As healthcare heads toward value-based payment, radiology is challenged to move beyond the relative value unit to measure physician performance
When it comes to measuring and evaluating a radiologist’s productivity, there is always going to be the potential for divisiveness within a practice. The only way to completely avoid it, Columbus Radiology CEO Charles McRae said—only half in jest—is “if you’re talking about a practice that has one or fewer people.”
“I think that we have to recognize that productivity has a lot of different meanings and connotations and is a sensitive topic throughout radiology,” adds McRae, who heads a 47-member practice headquartered in Ohio. “It always has the potential to be a divisive issue.”
Vikram Krishnasetty, MD, Columbus Radiology vice president and medical director of information technology agrees that physician productivity can be “very divisive” if mishandled. “At the same time, if it’s monitored properly it can improve the relationship between a radiologist and the practice.”
According to Krishnasetty, the prevailing strategy pertaining to productivity at Columbus Radiology is to evaluate the practice’s overall workload balance and efficiency rather than any individual radiologist’s productivity.
“We’ve gone away from looking at individual productivity,” he says. “Instead, we’re looking at the work that’s coming into the practice and how we can get that work completed in the most efficient manner by allowing each radiologist to do a fair amount of the work without a significant amount having to be performed by a few.”
McRae adds: “And do that fair amount of work at a pace he or she is comfortable with, while being able to provide a high level of quality.”
Trial and error
The productivity issue is one that has dogged Columbus Radiology for a while, says Krishnasetty. “We’ve considered a number of strategies that other groups have utilized,” he notes, “and as we’ve gone through them realized there were problems with each.”
For example, he says, many groups use an exam-assignment approach, in which a given number of exams are assigned to a radiologist during a given period of time. That approach could end up actually increasing turnaround times, he points out, particularly for STAT exams for which results need to be reported as quickly as possible.
“I could have an exam assigned to me but then get involved in a [fluoroscopic] procedure that takes longer than expected,” explains Krishnasetty. “So, you could have an ER patient waiting 40 minutes for a chest X-ray when someone else could have read it within a few minutes.”
Krishnasetty notes that Columbus Radiology also looked at an approach involving relative value units (RVUs), with the goal of ensuring that radiologists hit a minimum number of RVUs. This approach has the potential of negating what should be the approach of any practice manager—increasing the efficiency of the entire group.
Under this scenario, the group may increase the efficiency of one radiologist but risks reducing the efficiency of another. “Or, you could falsely increase the efficiency of a radiologist by forcing him or her to read higher RVU studies because that’s a way you can get them to achieve the goal you’ve set,” he says. “But that’s not going to achieve the desired effect [of increasing the efficiency of the whole group.”
So instead of setting RVU goals or determining that the practice’s radiologists need to read a certain number of exams in a certain time period, what Columbus Radiology has done is develop an algorithm that allows it to take a “perspective, [prospective?] real-time” approach to productivity.
“The biggest part of the productivity piece that we see missing in other practices is immediate feedback,” Krishnasetty says. “We’re all professionals and we want to be as efficient as we can, but without immediate feedback, it’s very difficult to gauge how you’re doing during the day.”
With this algorithm, individual radiologists are able to work at a pace that’s necessary to get the entire practice’s workload completed. “It’s a perspective real-time approach in which what the radiologist is doing is in accordance with what the practice needs him to do,” Krishnasetty explains. “We’re providing the radiologists with immediate, anonymized feedback on how they are tracking for the day in comparison to what the practice is experience to that point.”
Medicine is becoming more about data, McRae says, requiring better data management tools and technology, “We have the capability to use data to build this perspective algorithm and then evaluate it every 15 minutes and adjust it based on what is happening today in the hospital.” This is much more much more useful than an approach in which a practice is looking retrospectively at data that are a month—or even six months—old.
“I don’t know whether there’s a right way or a wrong way to do this,” McRae said. “But I think we’re doing it better than we’ve done it in the past, and I hope we’ll do it better as we head into the future.”
