10 years, and the practice hadn’t grown much,”

he recalls. “We had a haphazard billing system. You were handed a bill when you left, and if you paid, you paid. If you didn’t pay, nobody sent you a second bill.

The only way you got a second bill was if you came back to the same office for a second procedure and they said you had a balance.”

SJRA first tried using billing companies to collect its outstanding receivables, but this didn’t work well. Petrella says, “You gave them the information, and they charged a percent of collections as a fee. It was 8% or 9% at the time. When you look at the dynamic, if you work the percentage of what is collected, 85% comes in easily.

To collect between 85% and more than 90% requires a lot more effort, and the billing companies weren’t doing that because it cost them too much.”

Petrella convinced SJRA to hire a billing manager and bring collections in-house.

The amounts collected went up and the cost to collect them declined. With the heightened cash flow, the practice was able to open new centers and purchase imaging equipment.

“I saw that unless somebody made sure we were collecting our money, we were going to be in a difficult position in keeping up with technology,” Petrella says. “I said, ‘OK I’ll take the leadership role.’” He adds that he was lucky that his partners valued his administrative role.

He began with one full day per week devoted to administrative work and gradually increased that to three days.

“Not being full-time created the need for those long evening hours and weekends spent on the practice,” he recalls. “My partners pushed me to take more time

46 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

because, when working, I was constantly interrupted by administrative tasks.”

One of Their Own A key decision made by the SJRA partners was that the practice would be led by one of their own. “The alternative, which many are doing today, is to hire a nonphysician CEO,” Petrella says. “For some groups, that has worked, and for some, the results have been disastrous.

There is a big learning curve to the practice of radiology. We always felt we wanted a radiologist in charge.”

Another major decision that SJRA physicians made was to keep the administrative side as lean as possible and devote the money saved to upgrading technology and building a subspecialtyoriented imaging-delivery system.

“We don’t have a big administrative infrastructure,” he says. “The corollary to that is that it is very demanding on the infrastructure we do have.”

About 15 years go, Petrella was given the joint titles of president/CEO of the practice and chair at Virtua Health, Marlton, New Jersey. At SJRA, being president meant overseeing the activities of the board, and being CEO meant maintaining the vision for the practice, as well as dealing with major contracts. He had a single administrative assistant who maintained his schedule, and the practice continues to run with a combination COO/CFO, a director of human resources, and an IT director.

When Petrella led the practice, SJRA’s board of directors, on which each partner has a seat, met monthly to make decisions. Since Muhr took the reins, an executive committee was added to make intermediary decisions. Rules and bylaws were written governing which decisions are made by the executive committee and which must be made by the entire board.

As a hands-on leader whose children were grown, Petrella recalls poring over financial reports into the wee hours. Today, more of the day-to-day responsibility for running the practice has been transferred to the COO. Grooming a Successor Petrella says that it wasn’t too many years after he took over as president/

Enterprise Clinical Imaging Strategy Requires Four Classes of Service— Not Just Big-box Storage

By Charles Morris, Sr. Marketing Manager, IMPAX Data Center, Agfa HealthCare, United States Imaging Strategy Key to Best Care In today’s world of lofty patient expectations, medical imaging has become a key enabler for delivering top-notch care, giving physicians an effective tool for diagnosing patient illness and monitoring the effects of treatment.

As a result, a comprehensive electronic health record (EHR) must also include a patient’s longitudinal medical imaging record; for that record to be complete, it must go beyond conventional radiology and cardiology images and incorporate medical images and related data from the wide array of other hospital departments now involved in medical imaging. These include surgery, endoscopy, ophthalmology, pediatrics, pathology, dermatology, and numerous others.

To be useful, these medical images and data need to be easily accessible to clinicians, rather than siloed away within individual departments, as is often the case. The best way for health-care organizations to solve this and other challenges and complexities associated with leveraging medical imaging data for maximum clinical and business benefits is through a comprehensive enterprise imaging strategy.

First and foremost, an imaging strategy defines the clinical role (for example, improving patient care and health outcomes) and business role (for example, streamlining operations and maximizing insurance reimbursements) of medical imaging across the enterprise. It also identifies the underlying architecture, technology infrastructure, and workflows required for medical imaging to play those roles successfully.

New Class of System Fills EHR Gap One fundamental architectural aspect of an effective enterprise imaging strategy involves moving those siloed images, results, and related data (that is, metadata) out of departmental systems and into a new class of system—a single, centralized, enterprise-wide system that, until recently, I have been calling a medical imaging repository.

Upon further reflection, however, I find the term repository to be limiting because it suggests a storage-oriented solution, when what is really needed is a peer to the clinical information system (CIS), similar in function, but focused on imaging workflow: an information system that deals with all aspects of medical imaging data—creation, capture, storage, management, access, and distribution—not just storage in a longitudinal–patient-record context. This line of thinking is upheld when one considers, for example, all the workflow that has to happen around creating and capturing images and related data—arguably the most complex part of the imaging workflow—before they are even stored.

Imaging CIS (ICIS) is a more fitting name for this new class of system.

Not to be confused with the widely adopted CIS from the likes of Cerner, Epic, MEDITECH, and others, the ICIS should, however, be given the same level of importance as the CIS when it comes to constructing a hospital EHR, and should be shaped by the same longterm vision and driven by the same long-term planning.

Comprehensive EHR = CIS + DMS + ICIS To address the clinical needs of patients comprehensively, a hospital EHR construct must, in fact, combine information from several enterprise-wide systems, mainly the CIS, the document-management system (DMS), and the new ICIS.

VNAs Only Fill Niche Requirement Another class of system often discussed in the context of managing medical images is the so-called vendor-neutral Archive (VNA). In addition to features that focus mainly on image storage and life-cycle management, the VNA solves a common compatibility problem by bridging the difference between how different PACS vendors interpret and implement the DICOM communications standard. The VNA adds a layer of intelligence on top of the basic DICOM that transforms imaging metadata so that the particular vendor system accessing the data will see them the way the vendor system that stored them had intended.

VNA solutions are primarily storage centric and do not address how image data get created or captured or how the get distributed to enterprise users who are not PACS users, such as general-practice physicians, surgeons, specialists, and others. The primary goal of a VNA is to provide the most advanced storage capability possible for imaging data, which makes a VNA a good solution if storage of data is more important than access to information.

