Julie Kaufield, MA, RT(R)

Radiology, as a profession, is growing and changing. And, with those shifts, said industry experts at the Radiological Society of North American annual meeting, comes a fair amount of uncertainty. “Regulatory, environment, and economic changes have caused massive insecurity growing within radiology groups,” said Patrick Free, McKesson’s vice president of radiology, who currently works with almost 400 radiology groups of various sizes and classifications nationally. “There is a concern with where these changes are going.” Concern stemming from non-imaging entities creating competition, hospitals shopping for radiology services, and increased scrutinization of overall imaging utilization, Free said, has created a trend where groups are forming stronger relationships with both external and internal partners. To do so, they’re implementing a variety of prevailing growth models. Sharing examples of each model, Free acknowledged radiologists want to understand where they can provide the most value. 

 The most common model today, it exists either as a one-to-one individual or group relationship with their hospital. Positives include a high level of autonomy, the ability to easily navigate issues and set strategies, market-forces based income, and work/life balance. Negatives are groups owning all their own risk, difficulty being the best at everything within a complex setting, and difficulty managing strategic disputes over the long haul.  “There are a lot of dynamics in this model that can create stickiness with their own hospital partners,” Free said. Aggregation model. This model is seen with larger groups who create a consortium agreement, such as Strategic Radiology.  “The quality of care is their mantra and what started as a think tank evolved into an entity to share best practices,” he said.  Positive features include cross collaboration, group purchasing with expense savings, leveraging management talent across groups, and providing benchmarks combined with data analytics. Drawbacks include the need to guard shared data more closely. There is also difficulty leveraging national payer markets in areas that have been historically more regional. 

. Seen more often within academic centers, as well as integrated health care delivery markets, W2 employment models also serve smaller, rural areas. Positive characteristics from the hospital side include more control in the overall care continuum, ease in participating in broader hospital initiatives as they relate to radiology. On the group side, this model also provides income protection from market forces and makes it easier to recruit certain specialties and avoid turf wars.  Negative characteristics include a mal-alignment between pay-and-performance from the hospital perspective while groups may suffer a loss of autonomy or be underpaid. Clear and concise expectations along with fair compensation practices must be set and understood, Free said. 

.  The forced-takeover model is most commonly seen where a hospital system mandates a merger of several groups to service their patients. Benefits include a singular service agreement and easier marketing abilities with a consistent standard. Drawbacks include lack of synergy between groups and hospitals, as well as the inability to leverage the system.  

  Growing in popularity, Free used Advocate Health Care as an example where 10 or 11 groups serving the hospital were approached and told they needed to merge. By creating a contracting arm, groups can look merged from a contract and payer standpoint, but maintain autonomy from a group perspective. Positives include one service agreement and one quality standard, while the group maintained income autonomy. The group also had the strength to garner better pay rates, as well as manage risk through alignment. Negatives include a heavy administrative burden to keep cash flowing in through one tax ID, but then distributing it out to the respective identities. The model can also come under scrutiny if affiliations are crossed.   

 A model entails an entity buying a practice, and it is seen most often in smaller groups who are struggling to meet hospital expectations or sub-specializations. Typically, the partner is grandfathered for a period, and all non-partner members become W2 employees or are contracted into the agreement. Rad Partners is one such example. Positives offered are the gained confidence that a group can achieve higher quality and increase strength while removing stipend commitments. Negatives include alienation of medical staff and lack of reception towards outside change making it difficult to assess risk and cultural fit. 

