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

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For decades, the radiology practice partnership model has been the dominant form of imaging delivery. Change, however, is afoot. Health-care reform and other factors are driving the development of new imaging-delivery models that merit a close look, if imaging providers are to weather the storm of change that is remaking the health-care landscape. Radiologist Lisa Bielamowicz, MD, is managing director and national imaging practice leader for the Health Care Advisory Board and Technology Insights programs of The Advisory Board Company (Washington, DC), a global research, technology, and consulting company. She says that savvy health-care providers must recognize that the final rule1 implementing the Medicare Shared Savings Program (MSSP) is likely to kick-start the formation of MSSP accountable-care organizations (ACOs). Chalk it up, for the most part, to the many provider-friendly changes made (and features added) between release of the proposed and final rules. “The overall structure of the program has not changed, but CMS has scaled back many of the obstacles to operating in ACO mode and made the concept of participation more appealing to providers,” Bielamowicz notes. The reduction in the number of mandated quality-reporting measures tops the list of compelling revisions. Other attractive changes specify that providers can band together into an MSSP ACO without assuming any financial risk during the initial three-year contract period; allow for a prospective beneficiary-identification process, with retrospective reconciliation; and provide access to previously unavailable, identifiable patient-claims data generated under Medicare Parts A, B, and D. CMS also has reduced, through a revision of fraud and antitrust rules, the legal risks inherent in forming and operating ACOs. While the ACO model, as a whole, is in its infancy, some of its pieces are beginning to take shape, and providers have begun to move along the establishment continuum. Premier, Inc (Charlotte, North Carolina), a member alliance of more than 2,500 hospital systems and 76,000 outpatient facilities, currently has 20 to 30 provider partners with which it is collaborating on ACO formation. It is also assisting another 53 provider partners in determining whether following such a path would work well for them—and, if so, how to proceed. Josh Bennett, MD, MBA, serves as Premier’s partner for integrated care and delivery. He notes that no matter what the overall ACO structure will be, it is important to recognize that the general model brings with it a spate of additional reporting requirements. “For ancillary functions in a high-value network—and radiology is among them—there is significant mandatory reporting around patient satisfaction with the care at the imaging site,” he explains, “l look at everything from the experience at the registration desk to whether the radiologist had contact with the patient (and the caliber of that contact).” Reports required under the ACO umbrella must also cover instances of unnecessary or duplicated imaging services and whether alternative studies to those deemed inappropriate could have been ordered. Moreover, the MSSP demands information pertaining to adverse affects and conditions noted during imaging procedures: “the gamut, from the fact that a patient became extremely agitated in the middle of an exam to an adverse reaction to a contrast agent,” Bennett says. Documentation regarding quality assessments and improvements—such as peer audits of radiologist’s reports—falls into this category as well. At the same time, lines are being written into the ACO script from an accountability standpoint. The expectation is that participating radiologists will undertake initiatives aimed at achieving radiation-dose reduction: for example, adhering to the use of doses as low as reasonably achievable, or ALARA, as well as to the Image Gently guidelines for pediatric imaging. Similarly, a proactive approach to ensuring exam appropriateness is expected. Bennett says, “ACOs are holding radiology and radiologists to a high standard and, when selecting from among providers in a particular community, will partner with the one that offers not just the most cost-effective services and best clinical outcomes,” Bennett says, but the highest degree of imaging appropriateness. “This is going to become even more important as ACOs shift from fee-for-service and volume-based incentives to quality- and value-based incentives,” he believes. “It will be all about the right test, for the right patient, at the right time.” Bennett adds that wise radiologists are adopting a proactive stance in order to satisfy or exceed expectations on the imaging-appropriateness side. They are requesting of ACO leadership the right to counter a referring physician’s imaging request (should they conclude that the exam ordered would not be of value) and to propose alternative studies. The emerging ACO model calls for radiologists to receive, from referring physicians, patient information with a scope extending far beyond what’s seen on the typical imaging requisition. Detailed insurance and demographic data are only the tip of the iceberg, according to Bennett. Extensive information on preoperative procedures (as applicable) and on the reason that imaging services are to be provided is also being shared; so is access to electronic health records (EHRs). Bennett says, “The expectation, now, is that if radiologists are to produce clear, concise reports for primary-care physicians, with the answers to questions neatly laid out,” radiologists must be given patient histories and related information on which to build these reports. “The days of orders such as ‘Go see a radiologist for an MRI’ or ‘MRI for lower back pain’ are over,” he adds. Bennett also believes that while adopting the ACO model might not, for radiologists, generally entail attending many governance meetings, it behooves providers to involve themselves in governance nonetheless. “There is a wide berth for practitioners, primary-care physicians, and other types of providers on ACO governing boards,” he says. Ports in a Storm While the ACO model probably is the most frequently discussed radiology-delivery option, Bielamowicz points out, external forces make a compelling case for adopting one of the models wherein physicians are employed by a health plan, hospital, or practice owner. “We are seeing that about 50% of physicians, across all