Grand Junction: The Role of Radiology in an Integrated Delivery System
In the June 1, 2009, issue of The New Yorker,¹ surgeon-journalist Atul Gawande, MD, MPH, introduces the world to two US cities that, when contrasted with one another, expose the wide gulf in the cost of US health care delivery and outcomes: McAllen, Texas, and Grand Junction, Colorado. According to 2006 Medicare Part A and B data compiled in the Dartmouth Atlas of Health Care,² average Medicare spending per enrollee in McAllen approaches $15,000, nearly twice the national average of $8,000; in contrast, Medicare spending per enrollee in Grand Junction rests at just under $6,000, more than 25% below the national average. What, Gawande wonders, makes these two midsize cities so different when it comes to health care spending? In examining McAllen’s swollen costs, it is easy to point an accusatory finger at imaging. Gawande relates one McAllen surgeon’s assertion that overutilization is at fault, with McAllen-area physicians racking up extra charges by ordering unnecessary tests and procedures. “Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care,” Gawande writes. “In 2005 and 2006, patients in McAllen received 20% more abdominal ultrasounds, 30% more bone-density studies, 60% more stress tests with echocardiography, 200% more nerve-conduction studies to diagnose carpal-tunnel syndrome, and 550% more urine-flow studies to diagnose prostate troubles.”¹ Gawande’s findings raise a question: How does Grand Junction, which has achieved some of the highest Medicare quality-of-care scores in the United States,³ maintain excellent patient outcomes without overutilizing high-cost medical services, including imaging? The answer began to take shape in the 1970s, with the establishment of a nonprofit HMO, Rocky Mountain Health Plans (RMHP), and the Mesa County Physicians Independent Practice Association (MCPIPA). Defining the Mission RMHP was established in 1974; a few years later, area physicians founded MCPIPA. The two organizations worked together toward a shared goal: creating a physician compensation system that would equalize health care access for Medicaid, Medicare, and commercial patients, thereby removing the incentives tempting physicians to cherry-pick the most lucrative patients. Bob Ladenburger says, “There’s no magic at work here.” Ladenburger is president and CEO of St Mary’s Hospital and Regional Medical Center, the larger of two hospitals in Grand Junction, which has a population of around 100,000. “Grand Junction has a population that supports a strong medical community, and it has a collaborative spirit among the community and its health care providers that has existed since the establishment of the IPA and RMHP. Our compensation system incentivizes providers to look at the cost of health care and at what makes the most sense from a quality and cost perspective.”
Cherie Gorby, COO
The relationship between MCPIPA, which today has more than 200 physician members (including 12 full-time radiologists) constituting an estimated 90% of Mesa County physicians, and RMHP, which serves 177,000 beneficiaries in Grand Junction and the rest of Colorado, was established primarily to enforce this mission. MCPIPA members benefit from the negotiating clout of the organization, which enables them to receive higher reimbursement from RMHP and other payors than they might if they were negotiating on their own; they are also reimbursed at similar levels for all patients. Kevin Fitzgerald, MD, chief medical officer at RMHP, explains, “There’s no delineation of care patterns from the perspective of physicians taking Medicare and Medicaid. If they’re a part of RMHP in Mesa County, they take those patients.” RMHP maintains its nonprofit HMO status today, and is managed by Rocky Mountain Health Management Corp.
Joe Cruz, MD
The physician-incentive program established between MCPIPA and RMHP rewards IPA physicians for lowering systemwide costs while meeting or exceeding quality benchmarks. RMHP reserves 10% to 15% from each MCPIPA physician’s professional reimbursement; the amount withheld is placed in a savings account until the end of the year. “If the health system comes out ahead at the end of the year, the physicians receive a bonus paid out of those savings,” Fitzgerald says. “The system has to be in a positive position financially before they will receive that incentive fund.” Joe Cruz, MD, medical director of radiology at St Mary’s, notes that MCPIPA specialists (including radiologists) are also subject to the paycheck withholding and subsequent potential bonus payment. “At the end of the year, the health plan says, ‘You billed this amount, we withheld this, and now you’ll get a percentage back,’” he says. “The amount returned has to do, on one side, with how much you billed, because that dictates how much is withheld; on the other side, it has to do with the financial bottom line of the health plan.” Maintaining Quality and Efficiency To ensure that physicians don’t engage in cost-cutting measures that could have a negative impact on patient outcomes, RMHP only distributes the bonus payment to those who have met or exceeded quality measures. “The incentive is paid out of the savings, which come from the physicians making cost-effective decisions,” Fitzgerald says. “The funds left over are distributed based on quality measures and action metrics, such as use of available health care IT.” Fitzgerald explains that metrics are built by physicians with input from the health plan, not the other way around. “This is a very dynamic system in terms of what physicians want to keep an eye on,” he says. “The metrics change every couple of years.” Radiology benchmarks are determined with the help of clinical-resource specialists in each modality. These are technologists in supervisory positions who, among other tasks, gather data and review quality metrics with the director of imaging, managers, supervisors, the radiology staff, and Cruz on a quarterly basis. Bill Voss, director of laboratory and radiology services at St Mary’s, says, “We’ve come up with five indicators per modality that we’ve targeted. We’ve consolidated our indicators, ACR metrics, Mammography Quality Standards Act benchmarks, and Joint Commission National Patient Safety Goals into what we call a quality-assurance (QA) dashboard: a spreadsheet that delineates the different indicators and what roles they serve to support.”