It is not very common, but one example would be Radnet. This option is prominent in the outpatient market, offering the opportunity to become a turnkey alternative within the hospital space. This model works when hospitals do not want to manage their own radiology department. The entity provides technology and management, Free said, to take over the day-to-day running of the department. Positives include relief from IT investment, ease of leverage data by the entity, and in some cases, they can provide a higher level of service because of the broader group that comes in. On the downside, hospitals may not want to partner with a publicly-traded entity. There may also be a reluctance to turning over management control, and both parties may not agree on how to manage departments.  “These are the seven strategies we have seen most prominently, but I think the rapid pace radiology is going through is likely to continue to evolve. I don’t think anybody can really say where each of these strategies is going to take us,” said Free, sharing eight imperatives all groups should look at when it comes to gauging the healthiness of their hospital partnerships.  Knowing where your group ranks on clear and concise communication, innovation, visibility, quality, metrics, unnecessary spending, information sharing, and positive culture will help identify ways to remain vibrant and growing, he said. “Groups will continue to evolve and grow to diversify their risk,” he said, noting  imaging is the single most valuable diagnosis specialty in hospital. “The goal is to thrive, survive, and grow in both quality and sustainability.” 

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In the rapidly-changing radiology world, these practice models are impacting physicians and their hospital partners. 

Seven Top Growth Models & Their Impact on Physician-Hospital Partnerships 

Understanding the new value-based payment models within imaging is crucial to achieving both operational and fiscal success on both the physician and hospital side in the upcoming years, according to experts at the Health Administrator’s Symposium during RSNA 2016.

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, a dense document unfamiliar to many physicians, said Ezequiel Silva, MD, vice chairman of the American College of Radiology (ACR) Commission on Economics, has a performance period beginning in January 2017 with a 2019 effective date.  Directly tied to the public sector of payors, including Medicare and Medicaid, he said the ultimate goal for the Centers for Medicare & Medicaid Services (CMS) is for hospitals to have a combined payment system with physicians.

“Administrators need to be conversant in the proper and updated terminology,” said Silva, noting MACRA is now called a Quality Performance Program (QPP) and considered budget neutral.

Containing two different payment tracks – the advanced payment model (APM) and the merit-based incentive program (MIPS) – QPP ultimately influences the private payor sector, as well.

While quality reporting makes up a large portion of both MIPS and APM reimbursement, there will be a shift away from physician quality reporting systems that are claims based towards registry based systems.

Improvement activities will make up the other major sector related to new payment models. Adding  there are 90 measures that would satisfy MIPS, Silva suggested the use of 

“The arc of where CMS is taking healthcare in the U.S. is towards alternative payment models (APM),” said healthcare consultant Richard Weil, PhD.

Whether traditional APMs, such as Medicare shared savings programs or bundled payments, a MIPS APM model, or an advanced APM, the shift continues to move from fee-for-service RVUs towards value- based systems.

“In 2016, 30 percent of Medicare payments were tied to an 

,” he said, with an anticipated increase to 50 percent participation by 2018.

APMs focus on episodes of care, specific clinical conditions, or specific populations, and the advanced track focuses more exclusively on patient outcomes.

“CMS expects less than 10 percent of physicians to participate in advanced APMs in 2017. Yet, there are strong incentives for well positioned groups,” said Weil, who shared incentives will increase over time affecting Medicare, Medicaid, and commercial payors.

“2017 is the training wheel year where no-one is going to get hurt,” he said, acknowledging groups may not be ready to take on more of the risk required with advanced APM models. Yet, groups that can maximize their benefits including the use of care management now will create a stronger foundation for the future and adapt to bigger risk-taking that offers higher incentives.

Drivers for advanced APM systems focus on groups of patients versus the individual, including episodes-of-care managed, conditions managed, and ultimately populations managed. It changes the basis of competition, he said, by creating drivers of revenue based on physicians understanding what percentage of the market they are responsible for and how many patients within those markets chose them.

“Physicians become population health managers,” Weil said. “With MIPS, it is you against the government. In an advanced APM, you provide a service and may have a lesser or bigger role based on differentiation.”

It is important to understand outcome metrics, profitability per groups of patients or episodes-of-care, and to fully understand where patients go for care and the types of care they are getting.

“You can expect utilization to go down initially with duplicate studies largely eliminated,” he said, sharing there may be increased overhead related to this model, including facility leasing and administrative help. Areas of opportunity may come from advanced imaging and commercial contracts.

 “Pay attention to what is going on in your market,” he said, concluding it is imperative to understand what is important and preferred by the care quarterbacks within your market. To achieve success within new value based structures, he said, you must “understand the metrics and how you compare to other folks then come up with a plan for improvement.”