specialties, are employed,” Bielamowicz reports. “Economic pressure in general, reimbursement issues, and the uncertainty of what will happen next with health-care reform are pushing many, including radiologists, to seek employment ports in a storm.” Like Bielamowicz, Paramjit (Romi) Chopra, MD, director of the Midwest Institute For Minimally Invasive Therapies (MIMIT) in Melrose Park, Illinois, perceives factors like declining reimbursements as favoring the employed model. MIMIT, a provider of interventional-radiology services and minimally invasive surgical procedures, operates under an employed model in which physicians (currently, four) work for the practice strictly on a salaried basis. Chopra had multiple reasons for embracing this practice structure. He did not want to grapple with the governance headaches typically experienced in traditional partnerships. In that environment, he says, “Every partner wants to have a say in the decision to be made, whether it is about a major investment, an operating policy, or something in between. More often than not, there is infighting, and getting a group of partners to come to agreement can be like herding cats.” He continues, “When you bring a corporate-type employer/employee structure to a radiology practice, decision-making power—from strategies to the way in which money will be spent—rests on the shoulders of one individual. That is a key benefit.” In the case of MIMIT, that person is Chopra. Chopra also was uncomfortable with the costs inherent in governance by partnership. “The cost of governance in a partnership is huge, and radiology expenditures are going through the roof,” he says. “Partners want massive salaries and weeks and weeks of vacation.” In contrast, the employed model affords owners/practitioners “the advantages of control and the ability to pay based on performance. For physicians, the attraction is that they are paid a salary and know what they will be earning and what they need to do to get the job done. It’s less ambiguous, all around,” he explains. The employed model under which MIMIT and other practices deliver imaging services has its drawbacks, compared with employment by a hospital or health system, Chopra acknowledges. For instance, he says, individuals working for private radiology practices run the risk of job loss, should procedure volumes and reimbursement rates decline precipitously. Hospitals and health systems could present superior job stability because declining procedure volumes and reimbursement do not have as much of an impact on these large institutions as they have on private practices. There is a downside to the golden handcuffs, however. Many hospitals, Chopra says, are demanding faster, better, cheaper imaging services from the radiology sector. They do not always provide employees with incentives for their effort. Radiologists who are on the staff of private practices stand a much better chance of enjoying these incentives, Chopra says. Further complications might arise down the road. Despite the forces that recommend the employed model—namely, the languishing economy and health-care reform—Chopra entreats those who are interested in exploring an employed private practice to keep in mind other factors that threaten its viability. For one thing, larger hospitals are acquiring smaller hospitals and/or imaging centers, enabling them to bring imaging services in-house or offer them under their own auspices instead of under contractual agreements with private practices. Teleradiology providers are also eating a share of the imaging-services pie, leaving an increasingly smaller slice for practices like MIMIT. The HMO Option For other radiology players, the employed model in a far different incarnation—the closed HMO—not only works well, but will probably continue to do so, by virtue of its scope. Consider Colorado Permanente Medical Group, PC (CPMG), Denver, Colorado, a multispecialty physician group made up of more than 800 members. Serving more than 400,000 Colorado residents, CPMG is one of eight such groups that operate under the Kaiser Permanente name. Like its counterparts, CPMG is self-governing, has its own board of directors, and functions as a contract service provider to Kaiser Foundation Health Plan (Oakland, California), one of the largest US nonprofit integrated health-care systems. Greg T. Mogel, MD, serves as CPMG’s regional department chief of radiology. He is quick to cite the benefits of a closed-HMO model for radiology, the most significant being, he says, “less burdensome, less red-tape–encumbered, more appropriate” delivery of imaging services because all physicians within the practice regard each other as partners in patient care. “In this direct model, with everyone working within the same partnership, it is easier to say (and gain acceptance of the fact) that maybe a patient needs an additional study, or a study with contrast versus a study without contrast,” Mogel says. “We don’t need to discuss it with 20 or 30 people and multiple payors. There’s a straighter line between radiologists and other physicians, as under the model, we are all coming at care with the same patient-oriented motivations and goals, as opposed to delivering care from multiple agendas.” Mogel adds that the straighter line, aligned goals, and simplified decision making inherent in the closed-HMO model contrast somewhat with typical private-practice and academic models. He says, “For example, in a university center, there can be divergent goals and a lot of parties at the table, whereas here, there is a synergy. Suppose, for example, that a new MRI system is needed. In a university setting, you may have researchers leaning toward a cutting-edge, new model, while the hospital is clamoring for something that’s going to allow it to improve throughput. In a closed HMO, again, you have one agenda. It is a lot simpler.” Payor Benefits The advantages to the payor rival the advantages to the radiology department. According to Mogel, the single angle from which imaging services are decided upon and provided (coupled with the fact that the model features a preventive focus, rather than a fee-for-service focus) reduces barriers to patient care, keeping costs in check; so, too, does the fact that the closed-HMO structure facilitates the sharing of patient information through EHRs. Mogel says that the lower patient-service barriers afforded by the closed-HMO model also benefit Kaiser Foundation Health Plan in that they reduce the time and human resources needed to coordinate care across various