AHRA 2019 Q&A: Dr. Carrino on Value, Collaboration and Putting the Patient First

With the “volume to value” movement pushing radiologists to prove their contributions to cost containment, some are feeling uneasy. After all, imaging utilization stands to be curbed—or at least eyed more closely than ever before for appropriateness.

Of course, they’re right to be concerned.

Those looking to turn their anxious energy into positive action would do well to attend a discussion on the value of radiology at AHRA 2019 led by John Carrino, MD, MPH, vice chair of radiology at the Hospital for Special Surgery, the orthopedic and rheumatologic specialty institution based in New York City.

Carrino, who is also a formal collaborator in the Laboratory for Imaging in Surgery, Therapy and Radiology at Johns Hopkins, will specifically speak on the prove-your-value challenges and opportunities radiology has before it today. He took our questions during the lead-up to the conference.

John Carrino, MD, MPH
John Carrino, MD, MPH

RBJ: Your topic is nothing if not timely. Do you have the sense that many radiologists have been slow to adjust their mindset to the gathering demands of value-based reimbursement?

Carrino: Yes I do. For many things, radiologists have been reactive instead of proactive. They’ve allowed other organizations to control imaging use and control costs through changes in benefits design. But now, looking at value-based healthcare delivery, a couple of things are looming.

One is clinical decision support. CDS is looming as one regulation that is looking at utilization. (Starting next New Year’s Day, the Protecting Access to Medicare Act, aka PAMA, will require referring providers to consult appropriate use criteria prior to ordering advanced imaging services for Medicare patients.)

CDS actually was something that radiologists were proactive with. Acting on PAMA, radiologists and other professionals and professional organizations partnered to develop appropriate use criteria, as opposed to having CMS go to something like other health insurances, where they would require a precertification. That’s been the main thing to focus on.

The other thing is the development of accountable care organizations (ACOs). However, the way ACOs are panning out, they’re going to be more for primary care physicians than for specialists. So while that looked like something that had potential for radiology, participation by radiologists in ACOs is probably not going to be as once thought.

The other thing that’s coming down the pike is metrics for MIPS, the Merit-based Incentive Payment System. There are going to be more sticks than carrots. There’s no more new money, so it’s more about avoiding penalties. That’s what’s coming to the forefront now.

To what extent should radiologists lead referrers in optimizing the use of CDS mechanisms (CDSMs)? How
is collaboration best maximized and tension best minimized so that good working relationships are maintained or even improved?

Radiologists should be very proactive with managing imaging utilization. For some practitioners, it would be great to have a consult service when they’re ordering imaging exams. They could say, ‘I have a patient who has such and such signs and symptoms; this is what I’m concerned about.’ And with that the radiologist could help guide them through the next step. This is where we see the biggest benefit from CDS.

Do the referrers tend to sit back a little bit, watching to see what happens with the CDS tools?

Many of them are not aware of what’s involved. CDS has not been as well promoted through the referring organizations as it has been for radiologists. Radiologists often need to take the lead there, driving the education process and the implementation even though there’s some tracking and penalties for ordering providers.

In taking the lead, is there risk of rubbing some referrers the wrong way, to where they entertain the idea of sending the work elsewhere?

Well, they can’t really do that because anywhere else they would send the work has to be using the same CDS tools. On the positive side of relationship building, CDS is a way for referring providers to help with the shared decision making with their patients. It can help them with patient education, where they can send patients to resources explaining what is the most appropriate exam. This can be especially helpful when a patient is asking for a specific type of exam.

And into that mix comes the radiologist—the “doctor’s doctor” who can help the referrer help the patient.

Yes. There should be a specific education campaign where you go out and meet the providers. Instead of marketing, you’re educating on CDS. Or you can combine the education with your marketing. Meeting the referring providers in their environments, wherever they gather at their professional meetings, you can give them the updated information about CDS—how it works and what benefits it offers.

That will require carving out some time for a new work-related activity. It could mean a few longer days and more hours in the work week.image

The days of sitting in a dark room interpreting images is no longer the paradigm. The modern paradigm is more toward radiologists providing consulting services, meaning they’re asked about the types of imaging exams, not only the interpretations. This kind of activity would help move things toward that. It also puts a face to the name of the radiologist for the referring provider.

This should be done in a way that’s as seamless to the ordering provider as possible, whether it’s integrated into their information system or they use a mechanism that’s facile. This may help promote things like computer order entry, which would be a more facile way to access the CDSM.

In cases of disagreement over interpretation of evidence-based guidelines, in what sorts of scenarios should radiologists defer to referrers?

