Gearing Up for Value-based Payment: The Race to Define Quality in Radiology

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Today’s radiology dashboards let you know how your department or practice is running. They chart patient flow; report-turnaround times; critical-results reporting; and dozens of other data points that reflect cost, efficiency, productivity, and (sometimes) effectiveness. One of the primary goals of these dashboards is to support quality improvement, as CMS and other payors begin to link payment to performance—and to define performance using quality measurements. Yvonne Y. Cheung, MD, MS, holds quality-improvement black-belt certification from the American Society for Quality. Cheung, a musculoskeletal radiologist at Dartmouth-Hitchcock Medical Center (Lebanon, New Hampshire), holds dual associate professorships in radiology and orthopedic surgery at Dartmouth’s Geisel School of Medicine. She also is Dartmouth-Hitchcock Medical Center’s radiology vice chair for quality and safety. In 1896, Dartmouth College was the site of the first clinical radiography ever performed in the United States. Today, Dartmouth-Hitchcock Medical Center radiology, like many of its sister hospital departments, is creating quality-improvement measures and displaying them on dashboards (along with run charts), Cheung notes. As far as Cheung is concerned, health care is finally catching up with Motorola’s Six Sigma™ quality-improvement principles: recognize, define, measure, analyze, improve, and control. These were initiated by Motorola in 1985, and manufacturers have since applied them to reduce the production of flawed goods. “This system got adopted by different industries and is now slowly moving to health care,” Cheung says. “There are different levels and abilities in improvement work, based on certain methodologies. We are making changes at all levels.” In fact, there are many radiology quality-improvement initiatives in the works now, coming from CMS, hospitals, health networks, specialty societies, insurers, and imaging providers. For health care as a whole, some argue, the proliferation of quality measures has gone too far (and too quickly): Quality markers are getting in the way of care. That’s what members of the US Senate Committee on Finance complained of in June 2013, when they called for more attention to be paid to patient outcomes as quality measures. At that time, Sen Max Baucus (D–MT), the committee’s chair, was quoted as saying that Medicare uses 1,100 different measures in its quality-reporting and payment programs. He then asked whether we really need more than a thousand measures.¹ The committee’s senators went on to suggest that quality outcomes should be tied to provider payments not in traditional fee-for-service reimbursement models, but in team-based delivery models (such as accountable-care organizations). Cheung doesn’t think that there are too many quality-improvement initiatives in radiology, but she does agree that, soon enough, quality assessment and reimbursement will go hand in hand. “Quality improvement is something big,” she says, adding that payors are going to ask for it. “This is something that everyone should be doing,” she notes. ACR’s Top-down View Judy Burleson, MHSA, the ACR’s senior advisor for quality metrics, says that today’s quest for quality improvement in health care began with a 1999 report by the US Institute of Medicine.2 It found that up to 98,000 preventable deaths per year were occurring in hospitals due to lax standards or unobserved care protocols. “That was the impetus for a number of programs and for federal legislation that supported quality and safety initiatives in Medicare, and then in private payor and purchaser groups,” Burleson says. “That was the wake-up call, and a number of programs were initiated from that.” While the Institute of Medicine’s report called for preventable deaths to be halved in a decade, that hasn’t happened. A recent survey of 10 North Carolina hospitals found a patient-harm rate of 25.1 per 100 admissions, and the estimated number of preventable hospitals deaths annually remains close to 90,000. Some estimates3 suggest that today, there is a one-in-seven chance that a hospital patient will suffer harm. To what degree the old and the new preventable-death/harm measurements are comparable isn’t clear, and neither are the reasons that the preventable-death rate is nearly unchanged. What is clear is that a massive quality-improvement infrastructure is being laid down in health care, with radiology deeply involved; its intent, more than ever, is to deliver