Becoming a value-driven partner to hospital clients in the challenging quest to remake healthcare is the best insurance against commoditization.
Are radiologists suceeding in changing the perception within the health policy community that we’re more than just ancillary consultants, that our contribution to the care continuum is significant and not merely optional?
The prevailing belief that radiology is supernumerary to patient care is directly related to how value is measured; diagnostic radiology (as opposed to interventional radiology) is not viewed as being directly related to patient outcomes (e.g., morbidity and mortality) or to process measures such as infection or readmission rates
On the other hand, as radiologists, how much are we to blame for this apparent disconnect? How willing have we been to make the effort to define, measure and communicate imaging’s added value in a way that all stakeholders can understand and appreciate? Have we worked to offset this negative narrative, fueled by rising volumes and associated costs, or simply shrugged our shoulders hoping for the best?
As a profession we are at serious risk of being marginalized, or what others have referred to as “commoditized.”1 Part of that vulnerability is how and when we prepare for the eventual transition from the current fee-for-service model to new value-based reimbursement systems.2
Enhanced quality and patient safety metrics already are helping to quantitate the value we add as radiologists, while underscoring the national healthcare agenda’s focus on population health management. The 2015-2017 Value-Based Payment Modifier under the Patient Protection and Affordable Care Act (PPACA) is a differential payment mechanism from Centers for Medicare & Medicaid Services (CMS) for physicians and physician groups contingent on whether the care they provide Medicare patients meets specified cost and quality measures. Additional quality activities include participation in American College of Radiology (ACR) data registries, Performance Quality Improvement (PQI) projects, RADPEER, and applying ACR Appropriateness Criteria, Imaging 3.0 and ACR Select.
This complex amalgam redefines radiologists’ increasing accountability in the new healthcare reform environment. Viewed through the prism of proactive engagement, however, this period of entropic transformation can be our golden opportunity to affect meaningful change. The onus of responsibility, as we prepare for rationalizing the appropriate use of imaging, will be inextricably linked to our ability to meet—and preferably exceed—these objective performance metrics. In doing so, we highlight the value radiologists provide in affecting patient outcomes.
For instance, one important patient outcome (and a prerequisite for proper treatment) is the time, and therefore cost, to arrive at the correct diagnosis. A corollary to this is the time subsequently spent imaging patients as part of monitoring their response to treatment until desired benchmarks are achieved. As Lee & Enzmann describe, “These two measures of time savings can be converted to costs. They can also be of inherent value to patients because time is a ‘nonrenewable resource.’”2 In this context, time is both a process measure (important for determining internal care strategy) and an outcome measure (critical for navigating effective therapy).
The plethora of governmental requirements, reporting mandates and resource-intensive quality initiatives offer academic and economic solutions to the “value paradigm.” Nevertheless, radiologists struggle with their own identity as change agent, policy maker and hospital leader outside the familiar cocoon of the x-ray department.
Becoming a value-driven partner
As healthcare systems strive to define their role in population health management, medical imaging can play a critical role as a value-driven care partner. Within the construct of risk-based payment, several performance dimensions can have a powerful impact in building stronger, lasting partnerships with hospital administrators while promoting best practices and improved patient outcomes.
Below is a discussion of how these concepts are put forward by Advanced Radiology Consultants (ARC) in Park Ridge, a 20-member practice that provides the diagnostic and interventional services at Advocate Lutheran General Hospital in Park Ridge, Ill. They co-exist and complement the value-added behaviours incorporated across the Advocate Health Care system, the largest integrated delivery network in the state with 12 acute care hospitals, two medical groups and more than 250 sites of care.
Strategy One: Invest in alignment and share risk in emerging healthcare payment initiatives.
Radiologists must be in sync with “transition strategies to align care transformation with financial accountability.”3 In 2013, ARC addressed that objective by joining five other radiology groups in the Advocate System to form Integrated Imaging Consultants (IIC); today, there are eight groups in total.
More than a conventional shared-management agreement, the consortium model was designed so that each group maintains local autonomy and revenue schedules while collectively exploiting the obvious benefits of economies of scale, such as negotiating as a single entity within the physician–hospital organization. The latter will provide useful data for both internal and external auditing purposes (e.g., the value of subspecialty reads as improvements in service and patient care, potentially translating to higher reimbursement).