Everyone should defer to the evidence-based guidelines, although there are some unique situations that are patient specific. In general, radiologists have been good about that. But there are many professional societies that are helping put together the utilization criteria. The criteria that were done by the ACR are multidisciplinary in the sense that the ACR involved the ordering clinicians to help make those determinations.

What steps has the Hospital for Special Surgery taken across clinical departments to prepare for success in the volume-to-value era?

For the CDS program, we have a team that’s a combination of hospital IT, which maintains our EMR, and radiology IT, which works with the PACS and does some EMR. And we are partnering with our clinicians. We have champions among the clinicians. We have a CMIO who is part of the team, and we have radiologists, including myself.

We also have a dedicated project manager. The CDS project manager makes sure everything stays organized and gets done in a timely fashion, including working with the CDSM vendor and coordinating meetings with our referring providers and our administrators. We also talk to the practice managers. We make sure everyone is on board with the CDS program. Basically we go through an implementation plan similar to what the ACR has put forth online for CDS resources.

Does the CDS project fit within a broader enterprise program at HSS to rally people around value-based care?

Yes it does. We have an operational excellence team working on that kind of thing. And the OE team helps coordinate some of the activities we just talked about.

We also have a chief value officer, a position that was added three or four years ago. This is a physician who worked for an insurance company and is now a part of our organization.

Basically the principle at HSS for high-value care is: Put the patient first. Some of our stated aims within that are to improve health consistent with patient preferences, avoid harm, and measure and report outcomes. We’re focused on providing evidence-based care, so another broadly stated aim is to base clinical decisions on the best available evidence.

Within that aim, we have some specific situational guidelines that we go by. And the infrastructure to support value at HSS includes not only the OE team and chief value officer but also a healthcare research institute, an innovation center and a payer strategy office.

That’s a lot. It sounds like HSS is ahead of the curve in terms of enterprise-wide preparedness for the value-based care era.

Because we are a niche healthcare institution focused on our core services—musculoskeletal medicine—we have a strong presence within that area, and we want to further that.

What sort of long-range steps are still to come across the enterprise as the value era matures?

There are always lots of strategic roadmaps in process. A big part of it will be managing care episodes. For example, we have a fast track for spine care when the main symptom is back pain. It’s focused on getting these spine patients to the right provider in a timely fashion for the most appropriate care and having an entry point for episode management.

In other words, if somebody has back pain, we look at rapid access to a care provider within 24 to 48 hours. Then we develop an evidence-based treatment plan [that incorporates] the patient’s goals, preferences and risk factors. We apply appropriateness criteria, getting the patient value in there. And then we’re triaging the majority, potentially 95%, to nonsurgical treatment. These patients may need some imaging or nonsurgical procedures. In a minority of cases, there is surgery.

Underpinning all those activities is care coordination across various sites and service providers. So while you have some siloes of service—imaging, physical therapy, surgery—the key is to provide care coordination. And that should result in more timely care, better outcomes, overall lower medical costs, less time off of work for the patient. In other words, high-value care.

Your AHRA session description mentions professional branding. How does that fit in with radiology’s drive to show its value?

It’s very important. You have to put a face to the name of the radiologist so that patients as well as providers know there is value in expert interpretations. You know, a patient comes in for an imaging exam, and, apart from the front-desk staff, they only see the technologist. The technologists have been the face of radiology. And that’s been great, but the patients need to understand that there’s a physician behind the scenes, interpreting that imaging exam.

What can radiologists do to advance their brand?

We can become more team-based, more patient-focused to make sure we’re getting high satisfaction from the patients. And we should be making sure we’re getting recognition from hospital administration.

There are some subspecialty radiologists who routinely meet with patients. Mammography is a good example, but there are others as well. There’s a neuroradiologist at Penn Medicine who has a cancer imaging practice and often meets with patients to discuss their imaging exams.

At HSS we make ourselves available when patients request it. If someone were to call, we would certainly talk to the patient about their imaging. And we get good promotion from our referrers. The doctors who refer here want their patients to come to HSS for imaging because of the radiologists. So the goal for us is becoming a preferred provider for radiology services because of the quality of the clinical care we provide and the excellence of our service.

And again, that requires stepping out from the reading room to be more people-centric and demonstrate your value.

You’ll be at AHRA as a presenter but also as an attendee. Is there anything in particular you’ll be looking to learn more about?

I’m looking forward to a couple of things. One is hearing about artificial intelligence from my colleague and friend Dr. Woojin Kim. I also look forward to the regulatory updates, especially on things like fluoroscopy. The AHRA annual meeting is a good conference to catch up on those kinds of things. It’s also a great conference for networking.

In addition, in the volume-to-value movement, we need to leverage all the tools that are available to help us do our best work. So things like AI for helping us with our workflow perhaps even more than it helps with image interpretation—I’m looking forward to hearing more about that sort of thing.