On the other hand, the primary goal of the ICIS, which is a workflow-centric platform, is to make all imaging data readily available to more physicians across the enterprise for consumption in the care process. To achieve this goal, an ICIS must deliver a broad array of services—the four pillars of Agfa HealthCare’s ICIS strategy: capture, store, access, and exchange.

Four Classes of Services Make Possible Robust ICIS Capture The term capture has been used instead of the more common acquisition to connote that this suite of services provides much more than just the physical acquisition of the patient image from some imaging modality. For example, the Agfa HealthCare Capture suite enables an ICIS to provide efficient and flexible workflow to support the placing, filling, and billing of imaging orders. The order workflow automatically incorporates admission/discharge/transfer feeds to ensure accurate patient demographic data, and the Capture suite also provides for preassigned billing (CPT®) codes to automate the billing process and help organizations realize maximum insurance reimbursement.

For any department whose imaging modalities are not supported by

some type of local PACS or image-management system, the Capture suite also enables an ICIS to play a surrogate role, providing physical connectivity to many different modalities for the acquisition of image data, capturing image metadata to ensure the image can be associated with the right patient once the image and related data are stored in the ICIS. Appropriate to its clinical focus, the Capture suite provides word-processing capability so clinicians can report study findings and results.

Store Chief among critical attributes making up the Store suite is standards conformance. Having a standards-based method for storing images and data on physical storage media in an open, standards-based file format ensures ICIS flexibility and interoperability. An ICIS should be storage-vendor agnostic, support both file-based and content-addressable storage systems, and provide workflow in support of capabilities such as prefetching, multitier storage, and clinical-information life-cycle management.

An ICIS should also support the use of cloud-based storage. This allows IT staff to focus on IT innovation, rather than being consumed by menial tasks associated with constant storage growth and system maintenance.

This approach also offers infrastructure-financing options such as switching capital expenditure to operational expenses. As more health-care facilities find cloud-based storage an attractive model, increased service options are becoming available.

As part of an EHR, an ICIS must be massively scalable and capable of handling up to millions of imaging studies annually. It must also be highly available—a department-level PACS going down affects only the subset of patients being serviced by that department, but an EHR-level ICIS going down can affect every patient in the health system. Having two data centers or two sets of infrastructure in active–active mode is an effective way to ensure business continuity while making workload balancing and zerodowntime maintenance possible.

Access Access is all about making imaging data quickly and easily available to caregivers while delivering a simple, yet appealing, user experience. It should feel as though all patient medical data are in one system—the CIS— eliminating any need for users to bounce from one system to another to get what they need. To this end, the CIS needs to be tightly integrated with the ICIS, with the CIS serving as the host and system of truth for patient identity and demographic information and the ICIS providing the CIS with embedded visualization technology linked to and accessing imaging information it manages. The tighter this integration and the more transparent it is to the user, the better off care delivery and the patient will be.

Achieving a deep integration requires a well–thought-out relationship between Capture and Access services. The ICIS must be able to ingest the meaningful study information (that is, imaging metadata) during the capture process on the front end so that when it passes a link for the image data and metadata to the CIS, the CIS recognizes the admitting event, the care plan, and the particular disease state, for example, with which the data are associated. This gives the ICIS the ability to assist the CIS in organizing the presentation of patient information in a logical and flexible manner versus dropping all the information in a single medical-record–number bucket. The ICIS must also be able to make these linkage data available in such a way that the CIS can file them in a patient record using its own special organizational structure—each vendor’s CIS organizes patient data in its own unique way. This partnership between ICIS Capture and Access services and the CIS creates an optimum environment for physicians quickly, without difficulty, to access pertinent patient imaging information as part of the clinical record.

Exchange The fourth ICIS pillar—Exchange services—provides ICIS the ability for public and private, clinical and diagnostic health-image exchange, as well as interoperability between vendor imaging systems (PACS). Also included in this pillar, or set of services, are data-migration capabilities (to move archive data out of departmental systems into the ICIS). Exchange supports standards-based image sharing over private networks between

hospitals in the same health system and over public networks between different health organizations (for example, e-health and telehealth).

In addition to meeting basic image-sharing requirements, such as supporting IHE, HL7, and DICOM communications, as well as mapping data between vendors’ PACS systems that interpret DICOM slightly differently, an ICIS provides numerous advanced Exchange capabilities.

These include unique support for the imaging version of the international Cross-enterprise Document Sharing for Imaging (XDS-I) standard, which requires an ICIS to support XDS-DICOM transformations, as well as to be able to create and store a manifest or location ticket in an XDS registry for each image stored in the ICIS. Advanced ICIS Exchange capabilities also include medical-record– number localization, for example, as well as support for the new Imaging Object Change Management (IOCM) standard. IOCM requires the ICIS to be able to keep track of all locations that studies have been sent to and provides mechanisms for updating (or even deleting) already-distributed images, which not only recovers valuable storage space but also reduces potential legal risk posed by retaining images beyond their relevant lives.

ICIS Delivers Maximum Clinical and Fiscal ROI While most health organizations do not have an all-encompassing enterprise imaging strategy today, the widespread adoption of the EHR and the impending inclusion of imaging as a component of meaningful use, implications of imaging within accountable-care organization strategy, and rapid growth in the use of all kinds of medical imaging as integral parts of the diagnostic and treatment pathways are making such a strategy unavoidable. Only an ICIS can provide enterprise-wide imaging workflow and intelligence; storage management alone cannot reach these lofty, clinical-system–like goals.

A foundation for this is a robust ICIS with flexible and highly functional capture, store, access, and exchange capabilities. To date, these capabilities have largely been addressed on an individual department-by-department, system-by-system basis, with numerous niche vendors focused on individual components, especially storage; until now, none of the major vendors has come to the table with a completely integrated, end-to-end solution.

While a best-of-breed point solution for storage, for example, will be likely to deliver storage-specific return on investment (ROI), these systems— when considering the complete role of imaging in the EHR—are simply components. The highest clinical and fiscal ROI around imaging can only be derived from a consolidated ICIS incorporating all four classes of services.

Charles Morris, Sr. Marketing Manager, Agfa HealthCare, can be reached at charles.morris@agfa.com

CEO that he spotted Muhr as a potential successorâ&#x20AC;&#x201D;a younger partner who had an interest in administration. â&#x20AC;&#x153;He got involved and, over the next eight or 10 years, he took on more and more responsibility for running the practice,â&#x20AC;?