Streamlined leadership representing and reflecting the objectives of its individual constituents facilitates productive communication with administrators. Together, physician and non-physician leaders can define mutually rewarding goals that best serve the needs of a diverse patient cohort from a global population health management perspective.
Radiologists are coming to the realization that the cost of doing business in the new health care reform era includes attracting and retaining a corps of subspecialty-trained physicians. Forming group alliances or mergers is a way to defray this expense, allowing services to be provided by a desired radiology subspecialty within and across practice settings. This desirable seamless coverage improves patient, referring physician and hospital satisfaction.
Strategy Two: Identify quality metrics, advanced technology and research as key differentiators in the market place.
The value-based purchasing (VBP) program is based on objective performance metrics defined by the Centers for Medicare and Medicaid Services (CMS): (1) improve clinical quality; (2) address problems of underuse, overuse and misuse of services; (3) encourage patient-centered care; (4) reduce adverse events and improve patient safety; (5) limit unnecessary costs in the delivery of care; (6) stimulate investments in structural components and the re-engineering of care processes system-wide; (7) make performance results transparent to and usable by consumers; (8) avoid creating additional disparities in health care and work to reduce existing disparities.4
To validate our emerging role in population health management, radiologists should recognize the importance of programs and processes for continuous quality improvement. Cost-efficient care delivery models are created when radiologists and hospital leadership collaborate to identify empirical performance guidelines to gauge success. Radiology groups that demonstrate measurable, high-quality services are at a distinct advantage: Hospitals can use these quality achievements to its strategic advantage, and the radiologists are identified as a key differentiator for the hospital in the community.
Advocate Lutheran General Hospital has gained local and national recognition for its pioneer work in breast tomosynthesis5, low-dose CT lung cancer screening, CT radiation-dose reduction strategies6 and personalized administration of IV contrast7. Advocate Lutheran General Hospital is the first hospital in Illinois to receive ACR CT Lung Cancer Screening Accreditation. Our radiologists are actively engaged in research, publish in peer review and trade journals, speak at CME symposia, lecture internationally8 and identify opportunities to incorporate cutting-edge imaging technologies to improve outcomes.
The CT radiation dose management quality improvement project (QIP) at Advocate Lutheran General Hospital is just one example of how analytics tools are used to monitor and track dose through assessment and protocol optimization. Our multidisciplinary QIP team defines short- and long-term objectives that will be incorporated into an Advocate-wide dose management program, including dedicated comprehensive radiation dose reduction strategies for Advocate Children’s Hospital.
The model integrates a robust feedback mechanism, an education platform for technologists, internal auditing and sending data to the ACR Dose Index Registry to measure our performance against national benchmarks. Our work has garnered much positive attention both within and outside the hospital and is one way we demonstrate to stakeholders our commitment to patient safety, quality and outcomes.
Strategy Three: Eliminate redundant services by focusing on utilization management.
Radiologists are in a unique position to help hospitals eliminate waste and economize utilization of services. One important way to accomplish this is through clinical decision support (CDS) for ordering physicians.
As a bridge to full implementation of the ACR Appropriateness Criteria, Advocate Health Care has developed a power plan for some of the most commonly ordered CT studies. This tool is incorporated into computerized physician order entry and is a way to educate physicians to the proper exam to choose that matches the clinical question(s) to be answered.
Radiologists also should engage in regular protocol review and modification to ensure that the most effective imaging options are available and implemented to minimize duplication of services. Identifying ordering trends among referrers, partnering with hospital leadership on unique and interesting venues to educate the medical (and house) staff and attending multi-specialty conferences are just some of the ways radiologists can contribute to utilization management.
Strategy Four: Create a single service line to broaden coverage, provide subspecialty reads and facilitate standardization.
It is now the accepted norm for radiology groups to provide 24/7 coverage 365 day a year. As demands for quality improvement and reporting escalate (e.g., turnaround times, internal peer review), so do the pressures imposed by the highly competitive healthcare market environment.