Bob Ladenburger, CEO
Recently, St Mary’s, a level II trauma center, focused on reducing time elapsed before CT exams for acute stroke patients. Though the quality indicator for time before a CT exam is performed in trauma cases is 45 minutes, the hospital was successful in reducing that time to 30 minutes. Cherie Gorby, executive vice president and COO of St Mary’s, says, “That came from our team working together to find out what could be done to enhance the quality of the outcome.” Voss adds, “We have very strong clinical-resource specialists and technologists in the CT arena, as well as for other modalities, and great support from the radiologists. All that, coupled with the efficient use of our PACS software and active vigilance, leads to quite a few victories.” St Mary’s radiology department includes state-of-the-art equipment ranging from 3T MRI to 64-slice CT; uptime is maintained with the help of an internal biomedical-services department. Its members attend weekly radiology-department meetings and issue a weekly report on which systems are up, which are down, and which are awaiting repairs or upgrades. “We have productivity measures based on each modality, and there is an expectation here of 100% productivity,” Gorby says. “It’s not always achieved, but we’re always trying.” Efficiency is also aided by having radiologists self-edit their own dictation via voice recognition, and by the fact that St Mary’s shares its radiology staff with its outpatient imaging center. “From a productivity standpoint, if we’re busy on one side and not on the other, we can move the radiology staff,” Gorby notes. Help from Health Care IT St Mary’s shares a staff of 10 radiologists with Pavilion Imaging, an outpatient imaging center located across the street from the hospital that is a joint venture with Western Colorado Radiologic Associates. “We’re better off working together to serve community needs than duplicating outpatient imaging resources,” Ladenburger says, “and that’s been a big part of our radiology success.” All radiologists at both locations share a PACS, and that system is bolstered by the use of integrated communications software that enables radiologists to send direct messages to each other, speeding up delivery of critical results. “Our PACS does multiple things,” Voss says. “It allows better interdepartmental communication between the radiologists and the technologists, and it gives us better communication between radiology and the emergency department. We also use it as a QA tool, and for peer review.” Through the hospital’s virtual private network connections, St Mary’s/Pavilion radiologists can also read for outlying sites such as small clinics; this saves those sites money by eliminating the need for them to hire their own radiologists. Though St Mary’s has no ownership relationship with these sites, “We encourage those outreach relationships because, in the grand scheme of things, they help to catch some referrals for more complicated conditions,” Cruz says. In the next few months, the state-funded Colorado Telehealth Network will increase the network speed experienced by the hospital, allowing radiologists to be more efficient in their outreach to outlying areas. Cruz notes that leveraging health IT has enabled the health system to equalize quality and efficiency across all locations where radiological procedures are performed. “Whether a patient is being imaged at an outpatient facility, an outreach facility, or right here in the hospital, it’s transparent to the radiologist,” he says. “The communication is the same, and the calling for results or follow-up is the same, so all patients benefit equally from the efficiencies we’ve developed.” Physicians and specialists also have access to a regional health information organization (RHIO) called Quality Health Network (QHN), established using funding from RMHP, MCPIPA, St Mary’s, and other community organizations. QHN connects both of the city’s hospitals, all of its laboratories, its outpatient surgical centers, and the majority of its physicians. “There’s a very extensive communication network here, from the standpoint of the physicians, making sure they’re not double ordering,” Gorby says. “If an imaging test was done somewhere else, we try to get that report; if it was here in the community, our RHIO allows us to access that information. The ability to check for duplication has a safety consideration built into it because you don’t want to expose patients to unnecessary tests.” Fitzgerald says, “There’s a lot of investment from the community in QHN. One of our action metrics for next year will be how many hits QHN has, both in how often physicians check it and in how often they contribute to it. There are cost savings to be had there, if we can get all of our physicians to use it.” Fitzgerald also notes that a database is available to all RMHP physicians that enables physicians to choose specialists based on both quality and cost. “Physicians can see who the high-cost specialists are and make their referral decisions accordingly. If you have two different back surgeons, and every patient for physician A gets an MRI before being seen, while every patient for physician B does not, then physician A (who doesn’t see the patient first) will have higher costs than physician B. If you give primary care physicians that information, and they see that the quality is similar, guess which physician they’re going to refer to,” he says. Curbing Utilization Because all players in the MCPIPA–RMHP health system