Petrella says. â&#x20AC;&#x153;Bill was willing to roll up his sleeves. Succession is a matter of finding somebody who has the talent and the interest to put in the time.â&#x20AC;?

Petrella groomed Muhr by involving him in specific projects and research, as well as introducing him to the hospital administrators and various payors.

Involving Muhr in contract negotiations with payors was an important step. â&#x20AC;&#x153;You have to know where the data are, and youâ&#x20AC;&#x2122;ve got to look at what is happening to your costs,â&#x20AC;? Petrella advises. â&#x20AC;&#x153;Our costs are not static; there is competition for technical staff. Our rates may not go up, but our costs do. There is an analysis that has to go into it. We have to work as a team, so we incorporated Bill into that process. We opened a couple of

facilities in the past two years, so you have to bring your future leader into that evaluation.â&#x20AC;?

When Muhr took over as SJRAâ&#x20AC;&#x2122;s president and CEO, Petrella says, it was easy to hand over the reins. â&#x20AC;&#x153;I always said I want to get out at the top of the game,â&#x20AC;? he says. â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;d rather leave when I want to leave, instead of mumbling my way out the door.â&#x20AC;? Petrella adds that the era during which he presided over SJRA was one of outstanding growth for radiology, but the coming era that Muhr will confront will be much more austere than his own. â&#x20AC;&#x153;Many like leadership titles, but are unwilling to do the work necessary to lead and grow a practice,â&#x20AC;? Petrella notes. â&#x20AC;&#x153;Some practices give the title based on longevity, rotate leadership, or go on autopilot.

Selecting new leaders means evaluating who will do the work. Bill showed up and helped do the work necessary to run the practice and business.â&#x20AC;? Working halftime now, Petrella plans to retire at the end of 2011.

Looking Ahead Muhr is well aware of the fiscal tightening that is taking place in all of imaging, including SJRA. â&#x20AC;&#x153;I think of the environment of the late 1990s through 2008 or so, when we were seeing doubledigit procedure growth: If you put the scanner in, they would come,â&#x20AC;? he begins. â&#x20AC;&#x153;That was national and international, but in the past several years, the market has been flat, and CT volumes have seen a decrease. We are now static or consolidating.â&#x20AC;?

One reason that Muhr wanted the SJRA CEO/president job was to guide the practice through the new austerity initiatives that payors are imposing. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s an interesting challenge to take our practice, as structured, and refashion it for the new world of health care,â&#x20AC;? Muhr says. â&#x20AC;&#x153;We may not be recognizable, 10 years down the road.â&#x20AC;?

Muhr points to the mergers and acquisitions that are taking place throughout health care. â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;re seeing a lot

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www.imagingbiz.com | October/November 2011 | Radiology Business Journal 49

Cloud-based Email Archiving:

Improved Compliance, Security, and Bottom Line Like other enterprises, imaging centers, hospitals, and radiology practices depend on information and, therefore, information technology (IT). With this reliance on IT, organizations must understand and adapt to constant and rapid changes in the technology—and in their own needs and obligations.

Data backups and built-in archiving don’t substitute for end-toend archiving solutions. Most email systems today have records-

capability and efficiency, yet they also require upgraded infrastructure: hardware, software, storage space, square footage, power, cooling, and more. There also is the need for strong data security and integration with mobile devices. These, along with regulatory and other obligations, add up to increases and unpredictability in costs and management burden. What may be surprising, however, is that email figures prominently into this equation.

management capabilities, including archiving, but these have limited, noncustomized functionality. Some organizations archive their emails using basic backup methods, such as data tapes. Both of these methods permit long-term retention, and they can help optimize servers and storage—but they are utterly unhelpful with regard to e-discovery and email retrieval.

One reason for maintaining an archive is to be able to respond to legal inquires, which means producing the needed files. Without refined search capabilities and compliance-minded functionality, data backups and generic tools in email applications dramatically complicate the task of finding and retrieving emails. The risks are not just expensive fines, but also unpredictable and potentially high costs associated with e-discovery.

Email and email archiving contribute to organizations’ IT and business challenges. According to market-research and analysis

On-site, purpose-built archives offer better security, ease, and compliance. More and more organizations are using purpose-

company Enterprise Strategy Group (ESG), 40% of organizations are experiencing an annual growth in email traffic of at least 20%. ESG’s research also suggests that the average organization’s email archive grew in size by 200% to 300% from 2007 to 2009.

While email and email archiving may not appear to top the list of IT priorities, they are a significant IT—and business—concern. Emails are covered by stringent regulatory/legal requirements and internal policies for retention, electronic discovery (e-discovery), and disaster recovery. Like other types of data, archived emails also require storage space, maintenance, and other IT infrastructure and resources.

built archiving solutions, which capture emails directly from the email application and manage them intelligently in dedicated on-site archives. Automatic capture means minimal IT labor and risk of deletion. Purpose-built systems also are customizable and make possible numerous retention policies, automatic expiration/ deletion, greater security, easy e-discovery/retrieval, and a seamless user experience. While very effective, on-site archives require significant in-house compliance and IT expertise, thus posing a challenge for organizations that lack such resources.

IT-related changes create advantages—and increased obligations and unknowns. IT advances provide new functionality and greater

Compliance, legal exposure, and retention are primary issues.

Physician practices, hospitals, and imaging centers must keep their emails safe and secure—and keep them for specified amounts of time. While HIPAA doesn’t mandate durations for retaining emails, it is generally interpreted that emails fall under HIPAA’s six-year– retention rule for privacy and security policies. Organizations also implement their own email-retention policies and need to retain emails to protect the organization in the event of complaint, litigation, and investigation—all common in healthcare. An email archive can therefore have several different retention policies in effect.

E-discovery, storage-space restriction, and the challenges of archiving emails. Important parts of healthcare organizations’ obligation to retain and archive email are e-discovery and email retrieval.

Practices/providers do not merely have to retain emails; they must be prepared and able to find, retrieve, and produce them as needed or required. This is where email archiving becomes particularly important—and becomes a problem.

As email volumes consume ever more storage space, IT departments must either deploy additional infrastructure (at considerable, and often unpredictable, expense) or enforce email-volume limitations (quotas).

The first response, of course, is to implement quotas on users, who respond by creating personal archives on their local machines. This creates a significant e-discovery and email-retrieval problem, requiring substantial labor to find and retrieve emails stored on users’ machines.

How many copies? Where are they? How much labor? Is compliance achievable?

