Shared Management: A Manifestation of Imaging 3.0

Imaging 3.0 is the ACR’s manifesto for moving radiologists from volume-based to value-based care; transactional to consultative medicine; radiologist-centered to patient-centered care; and finally, after years of discussion, from invisible to visible, or at least more accountable, explains Syed Zaidi, MD, president, Radiology Associates of Canton, Ohio. Zaidi delivered a talk entitled  “Imaging 3.0: Better Together,” with practice CEO John Vizzuso on October 21, 2014, at the Fall meeting of the Radiology Business Management Association in Seattle.

The Imaging 3.0 blueprint, introduced at the ACR annual meeting in 2013, specifies activities and services that a state-of-the-art radiology practice must provide, including imaging appropriateness, documenting safety, providing more actionable reports with patient follow-up, collaborating with other physicians to improve care and empowering patients.

Clearly, the mandate is to provide more not less service, both before the interpretation (in making sure the study done is appropriate and performed with the correct protocol) and after the interpretation (by following up on patients). “Part of this,” says Zaidi, “is [figuring out] how to get paid for all of this.”

For those practices considering making the concept of Imaging 3.0 concrete in their settings, the path of the 24-partner Radiology Associates of Canton (RAC) may be enlightening. In 2010 when Zaidi was elected president of RAC, the practice was successful, had three stable hospital contracts, had never outsourced its nighthawk service and had earned an excellent reputation with clinicians.

It was, however, confronted with the same pressures others in the specialty were facing: reimbursement cuts, a lack of service engagement from all partners, productivity gaps, mediocre relationships with hospital administration, a stagnant local economy and national competition from teleradiology companies (four of which were located and actively seeking contracts in Northeast Ohio). Like other democratically run private practices, it struggled with effecting change. “One partner could veto something,” he relates. “People had their pet peeves, and they would turn into big issues.”

Driving change

The first step in driving change was swapping its governance model for a more central model, electing a five-member board with strong decision-making authority. “The only items that go to the partners are when a new contract is being considered or if we are potentially leaving a hospital contract,” he says.

The group initiated regular strategic planning retreats in the fall of 2010, adopted a service and ownership mentality, made a strategic plan to partner with its hospitals and planned to invest in information technology (IT) to deal with the operational issue of routing work to radiologists so that they could be more productive.

Zaidi also began to attend leadership conferences, beginning with the ACR’s three-day annual leadership conference, a low-cost option. “If you want to drive change, send your radiologists to leadership conferences,” Zaidi says. “If you are a 10- to 20-radiologist group, you can drive change very quickly rather than the 70-person or academic group, where you have to go through layers of hierarchy. The key is leadership.” RAC now sends two radiologists a year to the ACR’s annual Radiology Leadership Conference, an investment in time and tuition that the practice agrees to supports.

RAC came together around the following mission: excellent and appropriate patient care is the best business model. It adopted a service commitment to clinicians and patients and required partners to take ownership. “If something isn’t working, fix it, take an active role in making sure things get done,” Zaidi says.

A pivotal concept that RAC gleaned from conference attendance was the definition of value. While some define value as quality over cost, Zaidi believes the equation must be outcomes over cost.

“I think you need to better define quality and that is outcomes, actual clinical outcomes,” he says. “We talk about the value of hospital-based radiologists, and there is a key role there for us because we are in the trenches where we can coordinate admissions and help decrease the length of stay. There’s a particular role for interventional radiology (IR) in providing high-value care, because any procedure done in the IR suite is an automatic savings compared to the OR, and we need to make that pitch to the hospital management.”

Path to co-management

Those talking points were on the agenda when RAC approached the administration at Aultman Hospital in Canton, Ohio, with a proposal to co-manage the radiology service line. “It’s out there and being done in cardiology and orthopedics,” Zaidi notes. “Why can’t we do it in radiology?”

Zaidi describes co-management as formal shared governance of the imaging service line. “You may have a great relationship with hospital administrators and you may be meeting with them regularly,” he acknowledges, “but until you have a formal committee around it, you risk being taken for granted.”

