October 2014

Adding Value: What Does It Mean? Radiologists Share Their Thoughts
By Beth W. Orenstein
Radiology Today
Vol. 15 No. 10 P. 16

In yet another effort to contain medical spending, seemingly everyone in the industry is looking at how physicians, hospitals, and other health care providers are paid. Slowly but steadily, many are shifting from fee-for-service to a fee-for-value reimbursement model. The thinking is that value-based reimbursement is at least part of the solution.

Value-based reimbursement is not new for radiologists, says Shawn McKenzie, president and CEO of Ascendian Healthcare Consulting in Roseville, California. About 15 years ago, when radiology transformed from film-based to digital departments “and you could have images everywhere at the same time it changed the way radiologists consult in the acute care environment,” he says. Referring physicians no longer had to walk to the radiology department to discuss findings with the radiologists interpreting the study. Radiologists then realized that if they wanted to be what McKenzie calls a “true partner in the care continuum,” they would have to make changes in how they performed their jobs. McKenzie, other health care consultants, and radiology leaders agree that the shift to value-based care has accelerated the need for radiologists to rethink their roles.

Image interpretation is and will remain the radiologist’s most valued contribution, says Bibb Allen, Jr, MD, FACR, a diagnostic radiologist in the Birmingham Radiological Group in Alabama and a leading proponent of Imaging 3.0, the ACR’s strategy for moving toward value-based health care. Image interpretation is what radiologists study and practice, and it’s their true area of expertise. However, Allen says, accurate image interpretation is not the only way that radiologists can add value to the patient care equation. Radiologists also can add value to the patient’s care by making sure the right study is ordered and that the right protocol with the lowest feasible dose is used when performing the study, he says.

If radiologists want to be included in the value equation, Allen says they must play a role even before the interpretation. “Look at it this way,” he says. “A lot of imaging care occurs before the patients ever get to the hospital or imaging center. If you think about it, an imaging study begins when an ordering physician has a patient encounter and is considering imaging to help in the diagnosis or treatment.”

Imaging 3.0 offers tools to ordering physicians to help them ensure that the requested study is the most appropriate and will get them answers to the questions they are asking in the most efficient and effective way, Allen says. Imaging 3.0 includes the ACR’s Appropriateness Criteria, which are evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for specific clinical conditions.

Allen believes ordering physicians are clearly understand what they are trying to learn from a test 80% to 85% of the time and order the appropriate exam. It’s for that 15% to 20% of the time, when they are unsure or when they enter the exam order entry system and it triggers a red light rather than a green light in the patient’s electronic health record, that they need to have a discussion with the radiologist—and the radiologist needs to be available to take those calls, Allen says.

Starting in 2017, referring physicians will be required to use physician-developed appropriateness criteria when ordering advanced imaging for their Medicare patients, he notes. The requirement is part of the Protecting Access to Medicare Act of 2014, also known as the sustainable growth rate patch. The law does not define what decision-support system should be used, but no imaging experts we’ve talked to think the ACR criteria will be excluded.

Radiologists have always made sure that referring physicians are ordering the most appropriate studies for the patient, says John H. Lohnes, Jr, MD, president of Wichita Radiological Group in Kansas, a member of a physician-led accountable care organization designed to better coordinate care for Medicare patients and provide incentives for providers to work together. “That’s always been a part of the unspoken but very real job of the radiologist,” he says. Interestingly, now whenever radiologists affirm or advise on a particular study’s appropriateness, Lohnes says, it’s seen as bringing “a value piece to the table.”

Dose Monitoring Adds Value
Monitoring radiation dose is another area where radiologists can add real value to the continuum of care, says Jef Williams, chief operating officer of Ascendian. “There are dose technologies out there to help with decision support,” he says. If ordering physicians were to see that a patient was close to reaching a threshold of radiation that they are not comfortable with, radiologists could be consulted and possibly offer an alternative study that could be done with less or no ionizing radiation, such as a sonogram or MRI.

“No other group of physicians is going to understand radiation exposure better than radiologists,” says Allen, who also believes radiologists can add tremendous value to the health system by helping referring physicians reduce or eliminate unnecessary radiation. Patients, too, would appreciate this input, he adds.