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Email archiving with Enterprise Vault.cloud means that your organization achieves retention and regulatory compliance, reducing not just the risk of noncompliance, but also the unpredictable and potentially high costs of trying to comply. At the same time, Symantec’s hosted archiving solution resolves a variety of end-user and administrative challenges by offering unlimited mailboxes, easy 24/7 Web-browser access, granular retention policies, instant scalability, rapid deployment, and expert management and support.

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The Practice | Succession Planning

We’ve had a successful practice, but we have to keep our eyes on the future because we may have to change. Businesses that don’t change almost inevitably fail—that’s a reality check.

—William Muhr, MD South Jersey Radiology Associates

of activity,” he says. “Everybody is looking at it. There also is a rethinking of the way we approach patients. Radiologists are faceless, behind closed doors. There has to be a more integrated mindset of collaborating with other physicians and other health systems.”

One of Muhr’s challenges is to give the SJRA physicians constant reality checks about outside pressure to cut imaging costs as part of reshaping health care.

“When you’re managing physicians, you’re basically trying to manage people who are smart, successful, typical type A people, who are driven on their own,” he notes. “You can’t be high-handed.

You’ve got to engage the physicians and make them want to make the changes that you want to make. You can’t just live with things, either; that’s not going to work.”

The other radiologists in the practice need to be reminded of broader healthindustry patterns, Muhr says. “We’ve had a successful practice, but we have to keep our eyes on the future because we may have to change,” he says. “Businesses that don’t change almost invariably fail—that’s a reality check.”

Muhr says that the toughest thing that he has done was making the decision to close an underperforming vascular angiography interventional center, which involved laying off staff. “The most challenging are the personnel decisions,” he adds.

It also has been challenging to stand up to his fellow physicians. “You do have to talk to them, if you get a complaint from a referring physician,” he says. “You have to tell them, in a bosslike way, that they

can’t keep doing that. I’m increasingly comfortable, but the first couple of months were interesting.”

Muhr, as CEO and president, receives no extra pay or additional benefits, but the practice grants him three days a week for administrative work. He has one vote on the SJRA board of directors, and he shares equally with the other partners in the profits of the practice. The single leadership benefit, other than the pleasure of meeting the challenge, is that he is relieved of on-call duties.

A Personal Stamp Muhr says that he has aimed to head the practice ever since taking over the body-imaging section years earlier (a role he’s had to give up, as CEO). One thing that he has refused to do is to give up clinical work. He interprets MRI studies at least two days per week. “I love MRI,” Muhr says, but he also recognizes how important solid leadership is.

“In a lot of medical practices, not a lot of value is given to the management and operational infrastructure,” he says.

“When I started here, the chief of the group (Joseph Centrone, MD) ran the practice on the fly, out of a briefcase, and with one secretary. As we grew, it became clear that we needed support staff. There was a fair amount of resistance when we needed administrative infrastructure, a COO, and operational support. I think it makes sense that medical practices keep physicians in the top level of leadership— they need that insight—but it’s also critical for medical practices to have appropriate management in place. I inherited a very nice infrastructure.”

52 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

Muhr has already overseen the creation of the seven-member executive committee, as a more flexible vehicle for making quick decisions on midlevel matters. It can approve six-figure expenditures, Muhr says. For bigger expenditures (such as buying scanners or opening new imaging centers), the full board of directors must still approve.

In the future, SJRA will focus more on what Muhr calls reproducible reporting standards. He wants protocols in place so that reports are completed in the same way by all the radiologists, at least within each imaging section.

“One of the problems, in all of medicine, is that we’re not a reproducible industry,” he says. “When you get on a plane, the pilot goes through a checklist used by every other pilot. In radiology, a report might be issued eight different ways. We want the reports to agree for each imaging section. Reproducibility is the first measure of quality. I’m pushing hard for that.”

Thinking of the Entity Muhr is also pushing to get younger leaders into the administrative pipeline.

Even though he has been CEO for only a few months, he’s already looking at a longer continuity of leadership than just his own turn at the helm. “We want to get somewhat more formal management training for people,” he says. “We do have one physician with an MBA, and he could be the vice chair. We have a qualityassurance director. I’m identifying people to put in key positions.”

One lesson that Muhr has learned at SJRA is that the practice rules. “We have always taken a long-term view of what is appropriate for the practice,” he says. “I saw physicians at the end of their careers voting to add new technology (which would eat into profits and pay) because they knew it was for the long-term health of the practice. They said, ‘Don’t think of me; think of the entity.’” That might be the single best reason that succession planning in leadership is important. The practice depends on it.

George Wiley is a contributing writer for Radiology Business Journal.

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Imaging and ACOs | Prototype, Rule, Competencies, and Opportunities

ACOs:

A Concept in Motion An RBMA panel presentation suggests that the accountable-care movement is well underway, despite the absence of a final ACO rule

By Cheryl Proval

W

hile health-policy experts debate the potential of accountable-care organizations (ACOs) to address the problem of cost in US health care, a panel held on July 22, 2011, at the RBMA Executive Education Program in Scottsdale, Arizona, reveals that with prototype ACOs already in play and health-care systems assessing their ACO needs, radiology practices should waste no time in securing a seat at the table.

Otherwise, they risk being left on the sidelines, with limited options.

The panel, “Setting Up an ACO: The Good, the Bad, and the Ugly,” included Palmer C. Evans, MD, senior advisor, Southern Arizona Accountable Care Organization (SAACO) in Tucson; Brent Hardaway, vice president, Premier Inc (Charlotte, North Carolina); and W. Kenneth Davis Jr, JD, partner, Katten Muchin Rosenman LLP (Chicago, Illinois).

I also was a member of the panel.

The Prototype

Evans presented first on the ACO built by the 612-bed Tucson Medical Center (TMC) before the term gained currency. TMC shares the Tucson market with the Carondelet Health Network division of Ascension Health (St Louis, Missouri) and the University of Arizona Medical Center, among others; in this region,

some systems are attempting to purchase additional practices, Evans notes. TMC is not pursuing that strategy, preferring to confederate independent practices.

The seeds for the ACO were planted in 2007, when TMC discovered that it was going to have to partner differently with its physicians in order to succeed.

One indicator was supply costs. TMC’s primary orthopedic practice was ordering more hips and knees from one major orthopedic vendor than any other practice in the country was, but it was paying list price.