To meet these challenges, hospitals are differentiating themselves by offering deep and broad subspecialist availability and diagnostic interpretations in all service locations. We are addressing this need at the consortium level of IIC. Some of the individual groups outsource after hour reads to a nighthawk service. Moving forward, the plan is to provide those interpretations by radiologists within IIC.
At Advocate Health Care, committees of imaging leaders from each of the 12 acute care hospitals and Dreyer Medical Group meet on a regular basis to identify opportunities for improvement in achieving standardization, enhancing efficiency and developing service uniformity across the enterprise. There are currently two operational committees (Mammography Medical Directors and CT Medical Directors) with the intent of expanding this leadership forum to include other modalities.
Collaboration of this type can have a positive impact on radiologists, patients, hospitals and payors. For example, The Advocate CT Symposium brings together recognized experts in the field to present state-of-the art technologies, best practices and strategic recommendations for radiation dose reduction and more.
In recent years, the concept of a single pediatric hospital was established within the Advocate Health Care System. Advocate Children’s Hospital has two flagship campuses, one north of Chicago at Lutheran General Hospital, Park Ridge, and one south of Chicago at Christ Medical Center, Oak Lawn. A single chairman of pediatric radiology, Richard Heller, MD, MBA, oversees medical imaging performed throughout the enterprise at all the acute care hospitals and medical groups.
Consolidated leadership will help facilitate subspecialty reads by pediatric radiologists 24/7, standardization of protocols and unified discussions with administration. Integral to the model is addressing issues related to pediatric population management, including radiation dose reduction strategies. Parallel to the work being done with adult patient dose-management, initiatives are underway at the Children’s Hospital level.
Strategy Five: Enhance the patient experience by understanding the significance of HCAPS.
This year CMS added another variable in determining how hospitals are reimbursed by instituting the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The first national effort to collect patient satisfaction feedback, HCAHPS is a survey tool with three goals: produce comparable data on how patients perceive their care; give hospitals information needed to improve their care quality; and increase transparency surrounding hospital care. Patient satisfaction scores will ultimately play an important role in hospital CMS reimbursement for services rendered.
With the exception of breast intervention, special procedures, fluoroscopy and minimally invasive women’s health studies (e.g., hysterosonography, hysterosalpingography), there are few opportunities for radiologists to interact with patients in a meaningful way. However, those contacts can have both positive—and negative—lasting effects on patients.
By understanding what the HCAHPS survey queries, radiologists are better equipped to incorporate simple and effective measures to improve the patient experience within the radiology department for both inpatient and outpatient settings. Traditional methods of recruiting feedback include satisfaction cards and phone surveys. At Advocate Health Care, we use the AIDET method (Acknowledge, Introduce, Duration, Explain, and Thank You) to address, engage and support patients.
The AIDET approach is an evidence-based interactive model that provides a framework for communication with patients, families, and co-workers and has been shown to lead to better patient satisfaction, staff satisfaction, and clinical outcomes9. What seems intuitive and straightforward to the imaging professional (e.g., why IV contrast is needed for a CT) should nevertheless be explained to the patient.
Acknowledging anxiety and trepidation before a procedure, keeping the patient and family abreast of possible delays and demonstrating genuine appreciation for the privilege to serve will go a long way in garnering positive feedback. Making eye contact, offering a reassuring smile and extending a hand to help are gestures that are deeply appreciated, long after the survey questionnaire is completed and mailed.
Strategy six: Continually strive to improve medical staff satisfaction.
Beware the pitfall of taking for granted the “captive audience” medical staff for hospital-based providers such as radiologists. Maintaining referring physicians’ trust and support is a full-time job. It requires collaboration between radiologists and administrators in developing effective communication portals and feedback mechanisms to listen and respond to clinicians’ needs.
The onus of responsibility for educating our colleagues and increasing awareness about appropriate imaging options falls on our shoulders, and we must be willing and prepared to meet this challenge. Whether it’s speaking at a grand rounds lecture, having a casual conversation in the doctors’ lounge, or explaining a complicated MRI to the surgery team, as radiologists we must actively reach out to our colleagues by being more visible, engaged and genuinely interested.
At Advocate Lutheran General Hospital, radiologists are actively involved in resident and medical school teaching. A new activity allows internal medicine teams to meet with cross-sectional imagers on a scheduled basis to review interesting and/or diagnostically challenging cases.