One of the problems with a focus on productivity is that it ends up with practices following strategies in which the pressure is on for radiologists to simply “do more, do more, do more,” says Lawrence Muroff, MD, CEO and president of Imaging Consultants, Inc. According to Muroff, an optimal situation should have a practice understand that all of its members are contributing to the success of the group to their best of their ability and doesn’t overemphasize productivity.
That’s not to say that groups shouldn’t address those outliers who with no explanation aren’t pulling their weight and adding to the success of the practice as a whole, Muroff qualifies. “But groups that heavily emphasize productivity create a variety of problems,” he says.
For example, if a group overemphasizes productivity and defines a radiologist’s worth by the work RVUs he or she produces, then chances are that radiologist will just churn out studies instead of spending time on non-RVU producing activities, such as consulting, serving on hospital committees and practice building.
“The problem with that is that if you don’t integrate yourself into the medical, social and political fabric of your hospital and community, you’re going to endanger your contract and tenure at the hospital,” Muroff says. “When people explain to me that they can’t go to conferences or serve on hospital committees because their RVUs will drop, my answer is that if they don’t pay attention to those non-RVU producing activities, they won’t have to worry about their productivity because they won’t have a job. There are many ways in which you can be replaced by entities that will pay attention to those other activities.”
It’s important for practices to have strategies in which they focus on efficiencies, he adds. “By simply doing more or focusing almost exclusively on work RVUs, you are going to leave yourself vulnerable because you aren’t paying attention to non-work RVUs.”
According to Muroff, a practice ideally could reward its members by allocating non-clinical RVUs that could be factored into a total productivity measurement. For example, if a radiologist spent an hour sitting on a medical executive committee meeting of a hospital, a practice could assign an RVU equivalent value for that time. The same could hold true for a radiologist who attends a tumor conference or gives a lecture promoting a special capability of the practice.
“If you can provide an assessment of non-clinical RVUs and combine them with clinical RVUs, then you would get a more meaningful measurement of one’s contribution to a practice,” Muroff says. “If a group really wants to reward or punish a radiologist for variances in productivity, then they should take these non-clinical activities into account. If I teach a technologist or sit down with he or she and develop protocols, those are important activities. Yet, there is no RVU accountability for that. You have to find a way to reward members for providing all of that work that is non-RVU productive.”
Krishnasetty pointed out that Columbus Radiology factors in non-clinical activities such as tumor boards and meetings in its algorithm. “The number of exams that a radiologist reads is not the end-all of the value that a radiologist provides to the practice,” he says. “There are customer service aspects, consultations and tumor boards, and lots of other factors. We don’t want to lose those by focusing on how many studies we read, and I think many productivity solutions really only focus on that.”
Beyond the RVU
Over the years, Richard Duszak, MD, chief medical officer and senior research fellow at Harvey L. Neiman Health Policy Institute in Reston, Va. has spent much time before groups talking about issues related to productivity and the use of RVU-based systems, once calling productivity “the third rail of radiology.” Recently, he has begun to change his approach when talking about the issue.
“I’m getting away from talking about ‘productivity’ because it implies RVUs,” he says. “Instead I’m focusing on performance, of which productivity is just component. If society and payors want to pay our practices based on value rather than volume, then we need to be working on developing internal value-based metrics lest our priorities be misaligned.”
While RVUs are a “reasonable surrogate” of clinical work, Duszak says, he echoes Muroff’s point that it doesn’t address non-clinical work. In fact, he points out that in 2010 he and Muroff co-wrote two articles1,2 on measuring and managing radiologist productivity in which they encouraged practices to think beyond the RVU.
“The whole healthcare dynamic has changed quite a bit in the interval,” he notes. “One of my key messages to radiology practices today is that if part of the goal is to encourage physicians to do the type of work that allows your practice to succeed, then the behaviors they are looking for at the practice level need to be encouraged at every individual physician level. I think that calls for revisiting the way the specialty defines good performance, and that has to go beyond just RVU productivity.”
How that will be determined is a subject with which many practices currently are grappling. Duszak believes the answer can be found in examining how CMS and private payors envision radiologists (and other physicians) getting paid in the future.
He specifically referenced Health and Human Services (HHS) Secretary Sylvia Burwell’s January announcement of the establishment of a timeline and measurable goals for moving the Medicare reimbursement system—and the healthcare reimbursement system at large—from one based on volume to one based on value.