“In talking with the CEO, we decided the best place to start was in co-management,” Evans says. Beginning with orthopedics (and later adding neurosciences, cardiac imaging, and cardiovascular surgery), TMC announced each service-line partnership as an LLC, with 75% owned by the physicians and 25% owned by the hospital.

“What that does is get collaboration on a different level,” he says. For starters, TMC saved $13 million on orthopedic supplies within 18 months.

Late in 2008, TMC discovered that one of hospital’s primary-care groups had entered into a gain-sharing agreement with UnitedHealthcare (Minnetonka, Minnesota) that would result in shared savings if chronic-care patients could be kept out of the hospital.

On notice to expect reduced admissions from a loyal referrer—but understanding that this was the right thing for patients—

54 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

TMC reached out to UnitedHealthcare Western Region. It discovered that Tucson—with few major employers and many small businesses—was a tough market for UnitedHealthcare, and it was interested in working with a system in which physicians and the hospital were working toward better-quality care, lower cost, and higher efficiency. It had also launched seven patient-centered medicalhome projects in Arizona, four of which were associated with TMC. Brookings Comes Calling When the Engelberg Center for Health Care Reform/Brookings Institution (Washington, DC) approached TMC to become one of three pilot sites for the Brookings/Dartmouth collaborative ACO model late in 2009, the hospital already had experience with medical homes and in collaborating with primarycare physicians to manage chronic-care patients.

“That was the first time I heard the word ACO,” Evans recalls. Before accepting the offer, the board had to be convinced that TMC could reduce hospital admissions, improve population health, and remain viable. “Our board—which is a community board—as stewards of the community resource decided this was the best thing to do,” Evans says.

SAACO is 80% physician owned and 20% hospital owned. With the aims of local accountability for cost, standardized performance/quality measures, and

New Architecture Resolves Workflow and Interoperability Challenges Volatile fluctuations in reimbursements, painful strains on existing imaging infrastructure, increased scrutiny, and a demand for both improved quality and service have placed unprecedented pressure on imaging enterprises.

Today, they seek ways to improve efficiency that will not just offset the impact of rising costs and lower reimbursement, but will help increase output, which results in increased revenue.

In summary, potential MEDxConnect benefits include:

Hernandez outlines three keys to the success of workflow improvements:

• lower cost per transaction

1. Empowerment allows users to adapt the system to help achieve their own distinct set of goals, thus reducing the need for costly upgrades and outsourcing.

2. Access enables the user to modify, monitor and track key data points critical to implementing new business processes, governmental regulations, and financial constraints.

Interoperability is the capability of d ifferent imaging systems (that is, systems originating from multiple vendors or suppliers) to provide and receive services and information, between each system and every other system, in a seamless manner. Put simply, true interoperability allows various programs to talk to each other from any workstation.

Without this integration, departments will continue to operate as silos, thereby reducing efficiency and impeding critical progress toward addressing the challenges of accountablecare organizations, meaningful use, declining reimbursement, and the health-care system of 2012 and beyond.

According to Albert Hernandez, vice-president of engineering for Compressus, Inc, developers of MEDxConnect, one of the nation’s leading interoperability programs, the solution must also be measurable. He says, “Our goal is to maintain all the existing features of a given system while widening the range of problems that can be solved

8

by allowing users to improve workflow. Workflow improvements show up in measurable units.”

The challenge to today’s imaging business, then, is to determine the best use of its investment resources to help achieve efficiency goals, including the ability to create measurable results.

Fortunately, the technology required to make the required upgrades is not a work in progress, but exists today, in the form of seamless data integration, also known as interoperability.

The economic benefits that have grown from the adoption of interoperability result in a stronger imaging enterprise.

eIghth IN AN eIght-pARt seRIes

3. Simplicity establishes an ease of use that allows users to overcome more complex challenges with little additional effort, resulting in more productivity, as measured in RVUs.

To date, achieving true interoperability has been perceived as both costly and time consuming, and even when it is achieved, solutions are affected whenever a system or workflow is altered. That perception has little basis in fact: It has been estimated that aligning physicians, patients, equipment, technicians, etc., through interoperability could generate efficiency saving of up to $18 billion annually to the US health-care provider sector (source: Boston Consulting Group, 2006).

• increased operating efficiency • lower long-term design and installation costs • reduced long-term operations and maintenance costs • lower long-term support, systems restoration, and upgrade costs • higher quality of service • maintaining competitive advantage Janine Broda, Compressus’ chief marketing officer, notes that MEDxConnect has demonstrated its value. “We have vast experience in successfully integrating large medical networks, and are well aware of the challenges essential to enabling all users to take advantage of interoperability,” Broda says. “The new MEDxConnect architecture provides features, functionality and flexibility. It gets no better than this.”

About MEDxConnect MEDxConnect offers a holistic solution to connecting disparate systems. Designed to manage the workflow of an imaging health-care enterprise, the MEDxConnect system provides a suite of offerings that has the power to connect systems from multiple vendors, that offers proven interoperability, and that allows an organization with disparate multivendor systems to function as one virtual enterprise.

see a live demonstration of MeDxConnect.

Visit Compressus at the RSNA conference at McCormick Place in Chicago, Bldg. D, Booth 400, Lakeside, November 27 – December 2, 2011.

To learn more…

MEDxConnect

TM

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

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

Visit us at RSNA 2011 Bldg. D, Booth 400, Lakeside McCormick Place, Chicago, IL Nov. 27 – Dec. 2, 2011

Imaging and ACOs | Prototype, Rule, Competencies, and Opportunities

payment incentives for provider collaboration, SAACO formed a physician steering committee in early 2010 made up primarily of four primary-care physicians, a hospitalist, a cardiologist, and a general surgeon.

SAACO subsequently formed a management-services organization (MSO) that will serve as a steering committee for the Medicare ACO that it plans to

by UnitedHealthcare) that provides prospective predictive modeling of the likelihood that a patient will end up in the hospital, as well as some retrospective tools.

Although TMC was an early supporter of the state health information exchange (HIE), Evans says that it was not moving quickly enough to meet the ACO’s needs, so it is developing its own private HIE

You know that 20% to 30% of patients are readmitted to the hospital within 30 days of discharge. Medicare is going to start penalizing us for those readmissions.

—Palmer C. Evans, MD Southern Arizona Accountable Care Organization

build. “The purpose of the ACO is to collect shared savings, distribute them, and measure physician quality,” Evans explains. “The MSO will be the engine that will drive the ACO.” The MSO, a commercial enterprise run by a team from some of the participant physician groups, is responsible for providing an administrative infrastructure for coordinating IT and case/disease management, implementing medical homes for primary-care physicians who want to participate, and coordinating communications.