Part One of Two. Understanding value-based payment models to maximize financial success.

Administrator Focus: Payment Models 

Real time healthcare data is growing at a pace and volume that outpace humans, creating a need for business intelligence (BI) tools that can optimize operational efficiencies while minimizing large sources of data into small meaningful pieces of information, according to leading experts at RSNA 2016. “Business analytics (BA) is a collection of technologies and functions, both hardware and software, that enable the exploration of data to gain insights that can, then, inform business decisions,” shared Katherine Andriole, PhD, FSIIM, associate professor of radiology from Brigham and Women’s Hospital, noting it can be used to automate things, optimize processes, leverage data for a competitive advantage, and sometimes forecast the future. “Because it is capable of handling large amounts of information unstructured, BA can present and visualize data in a way  you can interpret dynamically in real time.” Often used interchangeably, Andriole said, “business intelligence asks questions of the data by changing the visualization, whereas business analytics is really a subset of the overall BI framework.” It uses stronger statistical and quantitative analysis to explain associations, asks why something happened, receives an explanation, and offers the opportunity to avoid repeating. “It’s not just documentation,” she said. 

Where does the data come from, and how is it used?

 There is an incredible amount of useful data  available to radiology professionals through a variety of system databases, including financial, research, electronic medical records, RIS, and PACS systems.  “By combining data from these disparate systems one can visualize trends, draw correlations, and detect gaps,” said Andriole, ultimately offering operational decision-making through metrics and reporting, as well as clinical and research knowledge.  “The good news is there is information everywhere, and it resides in different systems. But, that is also the bad news,” she said,  acknowledging the need for these kinds of technologies to understand data that is coded differently and coming from different locations.  Using a four-step process, creating data that is in a unified, consistent format is the most difficult part of BA. 1. Aggregation- Information is collected from many different databases.2. Integration-Using a three-step Extract, Transfer, and Load (ETL) system, data is extracted from sources, transformed through a cleaning process that reformats and standardizes data using a data integrity and verification process, and, then, loaded into a targeted system efficiently.3. Analyzes- Unified data is stored in a data warehouse where it is ready for analysis, often using an online analytical process (OLAP) that mines the data.4. Presentation- Ability to share information in the most useful, consumable way. When using BA tools within your organization, Andriole said, “it is important to understand what metrics will represent what you are trying to do and be able to validate it.” Setting department goals, including all relevant parties, and setting key performance indicators (KPI) that reflect progress are effective in creating change.  “Start with low hanging fruit,” she said, noting metrics around access to advanced imaging, order signing, patient falls, and ANCR are good starting points. 

Well thought out strategies ensure the best use of data

 “Information is not enough – it  is the insight it can provide,” said Luciano Prevedello, MD, MPH, Division Chief Medical Informatics, Ohio State University Wexner Medical Center, agreeing BA offers guidance through turbulent times to manage risks, improve quality, and anticipate change. The timing is now, given the shift from fee-for-service to value-based care, he said, to use it within both private practices and academic centers as a high-efficiency, low-cost value. In offering key strategies to ensure overall success when using BA, Prevedello said there are some pre-requisites to consider prior to beginning, including quality checks in place around unstructured or messy databases prior to data mining, using data that is unique and offers differentiation from the competition, and governance within each organization related to access and privacy of the data.  “Information is power. There is a natural maturity level that happens around the analytical process,” said Prevedello, explaining organizations will make wrong assumptions or predictive analysis with vendor-based solutions if the quality checks regarding data have not taken place. “There has to be someone overseeing that component.” Machine learning can also be used to verify clean data and do additional cleaning processes involved in predictive BA.  The highest level of maturation within business analytics systems is predictive analysis. “There are also a bunch of assumptions embedded in a predictive model as with any other statistical model,” he said, noting an algorithm or model that may work today may not have relevancy tomorrow. It is important to continually revise models as the future changes. Once the organization embraces BA fully and can use predictive capacities, it has reached its final level of maturity.  “Depending on the level of complexity at your site, at least some of the simple analytics can be used on a daily or monthly basis,” Prevedello said. Simple to more complex, BA can use pivot tables within Excel spreadsheets to determine the most commonly-used protocols, use natural language processing, such as open source, to create more mineable data from the clinical decision support tools, and, at the highest complexity, predicting the future with machine learning algorithms. Identifying delays in CD importation and increasing efficiency related to timely, accurate uploads using RapidMiner and deep learning was one example Prevedello used to demonstrate predictive BA. Identifying patients with an elevated risk for readmission within 30 days using a three-tiered stratification system (low, medium, high) and, then, embedding that information into the electronic medical record for every patient, allowing for specific, targeted interventions depending upon level of risk of the patient, is another type focused on outcomes. For example, at the population health level, predictive analytics using historical patient data can create predictions around breast health imaging, including underserved neighborhoods, access issues, and communication. “All of these techniques are very useful, and organizations should be familiar with them to be able to use them at a time that works best for you,” Prevedello said. 