Co-management is a vehicle for pay for performance for physicians, notes Zaidi, and can be done with an LLC, although RAC didn’t take that route the first time around. “In the future, we may choose to do it,” he allows.

RAC leadership met with hospital CEO Chris Remark in fall of 2011, and began to rehabilitate the relationship by establishing an atmosphere of trust. RAC laid out the uncompensated value of the practice’s 24/7 service and IR call, discussed joint pressures between RAC and the hospital and made a case for partnership. Aultman already had initiated co-management of cardiology with its employed cardiologists and three independent cardiology practices, and when the RAC contract was renewed, it included co-management.

A shared vision was developed during joint strategic planning in which RAC would partner with Aultman to form an imaging service line of excellence, institute patient-centered imaging services and develop a value-based payment model with AultCare, a health plan owned by the hospital. A governance model also was devised: An imaging service line steering committee meets quarterly and includes four physicians and four hospital administrators. An operating committee meets monthly, formally, and weekly, informally. Additional leadership positions include a residency and research leader, a physician leader for utilization management and quality assurance, a patient-centered leader and provider outreach leader.

The agreement included joint approval of capital equipment purchasing, joint decisions on staffing and the establishment of performance metrics for radiologists and the department. “When you choose metrics, you have to chose things that are not guaranteed,” Zaidi says. “You have to go out on a limb. You have to pick issues that may be chronic issues for you. It should not just be turnaround time, which we really should be hitting on anyway.”

Year one of the three-year agreement represented an investment for the practice, with shared savings in years two and three, and potentially gain-sharing. Together, RAC and Aultman agreed on the investments each would make towards their stated initiatives.

Co-management in motion

To support the first initiative, patient-centered radiology, RAC hired two patient care coordinators. “If you want to actively manage patients, then you have to have someone doing it,” Zaidi says. “Just like cardiologists hire physician extenders, we in radiology should consider hiring physician extenders or even a nurse or a technologist to help you manage patients.”

Other investments on the part of RAC were time (in medical directorships), hiring a marketer (who also invests time in the hospital) and reporting back to hospital leadership on leadership conferences attended,

The whole point is to help provide the right care at the right time in the right place. “By doing this, we optimize inpatient utilization,” Zaidi says. RAC has succeeded in cutting length-of-stay, with an initial focus on IR, including making sure biopsies are scheduled appropriately. The group is working to improve outcomes through the use of clinical data-mining software, an investment funded by the hospital.

Other investments made by Aultman include executive time on steering committees, payments for meeting metrics, the aforementioned data-mining software, upgraded voice recognition, a PACS upgrade and support for a residency slot, which was previously at risk.  The support also includes capital equipment in the form of two shiny new IR suites.  “Our equipment was very much outdated, and we are getting a new suite this year and a new suite next year,” he says.

The benefits of co-management are numerous from the radiologist perspective, not the least of which is improved cooperation around workflow changes and investment choices. “When the hospital is deciding whether they should invest in cardiology, or orthopedics or interventional radiology, with us they realize that they should invest in IR, because IR prevents leakage from the system.”

Radiologists benefit from improved departmental efficiency, help with marketing costs and more security through communications with hospital (not just department) leadership. “You get recognition up to the C-suite and the board and ultimately your contract is more secure,” Zaidi says.

From the CEO perspective, the hospital gets better cooperation from the group, aligned goals and strategy, improved quality, buy-in from radiologists on hospital-wide initiatives and engagement without the high cost of employment. “They lose $200,000 for every employed physician,” Zaidi notes.

The relationship is deepening, with RAC extending services to smaller hospitals in Aultman’s affiliated network and providing management services where requested. RAC is using data mining software, combined with Krebs diagnosis-related data and claims data from AultCare, to get at quality (defined as outcomes) metrics, including some Physician Quality Reporting System metrics and ACR-devised metrics.  Significant payments have accrued since co-management began and all partners are enjoying a renewed respect from the administration. 

“I still don’t think we are getting the full amount we deserve for doing full nighthawk, but obviously the hospital can pay only what it can pay,” Zaidi says. “You are not doing co-management to get paid, you are doing it to get cooperation, to get alignment, to secure your contract.” Pay for performance, nonetheless, has been part of the package.