Meeting the Quality Mark TMC also has been gaining experience with quality metrics through its work as a pilot site for the Brookings Institution’s starter set of claims-based measures to assess quality of care (and determine payments) in the CMS ACO program.

Of the 65 measures that must be met by Medicare ACOs beginning in January 2012, Evans estimates that his group could meet 52. “There is some question as to whether anyone can get to 65,” he notes.

Evans is enthusiastic about some of the technology that will facilitate providing physicians with information about their quality performance. After reviewing three systems, TMC chose one (owned

to aggregate hospital and physician electronic medical records, PACS, and other health information systems in use throughout the ACO. It also will have the ability to tap into the state HIE. Evans says that an ACO can reduce spending by implementing initiatives that have been proven to work: efficient use of nurse practitioners and physician assistants, extreme care coordination, aligned provider incentives, chronicdisease management, the use of data and collaboration, health-risk assessments, evidence-based medicine, and accountability. “You know that 20% to 30% of patients are readmitted to the hospital within 30 days of discharge,” he says. “Medicare is going to start penalizing us for those readmissions.”

Evans emphasizes the urgency of reducing costs: In 1965, when Medicare began, the average lifespan, after age 65, was four years; now, it’s 20 years. There were 10 taxpayers per beneficiary; now, there are three. There were fewer than 10 million beneficiaries; now, there are more than 44 million. By the time the last baby boomer turns 65, the over-65 population will be nearly double what it is today, and by 2050, one person in five will be 65 or older. “Tell me we don’t have a problem,” Evans says.

56 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

The Proposed Rule: A New Kind of Provider Beginning with a discussion of the statutory roots of the ACO in the Patient Protection and Affordable Care Act (PPACA), I presented on the CMS proposed rule, which engendered a firestorm of criticism earlier this year. At press, CMS had sent the final rule to the Office of Management and Budget, preliminary to its publication in the Federal Register. The program is set to begin on January 1, 2012.

The PPACA introduced the ACO, in March 2010, as a legal provider organization that is directly responsible for many Medicare services and that can ensure patient access to the rest. The law establishes a broad framework for ACO provider participation and the principles for sharing the savings. It makes clear that participation is voluntary, but it is a permanent program.

While the law is vague, it makes eminently clear that an ACO must be patient centered, and its language strives to ensure maximum freedoms and rights for patients (perhaps to deflect charges that ACOs are reminiscent of 1990sstyle managed care). It also specifies that a patient need not receive all care from the ACO to which his or her primary-care physician is attached.

The law specifies that CMS payments must be linked directly to the quality of care. It includes shared savings and provides for a mechanism to distribute those savings, both to promote accountability for a patient population and to encourage investment in the infrastructure to support redesigned care processes.

Eligible participants are physicians and other providers; networks of individual practices, partnerships, or joint ventures between hospitals and ACO professionals; and other groups of suppliers deemed appropriate by the DHHS. The law also stipulates that ACOs make a threeyear commitment and provide enough primary-care physicians to care for their assigned populations (5,000 patients or more).

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Imaging and ACOs | Prototype, Rule, Competencies, and Opportunities

Five Aspects In March 2011, the proposed rule— including proposals from the Federal Trade Commission, the IRS, and the Department of Justice—was issued to a hail of criticism. Many critics took exception to patients being assigned to an ACO based on use of a primarycare physician, internist, or geriatrician, thereby excluding specialists and the multispecialty groups that participated in the Medicare Physician Group Practice Demonstration. Critics also objected to having patients assigned to an ACO at the end of the year, after care has been delivered.

Organization: An ACO’s structure must include an integrated organization that invests in quality improvement and cost containment, with dedicated physician leaders at the helm. The ACO also must possess the requisite health IT for data aggregation and feedback and must have experience with non-Medicare payor initiatives, particularly managed care.

Reporting: Not only are ACOs required to report on many aspects of patient care, but they also must be able to process and analyze quarterly reports from CMS. At the outset, an ACO must include, in its application, its plans for promoting evidence-based medicine, beneficiary engagement, quality and cost measures, and coordination of care. The ACO will be measured against these self-developed standards.

CMS proposes making this a two-way flow of information by reporting quarterly with financial data, quality-performance scores, and metrics on assigned populations. At the start of the first year, the agency also proposes making health data on its historically assigned patient population available to the ACO. ACOs will be permitted to request beneficiaryidentifiable claims for beneficiaries who have received service from the ACO in that performance year.

Patient centeredness: Government establishes itself as a patient advocate by mandating that patients have a seat on the ACO governing body, by linking payment to quality scores, and requiring a patientexperience survey. ACOs are required to report their quality scores, prices, and shared savings or losses publicly. The

amount of shared savings permitted is capped to discourage withholding care.

Quality performance: ACOs will be assessed on 65 quality measures in five domains: patient–caregiver experience, care coordination, patient safety, preventive health, and at-risk population health. Benchmarks will be distributed at the start of the first year, and failure to meet the performance standards in any domain could result in warnings or termination.

In the first year, however, ACOs will be judged solely on the ability to report properly, and—provided sufficient cost targets are met—will receive 50% of shared savings based on complete and accurate reporting. This is to encourage investment in the IT infrastructure that will be required to monitor and coordinate care.

No quality measures are radiology specific, but Physician Quality Reporting System measures will be synced with the shared-savings program for all grouppractice ACO participants and suppliers.

All eligible providers, including radiology groups, can qualify to earn 0.5% of the ACO eligible providers’ total estimated allowed charges (under the Medicare Part B Physician Fee Schedule) during the first performance period.

Shared savings: The good news is that ACO providers will receive payment under the same fee-for-service program to which they are accustomed, in addition to shared savings, if earned. The rule proposes two levels of risk; the greater the risk, the greater the potential shared savings.

In track 1, savings are reconciled annually, in the first two years, using a one-sided approach that involves no risk.

In the third year, the program transitions to the two-sided method, in which the ACO agrees to share losses. The sharing rate for this method is 50% of savings beyond a threshold calculated as 2% of the benchmark. Track 1 shared savings are capped at 7.5% of an ACO’s benchmark.

Track 2 features the two-sided riskreward method, intended for ACOs with more experience in managing risk. They will be eligible for higher sharing rate of 60% of savings beyond the threshold, capped at 10% of the ACO’s benchmark.