sites. “We have more than 20 clinics in the Denver/Boulder area, and patients can go to any one of them without reams of paperwork and preapproval,” Mogel notes. “That is a big plus.” Even more significant gains come in the form of more appropriate utilization, cost, and productivity. Unlike what Mogel refers to as a straight RVU-generating model, the closed-HMO structure incorporates enough time to let radiologists assess the appropriateness of studies, truly review the questions that clinicians would like a given study to answer, determine whether the requested exam is the best choice, and (in general) engage in what would otherwise be considered activities that do not generate RVUs. In addition, the model makes enhanced throughput and productivity possible, despite the fact that greater productivity (in line with this model’s structure) does not result in individual provider gain. Much of the improvement is rendered possible through the use of incentives and bonuses tied to performance measures. “The goals and metrics do not remain the same; maybe, one year, it’s decreased imaging utilization, and another year, something entirely different,” Mogel states. Providers are involved in developing the goals and metrics (to ensure buy-in). Many positive changes in practice patterns, Mogel adds, are attributable to bonuses and incentives. For instance, CPMG set an objective of reducing the interval of time between the completion of a report’s dictation and its signing by the radiologist. A bonus pool was created, with the time decrease as one of the measures; the strategy proved very effective. Mogel says, “Increased imaging appropriateness, well-controlled utilization, and better productivity—coupled with an emphasis on prevention, wellness, and coordinated care” are the attributes wanted from radiology. He adds, “I believe the closed-HMO model is in a good position to provide them.” Emerging Models As the ACO, employed, and closed-HMO models of radiology services delivery take hold, others continue to emerge. Bielamowicz points to the clinical-integration model, wherein individual physicians across a range of specialties align with each other (and with additional entities) to deliver coordinated care, under the terms of joint contracts with payors. She cites Greater Rochester Independent Practice Association in New York, a partnership comprising 885 physicians and two community hospitals, as an example. Others include Catholic Medical Partners Independent Practice Association (Buffalo, New York); Mount St Mary’s Hospital and Health Center (Lewiston, New York) and its network of associated physicians; and Advocate Physician Partners (Oak Brook, Illinois). On the physician side, Bielamowicz observes, better rates that result from providing coordinated care to patients and lowering payor expenditures constitute the biggest benefit of this particular model. Enhanced access to IT and support for patient-care management from a clinically integrated network and more exclusive access to referrals round out the list of advantages that Bielamowicz predicts will foster heightened interest in the model. The model followed by Sheridan Healthcare (Sunrise, Florida), which can be described as a clinical-services model, fits loosely into the mold that Bielamowicz describes: It is a multispecialty practice of more than 1,400 physicians and other health professionals. Specialties represented encompass radiology, anesthesiology, children’s services, and emergency medicine. Physician led and managed, it offers services, on an outsourced basis, to 114 hospitals and outpatient facilities nationwide. Maria Rodriguez, MD, is Sheridan Healthcare’s chief of medical radiology services. She states that the organization’s model is dedicated to serving facilities with a single-source solution to their needs by providing clinical guidance and support for new government policies, quality initiatives, revenue issues, and patient-care concerns. “Our providers are given the flexibility to work in a multitude of environments in which they will thrive, and in turn, they are incentivized for bringing additional skills or time to the practice,” she notes. A Key Acquisition In a 2006 push to create a more comprehensive medical-specialty roster, Sheridan Healthcare established its radiology-service line through the acquisition of Florida United Radiology. The radiology division has since grown to include 63 fellowship-trained/board-certified radiologists who provide on-site diagnostic, pediatric, nuclear-medicine, mammographic/breast MRI, musculoskeletal, and ultrasound services to 30 facilities. An after-hours teleradiology component is also part of the radiology-service line, but it is not the only value-added service that Rodriguez deems critical to Sheridan Healthcare’s infrastructure and the appeal of its model; providers pursing a clinical-integration model must play up additional elements if they are to stand out from the pack, she says. Interventional-radiology services and subspecialty radiology consultations head the list of added values. An internal quality-assurance program affords monitoring of (and ensures compliance with) the existing and new requirements of local, state, and federal agencies and accrediting bodies, including CMS and the Joint Commission. As a means of shoring up the high caliber of care and bolstering clinical and operational efficiencies, the radiology-services department has deployed its own PACS, accessible by all 30 facilities. “We also collect an extensive scope of data pertinent to radiology, including a multitude of physician-related items (such as productivity) and quality metrics, to include peer review, report-turnaround times, voice-recognition self-edit rates, and critical-results data, in accordance with Joint Commission guidelines,” Rodriguez observes. While which of these existing and emerging imaging-delivery models will remain firmly grounded—and how health care will alter their shape—remain to be seen, one thing is certain: Radiologists themselves must proactively align themselves with payors and all others involved in forming partnerships. “Get involved at the get-go, take a seat at the table, and participate fully in the discussion. Ask, ‘How can we be a partner in this model? How can we be sure imaging is delivered in the most beneficial way? What can we bring to this table to make it happen?’ Be proactive, not reactive—or you will be left behind,” Bielamowicz concludes. Julie Ritzer Ross is a contributing writer for Radiology Business Journal.