Strategy Seven: Actively participate in hospital life.
Hospital administrators, colleagues and patients depend on radiologists to come forward with information and innovative solutions. The key to forging collaborative relationships with executive leadership is radiologist participation, if not initiation, of conversations about how to bring about mutually rewarding outcomes.
When radiologists demonstrate a proactive willingness to identify, champion and increase awareness about best practices, everyone benefits. The patient receives state-of-the-art technology, colleagues gain confidence in the radiologists’ expertise and the hospital is viewed as the preferred healthcare delivery service for population management throughout the continuum of care.
Although not always on the same page about what is prioritized or addressed, radiology and hospital leadership must stand united in their unwavering commitment to transparent communication, collaboration and innovation to achieve best outcomes.
At Advocate Lutheran General Hospital, radiology is represented on the Cabinet, our elected council of physician leaders and officers. Radiologists also serve on multiple committees, including credentials, nominating, bylaws, safety and internal peer review committees. This inter-departmental collaboration allows radiologists to engage proactively other department leaders in clinical, operational and strategic issues.
Radiology champions can be viewed as willing partners and respected liaisons between the imaging department and the administration with opportunities to affect meaningful change at multiple levels of participation. It is important to embrace the institution’s culture and contribute to the “hospital brand”.
All of these activities allow radiologists to play a vital role in building a hospital’s brand by bringing forth relevant solutions that showcase the mission, values and philosophy of the organization that serve to differentiate it from the competition. A consistent commitment to excellence adds value to the hospital brand which in turn benefits all stakeholders: patients and the community, physicians and associates.
Radiologists are poised at the crossroads of potentially powerful and groundbreaking change. We must assert ourselves, seize the opportunity to make a difference and reclaim our role as trusted colleagues and caring consultants. Whether it’s earning an advanced degree, immersing ourselves in local and national politics or simply being more present, we must take action.
Gone are the days when radiologists could cloister themselves in dark offices, ignore phone calls and resent interruptions by house staff. This is a surefire recipe for relinquishing decision-making power and influence to nonradiologists (and administrators) who possess neither the experience nor insight into best imaging practices.
Lisa Laurent, MD, MBA, CPE, is CT medical director and ultrasound co-director, Advocate Lutheran General Hospital, Park Ridge, Illinois, chair, CT Medical Directors and chair, Dose Management Project Steering Committee, Advocate Health Care, Chicago.
- Borgstede JP. Radiology: Commodity or Specialty. Radiology 2008; 247: 613-616.
- Lee CL, Enzmann DR. Measuring Radiology’s Value in Time Saved. J Am Coll Radiol 2012;9:713-717.
- Bowen. M. The role of radiology in the care continuum: A growing mandate. In Context. Accessed March 25, 2015: http://www.incontextmag.com/articles/2013/the-role-of-radiology-in-the-care-continuum--a-growing-mandate.html
- Keckley PH. (2011) Value-Based Purchasing: A Strategic Overview for Health Care Industry Stakeholders. Deloitte Center for Health Solutions
- Friedewald, SM, Rafferty, EA, Rose, SL, Durand, MA, Plecha, DM, Greenberg, JS, Hayes, MK, Copit, DS, Carlson, KL, Cink, TM, Barke, LD, Greer, LN, Miller, DP, Conant, EF. Breast Cancer Screening Using Tomosynthesis in Combination With Digital Mammography. JAMA. 2014;311(24):2499-2507. doi:10.1001/jama.2014.6095.
- Laurent, LA. (February, 2014). Contrast Dose – The Equally Important Dose. The American College of Radiology Quality and Safety Conference. Scottsdale: AZ.
- Laurent, LA. (April, 2015). A Successful Quality Improvement Project (QIP): Data-Driven Multi-Disciplinary Approach to Managing Patient Radiation in CT. The American Association for Physician Leadership Spring Institute. Las Vegas: NV.
- Laurent, LA. (April 2013). Leading Others to Lead: Inspiring New Leaders to Inspire. Second Annual Advances in Leadership Conference. London School of Business. London: England.
- Studer Group. Healthcare Coaching and Execution. Retrieved from https://www.studergroup.com.