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Finding Value at the Intersection of Price and Quality

By Allon Yosha

When I first entered the world of health care, it felt like a black box: so completely opaque that it wasn't clear anyone could fully understand everything going on inside. My knowledge of insurance types, government regulations, and reimbursement methods was mediocre at best. My understanding of diagnostic equipment, imaging protocols, and physician qualifications was even less impressive. Opacity notwithstanding, I naïvely believed that everyone in the health care industry worked happily together in the name of patient care. Suffice it to say, the reality did not meet my expectations.

The "Business" of Health Care
Five years later, I've become much less naïve about the "business" of health care. The current paradigm by which payers cover costs, providers deliver care, and patients (attempt to) navigate the system is rife with misaligned incentives. Further, although the system is structured as a business, it operates in an environment often hostile to business success and must contend with varying state regulations, woefully outdated payment models, and the collection, maintenance, and protection of silos of sensitive data.

While many facets of this system require correction, one stands out above the rest: the difficulty of evaluating a physician's skill in diagnosing and treating particular illnesses or injuries. It's hard to quantify the quality of the diagnosis and treatment you receive. That's a big problem for patients, payers, and providers alike.

Is Radiology a Commodity?
As with most problems, the first step to a resolution is the recognition that a problem exists. For me, that recognition came in 2014 during a series of meetings with diagnostic imaging providers. I visited hundreds of radiology centers in every corner of Florida that summer, each claiming to be the "very best" imaging center in the state.


It's easier to identify the best value among the TVs at Best Buy than the best doctor in a given area—and high-tech TVs are pretty much black boxes to me, too. At least the metrics on the TV ads are clearly tied to quality.

If every doctor is selling quality, then whom can I really trust? How could I ever distinguish between them? Certainly, I couldn't distinguish on the basis of credentials. All of the sites were accredited. All of the radiologists were board certified. And, according to the ACR, there is 97% agreement among radiologists' interpretations across the country.

Every time I saw patients referred to radiologists based solely on price, without any regard for provider quality or the impact of those referrals on patient care, I wondered, if there are really no differences among providers, then what's left to distinguish between them other than price? Is radiology, and perhaps the entire practice of medicine, an interchangeable commoditycompeting only on price? The answer is no.

Diagnostics Are Not One-Size-Fits-All
This first step in thwarting the all-too-common perception of radiology as a commodity is acknowledging that, although all physicians wear a white coat, some physicians are better at what they do than others. And even good physicians can make mistakes. It's been conservatively estimated that medical errors are now the third leading cause of death in the United States, accounting for approximately $20 billion in misused resources.

Certainly not all of those errors were diagnostic, but many of them were—and diagnostic errors compound themselves, leading to further errors downstream. Getting the wrong diagnosis matters, and according to a 2016 study in The Spine Journal, it happens more often than we think. It also happens more often to some providers than others. That's why provider quality matters.

In the last five years, I've seen the same patient travel to two different providers and receive completely different diagnoses. I've also seen the same patient receive completely different diagnoses after two reviews from the same provider. These errors were not only statistically significant but also clinically significant, meaning that patients' treatment pathways and overall health were impacted by their diagnoses. Needless to say, that level of variability in radiological interpretation is troubling. But if these differences are not captured by credentials, then we need a better way to measure them.

How Data Analytics Can Redefine Our Understanding of Quality
In thinking about provider quality, the question I now prefer to ask myself is, which physicians make the fewest mistakes? The answer lies in data analytics. Difficult though it may be, differentiating among physicians based on truly objective metrics is important for both patients and providers; with better information, patients can choose higher-quality providers and providers can improve the quality of the care they provide.

The silver lining in rising health care costs and high-deductible policies is that patients are beginning to demand those metrics. These market forces, combined with access to powerful, cloud-based technology, make it the perfect time for analytical efforts to quantitatively define quality of care, something that has never been done before.

For years, radiology providers have marketed an array of impressive-sounding characteristics about their practices to differentiate themselves: open vs closed, 1.5T vs 3T, online access to DICOM images, even the ability to watch TV during a procedure. I've found, however, that the most impactful way to differentiate one practice from another is to demonstrate the consequences of a poor quality imaging study to prospective purchasers of medical services. Whether you're a patient, a payer, or a provider, outcomes matter. Emphasizing the impact of errors on outcomes is therefore a tangible and persuasive marketing strategy.

Few radiology practices have shifted emphases yet; this only increases the advantage of doing so. By sharing internal statistics about practice volume and accuracy and participating in quality-focused research, radiology centers who have seen where the market is headed can demonstrate their ability to mitigate errors and deliver better patient care than other practices. To the extent that health care is a business, it's critical to remember that value is found at the intersection of price and quality; it is not a function of price alone.

Patients, payers, and providers increasingly understand the role of quality in driving value. Smart radiologists will therefore look to set themselves apart from the competition by competing on quality—which is definitively not a commodity—and selling value.

— Allon Yosha serves as director of provider partnerships at Spreemo Health, a health care analytics platform that performs clinical research, data science, and network management.