Healthcare data is growing, increasing the need for business intelligence tools to optimize efficiency while consolidating large data sources.

Business Analytics Improves Operations, Quality, Clinical Performance 

Radiology, as a business, has become increasingly complex as regulatory demands grow and revenues, both on the hospital and physician side decrease. Doing more with less has become a common theme and both the commoditization of billing as well as the implementation of ICD-10 codes have played an important role over the past year, according to industry experts at RSNA 2016.

 occurred approximately one year ago, and despite heightened anxiety prior to the shift, one year later the disruption has been minimal, said Melody Mulaik, MSHS, president of Coding Strategies.

“ICD-10 is the foundation for just about everything, including payment and communication to CMS and the patient,” she explained, emphasizing the importance of this new coding mechanism compared to its predecessor. “ICD-10 diagnosis codes are able to translate relevant clinical information into data used for research, social history, co-morbiditities, and underlying risk factors,” she said. “It’s not just a software update.”


One year later, Mulaik shared that while each organization experienced ICD-10’s implementation differently, overall observations for radiology demonstrated no major drain on productivity, and payment denials did not increase. Because the nature of the new coding system requires more detailed information than the last version, hospitals desired additional staff to support the transition, while physicians found their greatest pain was a backlog that, at times, affected productivity. ”Radiology practices have been in much better shape than most specialties because they have a system in place around coding already,” she said.

The few hiccups shared on a national scale have centered around the use of unspecified codes, particularly coming from referrers. The grace period allowing for the use of this code expired in October 2016. There is also a known issue with NaF-18 PET scan codes, Mulaik said. She suggested

 as a tool to decide on the best solutions for your group. “It takes time and effort to get that payment,”  and CMS does not currently intend to change the options, she said.[[{"type":"media","view_mode":"media_crop","fid":"56728","attributes":{"alt":"Radiology reimbursement","class":"media-image media-image-right","id":"media_crop_2127698339398","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7134","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 133px; width: 199px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Constantine Pankin/Shutterstock.com","typeof":"foaf:Image"}}]]


Ensuring the proper ICD-10 usage allows for both hospitals and physicians to get paid and steers quality improvement.

 today, you’ve got the CPT and diagnosis codes. As you look at other pieces of how quality programs are structured, there are a lot of things that go into play, including patient safety issues, severity of illness, and hospital acquired conditions,” Mulaik said.

Radiologists need to communicate their own interactions with patients. “If I look at diagnosis codes, I get the story of that patient translated from what the radiologist put into the radiology report,” she said.  Reports should be robust and contain the story of why the patient was there, what was done to them, and what was diagnosed.

The Quality Payment Program (QPP) formerly known as MACRA went into effect January 1, 2017, and further ties radiologists’ reimbursement to quality metrics that can be relayed through diagnosis code. Codes also offer data rich opportunities to look for variances within practices and departments as well as improvement opportunities to tell a patient’s story more accurately.

Get What You Pay for in Radiology Billing


While technology and coding efforts have allowed physicians to create robust reporting while managing a heavier workload, technical automation and the use of third party offshore vendors for billing to reduce cost has also become a growing trend.