58 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

Losses for ACOs participating in track 2 will be capped at 5% in year 1, 7.5% in year 2, and 10% in year 3. CMS will retain 25% of an ACO’s shared savings to cover potential downstream losses. CMS anticipates that 75 to 150 ACOs will participate in the program; an estimated $800 million of shared savings will be distributed in the first three years.

Imaging Services: Developing Partnerships in Accountable Care The largest healthcare systems are not waiting for the fine print.

Hardaway, reporting on the capabilities framework that the grouppurchasing organization has developed to help member systems develop ACOs, also notes that imaging has a significant role in these initiatives. As health-care organizations move from fee-for-service payment to accountable care, they must develop competence in six core components.

The first is a people-centered foundation that ensures that ACO population members not only receive the necessary care, but also believe that they can get the care that they need to improve their own health.

The second is what Premier calls the health home and others call the patientcentered medical home, which functions as the coordinator of care, from a primarycare perspective, for all care delivered by the system.

The third component is a high-value network, which contains all providers of services offered in addition to the health home (including radiology providers). A high-value network ensures the highest quality at the most efficient cost.

The fourth element is accountablecare leadership, the legal organization that provides structure and governance.

“One of the things that is an absolute necessity is that it is physician governed,” Hardaway says.

The fifth part is population health data management. “Right now, hospitals and health systems only have good data about what is going on within the four walls of that system,” he says. “We must

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Imaging and ACOs | Prototype, Rule, Competencies, and Opportunities

have a broader view of the information available.”

The sixth component is payor partnership. “We learned, in the 1990s, that providers were terrible at taking insurance risk, and we still need to have some partner who is able to do this with us and for us,” he says. “The payors are the only ones that have all of the data that we need to manage the system, so we have to work together in order to bring all of these pieces together.”

The ability to measure effectiveness is the foundation underpinning all six core components of accountable care, Hardaway says. “You can’t do this without measurements,” he advises. “You can’t show that you are making improvements without measurement.”

Assessing Readiness Premier’s capabilities framework is based on the six core competencies, which are dissected into 150 operating

activities. In its assessment of 60 healthcare systems, Premier has found that the average score is 20%. “What we see is that no one is doing very well, and that is to be expected,” Hardaway says. “This is all brand new. In order to do well in the system we have now, you do not need most of the capabilities needed to do well in the system of the future.”

Hardaway outlines the implications of the high-value network for radiologists and other specialists. The network represents a wide range of clinical providers and facilities supporting primary-care practices. A question that Premier is frequently asked is whether a health-care organization should limit its network of providers as it develops an ACO. The answer is no—not immediately.

“Currently, our reimbursement system is such that you don’t want to limit the number of folks in a network,” Hardaway advises. “What you want to say is, ‘Here are the criteria that you are going to be

Provider of Services (Baseline)

Likely to be one of multiple providers of imaging services

Requires the ability to receive and report information

to the case manager

Fee-for-service reimbursement Provider of Credentialed Services (Contractor)

Provides services of higher quality and acuteness than others;

may contract for services

Requires the ability to receive and report information

to the case manager

Fee-for-service reimbursement; potentially participates

in shared savings Coordinator of Care (Partner)

Coordinates imaging services among owned

and network facilities and services

Requires a fully functional electronic medical record

interacting between multiple providers

Is held accountable and holds others accountable for cost and quality

Fee-for-service or bundled reimbursement;

likely to receive shared savings Full Accountability (Driver)

Accepts capitated payments and quality requirements

Requires the ability to analyze cost and quality outcomes for various

medical conditions across multiple pathways Figure. Four types of accountable-care participants; baseline participation is unlikely to be sustainable; adapted, with permission, from Premier Inc. 60 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

judged by over the next 18 to 24 months.

Do you agree to those in the contract you sign with the accountable-care delivery system?’ It’s an all-comers strategy at the outset, but it’s a narrowing of that network as we go forward.”

Another attribute of the high-value network will be the development of evidence-based care models. Hardaway emphasizes that providers have to be involved in developing these care models.

The Imaging Partner Premier recommends that health-care organizations interested in developing an ACO look for five capabilities in their imaging partners: The first is resourcemanagement expertise.

“Imaging providers must have the capabilities to manage resources extremely well in this system of care,” Hardaway says. Second, imaging providers must be transparent in their quality and cost measurements.

Third, the imaging provider must possess a robust imaging-informatics infrastructure.

Fourth, radiology and consulting services must be immediately available.

Fifth, radiology providers must have the ability to optimize the patient experience.

This includes having the tools available to manage resources and to make cost/ quality information available not only to partners in the delivery system, but to all patients.

Hardaway concludes by describing the different models being created for partnerships between ACOs and their imaging providers. “The first one is baseline, and we do not think it is sustainable, going forward,” Hardaway says, “but there are some others that we see occurring (or that we think will occur).”

Apart from the baseline model, Premier envisions three other models (see figure): the contractor, an imaging provider of higher-quality/acuteness credentialed services on a contract basis; the partner, a coordinator of imaging services among owned and network facilities; and the driver, an imaging provider that would accept capitated payments and quality requirements.

“The difference between this system

and what we saw in the 1990s is that there are quality and patient-satisfaction hurdles that have to be met or overcome prior to being able to share in savings— or, if you are taking capitation, before you would be eligible for any bonus,” he concludes.

What Should You Be Doing?

W. Kenneth Davis Jr, JD, entreats radiology practices to get involved in reforming health care, offering a summary of strategic steps that practices and imaging centers should consider adopting. “You’ve got to get involved; it’s not much more complicated than that,” he says. “What it is ultimately about is, first and foremost, cutting costs, in the long term, for Medicare.”

Davis emphasizes urgency by pointing out that ACOs must enter into a threeyear contract with Medicare, and that the ACO cannot add participants (operators, founders, or owners) during that three year agreement period. It can terminate participants, but cannot add them.

Providers and suppliers can be added through contracting, but they will have no hand in governance. “What that suggests is that you need a seat at the table as soon as possible,” he says.

Drawing on an ACR® white paper,1 Davis outlines several fundamental concepts that practices should keep in mind when engaging with ACOs: Seek to be paid on a fee-for-service basis. While payment appears to be moving toward the adoption of risk, radiologists need to be careful that the ACO does not seek to offload risk to the practice (if other participants have no incentive to manage utilization, for example).