stand to benefit from reduced costs, physicians and radiologists alike are motivated to curb utilization wherever clinically appropriate. “We’re always looking for opportunities to be more efficient with the processes we have,” Gorby says. “With radiology, these are very expensive pieces of equipment, and there’s always new technology. We want to be good stewards in deciding what the best technology is for our environment, not bringing things in just because they’re the latest and greatest.” Though the responsibility for ordering appropriate tests lies largely with primary care physicians, the radiology department at St Mary’s plays a role. “We have a job title of radiology patient coordinator for a person who helps with scheduling and tracks procedures across the modalities to ensure greater efficiency,” Voss says. Cruz adds that the person holding the position, a technologist, has excellent clinical judgment. The radiology patient coordinator serves as a liaison between radiologists and clinicians whose patients are thought to need certain procedures. Voss explains, “She’s often able to help send the patient in the right direction, helping the referring physician make the appropriate choice.” Ongoing referring-physician education is conducted by RMHP, Fitzgerald says, to ensure that if a test is denied by the payor, the physician understands why. “We have recently done real-time education on cardiac PET/CT exams for ruling out acute myocardial infarction,” he notes. “We use Milliman Care Guidelines®, and we call the ordering physician and say, ‘We see your referral; here’s why we’re not approving this. May I send you the guidelines?’ We do that on a regular basis,” he explains. RMHP only requires preauthorization for PET studies, and this is a policy that Fitzgerald does not expect to see modified in the future; in fact, in January 2010, RMHP will begin allowing MCPIPA physicians to qualify for a gold card that will enable them to bypass the preauthorization system for PET exams, provided a retrospective review of their referrals doesn’t show any denials. “Mesa County is interesting in that we don’t preauthorize CT or MRI exams,” Fitzgerald says. “That was at the request of the IPA. Preauthorization can be very cumbersome and inefficient for the physicians, and utilization looks as though it’s where it should be, so we don’t do that. We think physicians know when it’s appropriate, and it would be more work for us to preauthorize those tests.” MCPIPA physicians have incentives to police on themselves on imaging referrals, but Cruz says that the incentive plan is not without its hazards when it comes to the evolving role of radiology in patient care. “The potential downside, and one that we’ve encountered to some degree, is that we face the risk that radiology tests and radiology in general will become commoditized,” he says. “We don’t want physicians to think mainly of the cost of the test and not what else they’re getting. If the only thing that matters is cost, there is always a way to get things done more cheaply.” He adds, “The good thing about the system is that our physicians are cost conscious, and they also try not to expose patients to inappropriate or unnecessary tests.” Grand Junction’s Big Secret Low costs, high-quality care, and no preauthorization for most imaging services: Does Grand Junction have a secret? Yes and no, members of its medical community say. “It doesn’t cost us less to do an MRI in Grand Junction,” Ladenburger says. “We’re paying the same amount for the same equipment, and we’re paying a similar hourly rate to the technologist. When you look at the aggregate data, the reason it works here is that we’re not doing unnecessary tests. Our overall costs are less because utilization of health care overall is less here, and imaging is part of that.” Perhaps it is surprising that this has not resulted in animosity on the part of radiologists or other specialists, but Cruz attributes this phenomenon to the collaborative, open spirit of the isolated city’s health care community. “Getting people here is the hard part,” he admits. “We’re very fortunate that in such a remote place, we’ve attracted really outstanding radiologists. This is a great medical community: a great place to live and to practice.” Would the same model work elsewhere? Cruz is unsure, in part because Grand Junction’s isolation and size ensure that collaboration can consistently trump competition. “This is a tightly bound community, professionally speaking,” he says. “There’s a shortage of primary care physicians, so they aren’t going hungry, and on the specialist side, there just aren’t that many groups. You don’t have the competitive pressures you’d have in a big city, where a hospital can put its radiology contract out for a bid, or payors can play competitors off each other to ratchet down reimbursement.” Mesa County’s seemingly idyllic health care marketplace has, in fact, drawn criticism in the past from other health plans; in 1998, MCPIPA attracted the attention of the US Federal Trade Commission for allegedly discouraging its member physicians from contracting independently with third-party payors. “In a community where there is more payor competition, it would be difficult to make an impact with an incentivization system like ours,” Cruz notes. “I’m still kind of surprised the whole thing works, but somehow, it does.” Quality of Metrics Table (1 of 2) Quality of Metrics Table (2 of 2) Cat Vasko is associate editor of Radiology Business Journal and editor of