Williams says radiologists today also need to be more like politicians, kissing babies and getting in the faces of their colleagues. He advises radiologists to get involved in direct patient care if they want to be regarded as a valuable member of the health care team. Radiologists who sit and wait for clinicians to come to them could be making themselves obsolete, he cautions. While some radiologists need to be in the reading room tackling the worklist, other group members need to be making the rounds with the attending physicians and attending tumor board meetings, Williams says. If radiologists are seeing patients, too, when the hospitalists or attending physicians call up the patients’ imaging studies at their bedside or a workstation on the floor, they can ask the radiologist directly at the point of care, he says. Williams suggests this idea to radiology groups every chance he gets. When he does, he sees eyes roll. However, he says, “If radiologists don’t start thinking this way, they could be left out of the discussions.” The days of radiologists sitting in a dark room and not engaging in the process are over, according to Williams. “They’re gone,” he says. “They’re gone.”

A Seat at the Table
Radiologists also need to take a seat at the table where decisions for the health care system are made, Williams says. Traditionally, radiologists tended to shy away from meetings where decisions around the care enterprise are made, but as the “eyes of the physician when it comes to a diagnostic perspective,” radiologists should take a central role in discussions about strategies that can affect them, according to Williams. Groups may leave this role to their members who enjoy or are good at it, but someone has to do it, he says.

Yet another opportunity for radiologists to show their value is informatics, McKenzie says. “There’s a huge opportunity for radiologists to look at trends and analysis and to take this data and manage it to the benefit of the health system,” he says. If radiologists show their colleagues how this information can be used to improve the care that they provide to patients, their colleagues are sure to see it as a valuable contribution, he says. “It’s a way for radiologists to contribute to better care, better quality, better outcomes, and a better patient experience,” McKenzie adds.

Christoph Lee, MD, MSHS, an assistant professor of radiology at the University of Washington School of Medicine and a faculty investigator at the Comparative Effectiveness, Cost and Outcomes Research Center, says radiologists should approach not only their colleagues but patients as well. Sometimes radiologists need to talk directly to referring physicians, and sometimes it’s patients they need to talk to directly, he says. To be seen as adding value, Lee says radiologists must do whatever it takes “to communicate their findings and help direct the patient’s care down the proper cascade.” A radiologist’s effort has to translate into actionable information—the next proper step in a patient’s diagnosis or treatment management, he says. That may mean the radiologists must convince the patients as well as the physicians treating them of their clinical recommendations. “They have to be willing to spend face time with patients to explain the clinical importance of their imaging findings and to clearly and effectively communicate their recommendations to the clinical team based on their image interpretation,” Lee says.

Be Proactive
David Smith, FACMPE, who provides executive and advisory services to radiology groups and imaging centers, says radiologists can’t afford to sit around and wait to be asked what value they add to the health care equation. “I encourage them to be proactive,” he says. Radiologists must work with customers to set the terms of what value is and what consideration there should be for providing additional value, he says. If they wait, the person sitting on the other side of the table will ultimately dictate it to them, and that’s not necessarily the direction they want the conversation to go. “If you aren’t proactive,” Smith warns, “you may end up with something that’s only going to be beneficial for the other party.”

Lohnes believes the opportunity for radiologists to become part of the value equation is theirs for the taking. “Imaging in general is now the center part of the medical enterprise,” he says. “Almost everything comes through imaging anymore.” While radiologists may do fewer studies, those that are done are targeted more effectively and hopefully get to the answer more quickly, Lohnes says, adding that if radiologists can help their practices and health systems get to the most appropriate level of imaging, that is true value. “We’re in the middle,” he says. “And that’s a great place to be.”

Still, while radiologists need to be concerned about adding value to the health care team so they can continue to be compensated fairly, that doesn’t change their top priority, Lohnes says. “To me, you are never going to go wrong if you do what’s right for the patient,” he says. “No one could ultimately criticize you for that and, if they do, frankly they look foolish. That’s part of the oath we took.”

— Beth W. Orenstein is a freelance medical writer based in Northampton, Pennsylvania. She is a regular contributor to Radiology Today.