HHS has set a goal of tying 30% of traditional fee-for-service Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50% of payments to these models by the end of 2018. HHS further established a goal of tying 85% of all traditional Medicare payments to quality or value by 2016, and 90% by 2018, through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs.
Volume to value
Viewed in that context, practices are under the gun to re-evaluate how they are defining performance. “Those are pretty ambitious goals,” Duszak says, referring to HHS’s expedited timetable. “And the agency hasn’t provided a lot of detail on how they define quality and value, so that provides a lot of opportunities for practices to start doing it themselves. With quality a big component, practices need to be encouraging their employees and partner physicians and rewarding them for quality and value initiatives.”
According to Duszak, this could mean that practices should be embracing professional quality improvement (PQI) projects, which he points out are part of physicians’ maintenance of certification requirements. The American Board of Radiology and the ACR have developed a number of resources that practices can access, Duszak says. He recommends identifying physician champions for individual projects, and getting physicians to participate in those types of projects.
Examples of such projects could include structured reporting and radiation dose reduction efforts. He says: “[Radiation dose reduction] is a hot topic right now and resources are available through the ACR for practices to participate in the CT Dose Index Registry where practices can start benchmarking their typical CT scan dose with those of peers across the nation and use that as a tool to implement changes in changes in protocols and behavior to reduce patient dose.”
A physician performance-based incentive plan—versus a straight RVU-based productivity plan—would allocate credit to physicians designated as champions of PQI or other performance-improvement projects, and for those who participate and show improvement in that project. “That would be a relatively easy kind of metric for a practice to determine how many points a doctor should get for co-chairing the effort, and how many points a doctor who participates in helping to modify protocols should get for their contribution,” he says.
Productivity in a fee-for-value world
In today’s fee-for-service environment, there is an inherent conflict between productivity on the one hand and quality and value on the other, says Duszak. “If you look at the concept of value, my goal shouldn’t be just creating volume, it should be about creating meaningful and actionable information. There is an inherent conflict and one of the goals in going to a fee-for-value system is to reduce that conflict.”
One of the issues going forward, Duszak adds, is that providers are collectively struggling with the question of what are good measures of quality and value. “While we can intuitively determine which of two healthcare pathways provides better value and quality, one of the challenges is going to be to develop robust criteria we can use as the basis for payment if we are really going to align our payment system with the delivery systems we would like to see in the future.”
That said, there is certainly a place for productivity in a fee-for value world. “If a radiologist says he only saw one patient in a day but that he really provided good quality care, that’s not going to serve anyone’s needs,” says Duszak, adding that this is particularly true in healthcare systems increasingly focused on patient access to care.
Duszak agrees with Muroff in that he believes the U.S. healthcare system isn’t necessarily going from one that is volume based to one that is based on value, but is actually going to one that is “fee-for-value-based volume.” He says: “We’ll still have to be able to get the throughput and have met the patients’ needs, but do it more efficiently and in a higher quality manner.”
Muroff warns that it would be a mistake to think that a move towards alternative payment systems means volume will go down. “I can’t conceive of any alternative payment model where volume is going to go down,” he cautions.
The reason, he says, is that there are three major drivers behind efforts to reduce healthcare costs—preventing unnecessary hospitalization, shortening those hospital stays that are necessary and avoiding rehospitalizations.
“The first two reasons can be profoundly impacted by diagnostic imaging, so it’s my belief we’re never going to see a drop in volume,” Muroff says “If anything, under alternative payment models there will be an emphasis on early diagnosis and speed in appropriately working up a patient, and I think our productivity is going to soar. Anyone who thinks the message is going to be that since we are going to move from volume to value that it somehow means that volume will drop precipitously is misguided.”
- Duszak R, Muroff LR. Measuring and managing radiologist productivity, part 1: clinical metrics and benchmarks. J Am Coll Radiol. 2010;7(6):452-458.
- Duszak R, Muroff LR. Measuring and managing radiologist productivity, part 2: beyond the clinical numbers. J Am Coll Radiol. 2010;7(7):482-489.