If an ACO is capitated, one economic incentive against overutilization would be to pay the radiologists within the ACO on a fee-for-service basis. “Believe me, those other participants in the ACO will have a strong incentive to manage utilization,” Davis says. Take the reins of utilization management, which will be the crux of the ACO. The ACR suggests deploying orderentry systems and decision support.

Be the party responsible for managing

all imaging within the ACO, and try to be compensated for doing so. If a practice is responsible for utilization management in imaging, it also makes sense (from operational, clinical, and financial standpoints) for the practice to be involved in the day-to-day operational management of the technical component.

Be prepared to operate under capitation. If that happens, it is critical that for appropriate utilization management to be built into the ACO;

radiologists should be involved in that, as well as in the technical implementation of computerized radiology order entry and decision-support software. “You want to make sure that if you are being compensated on a capitated basis, there is appropriate risk management,” Davis says.

Improve relations with your hospitals.

Some radiologists are going to become employees, and if that happens, it is best to be employed by someone with whom you have a positive relationship.

Imaging and ACOs | Prototype, Rule, Competencies, and Opportunities

Think like an investment banker both clinically and economically: Where are the value propositions? How is the patient care going to flow? How is the money going to flow?

—W. Kenneth Davis Jr, JD Katten Muchin Rosenman LLP

Davis is surprised that the ACR would acknowledge that some radiologists will become hospital employees.

Address referring-physician conflict of interest. While the ACR suggests doing away with self-referral, Davis recommends focusing instead on appropriateness criteria. “Talking too much about selfreferral can become self-defeating,” he says. “The economic conflict of interest is causing inappropriate levels of utilization, and you need to address that.”

Consider consolidation; this is a very fluid, moving environment. An ACO is likely to have more than one radiology group involved, and there is the possibility, especially with large radiology groups, that you will be involved in more than one ACO—yet another reason for further consolidation of radiology groups.

Adhere to rigorous quality standards and make that high quality known, Davis urges radiologists. “You cannot go wrong by selling quality. That is one of the absolutes,” he says. “Quite candidly, the risk radiologists have is the potential for being viewed as nothing more than a cost center in the ACO.” Recognize the different roles that imaging centers and hospital-based practices play in the ACO. Sell the ACO on the fact that outpatient imaging centers fundamentally are less expensive to operate than hospital imaging departments.

Create proper alignments within the ACO. Align with competing imaging providers, referral sources, and selfreferring physicians. The risk of not doing so, Davis says, is that in an environment that is designed to take risk, you will fail.

Coordinate the use and flow of images and information within the care environment. Radiologists have led the way in moving images and information,

and Davis says that they need to put that on steroids. Integrating with the electronic health record and adding decision support to order-entry systems will put radiology in a better position, in IT terms, to operate the ACO, he adds.

In conclusion, Davis recommends that radiologists think like investment bankers. ”That is not to diminish the clinical aspects,” he says. “Think like an investment banker both clinically and economically: Where are the value propositions? How is patient care going to flow? How is the money going to flow?

If you can follow that line through the entire process, you are going to identify problems you can fix up front, and you will identify upside propositions.”

Cheryl Proval is editor of Radiology Business Journal and vice president, publishing, imagingBiz, Tustin, California.

Reference 1. ACR white paper: strategies for radiologists in the era of health care reform and accountable care organizations: a report from the ACR Future Trends Committee. J Am Coll Radiol. 2011:8(5)309-317.

62 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

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FinalREAD

Love What You Do Passionate leaders like Steve Jobs inspire followership

By Curtis Kauffman-Pickelle

O

ne can’t help but seek significance in the death of someone as iconic as Apple cofounder and CEO Steve Jobs.

Of all the things that he meant to those of us who have made our careers in the business world, among the most important and lasting, I believe, is that he had a unique and highly visible passion and love for his chosen path. Yes, he was a genius on several levels, but for me, his genius was in his ability to persuade and transform a generation through inspiration. He inspired followership, and therein lies the message for today’s imaging leaders.

In thinking about this notion of followership as leadership’s corollary, it occurred to me that it can make a difference to entire organizations when leaders truly and demonstrably love what they do for a living. Through instilling in the organization’s stakeholders a true sense of mission, the inspirational leader calls upon the unique power of passion, focus, determination, communication, and vision to instill an ethos that will drive the team toward success. The

team will want to succeed, and it will follow its leader because he or she has combined these characteristics in a way that brings meaning to the endeavor.

At some point, we all strive for significance and meaning, and we are attracted to those who embody such

We tend to go above and beyond the call of duty when we see how these qualities can transform ordinary human beings into inspirational leaders, particularly in difficult times. attributes. We tend to go above and beyond the call of duty when we see how these qualities can transform ordinary human beings into inspirational leaders, particularly in difficult times. Theirs is an art form that includes a talent for motivating those around them to want to achieve and develop.

These are incredibly difficult times for imaging leaders. In a veritable perfect storm, issues have combined to create an unforgiving marketplace—one that is more competitive, less secure, increasingly confusing, and extremely unpredictable. This is not an imaging market that will suffer fools lightly, nor one that will be a safe haven for the mediocre, lazy, or ineffective. It’s tough, and it is going to get even tougher.

Heat and Grace If you are a leader who truly loves what you do, though, these challenges

64 Radiology Business Journal | October/November 2011 | www.imagingbiz.com

will not seem insurmountable. They will be a rallying cry for innovation and an opportunity to reinvent the way you manage your time, resources, and assets to show the way forward for those entrusted to your leadership. It is a huge responsibility, and it is most likely to be accompanied by a somewhat thankless audience, at times. The ability to take some heat and still demonstrate grace under pressure, however, will be yet another attribute of those imaging leaders who will embrace these new realities. Opportunity still exists for those willing to pave a new pathway toward its rewards.

When the days seem difficult, and the pressures add to the stresses that naturally accompany leadership positions, think of the lessons that can be learned from Steve Jobs—and the world’s lesser-known leaders like him. I recently learned of the passing of a fellow publisher, a colleague who loved what he did; he died at age 86, having worked at the profession he loved until just four months before his passing. There are countless stories of those who so deeply love what they do that they inspire those around them to achieve new levels of excellence and satisfaction.

Our profession needs such leaders.

We need to be surrounded by those who love what they do. We need to cultivate an appreciation for those who step up and take on such a responsibility. We need to be grateful for those who emerge as enthusiastic and confident imaging executives in this time of complexity and uncertainty.

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

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