“Billing is a manufacturing process, so you are always seeking efficiencies  to maintain quality and drive cost down,” said Patricia Kroken, principal at Healthcare Resource Providers. “There also is no real inherent value to the billing process.” Because billing is a stable process, she says often there is an assumption that it is easy to do and that quality will not be impacted, regardless of cost.

“I don’t think I’ve ever seen the volume of instability in the number of unhappy radiologists that I am seeing right now in terms of what they are getting for what they are paying for,” Kroken said. She noted that many groups are dissatisfied with financial performance and quality. “You can only drive cost down so far and then it becomes painful,” she said.

Lowest Cost Options Rarely Produce High Quality Outcomes


Instead of looking only at cost, practices need to look at cost value and may need to pay more to get more. The use of automated systems for billing is a trend that has reduced the need for in house staff by outsourcing bills to collection agencies sooner and calling patients directly through Automation.

“Just because you can automate doesn’t mean that you should,” Kroken said. “Even the best automation cannot overcome bad processes. It just does bad stuff faster.”  Automation can suffer from hiccups when transcription goes down or hospital technology has an upgrade or downtime. It might also not offer the patient the ability to correct the bill. The result is revenue that is no longer billable.

Outsourcing to third-party offshore vendors is another low-cost option for billing. Language barriers, lack of follow up on worker’s comp and patient calls, and errors regarding refunds and credits, are pitfalls to look out for. Internal audits and mini audits throughout the year should be implemented to manage those situations much more closely.

“A price only emphasis has gotten us where we are now,” Kroken said. She suggested a balance of intelligent automation backed by a skilled workforce is the ideal mix. “You can trust most of the time but verify often.” Paying more to get more may be the best option.

An overview of reimbursement and billing updates in radiology, from experts at RSNA 2016.

Reimbursement, Billing in Radiology: Updates and Issues

When it comes to quality and value within radiology, the ability to achieve positive results consistently relies heavily on collaboration and inclusion within the patient’s care experience, according to industry experts during the Quality Improvement Symposium at RSNA 2016.

Combining the value proposition within radiology of doing the right thing for the right patient at the right time with a patient- and family-centered care experience and cost awareness, Ella Kazerooni, MD, MS, director of cardiothoracic radiology at the University of Michigan, said, can make radiology providers the common champions of value.

“Pretty much everybody in this room has been a patient, is a patient, or has a friend or family member who is a patient,” she said, asking the audience to step away from their health care shell and imagine the impact, apprehension, and loss of control every patient feels walking through the doors of their health care provider.

“How would you want to interact with your health care system, your radiology department, and your providers?” she asked. “What would you want to know?”

The Evolution of Radiology Quality Performance


“Health care has changed tremendously at a pace that continues to accelerate, leaving physicians struggling to find value and drive quality improvement without knowing exactly where they are going,” Kazerooni said. She acknowledged a shift away from the “chaotic, doctor-knows-best” culture that existed up through the early 70s to the “standardized, fast-paced” culture of “one size fits all categories” which involves large data access and the beginnings of quality improvement accountability experienced into the 2000s. Today’s world is moving towards a place where, “we are now drilling towards individualized care whether it’s  personalized, precision medicine using data analytics or personalized patient- and family-centered engaged care, we as radiologists are trying to figure out how to keep up with this evolution,” she said.

Current competition, both within and outside of radiology, that offer imaging-based services or threaten automation are drivers for radiologists to differentiate and distinguish themselves. Threatened by groups that demonstrate their value through marketing, she said, “Radiologists should be re-associating themselves with their patient base and directing care for patients.”[[{"type":"media","view_mode":"media_crop","fid":"56238","attributes":{"alt":"Qualty improvement in radiology","class":"media-image media-image-right","id":"media_crop_6782988836623","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7063","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 133px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©phoelixDE/Shutterstock.com","typeof":"foaf:Image"}}]]

Radiology has evolved into a team culture that provides a continuum of care. Every person on the team that interacts with the patient should be part of a quality improvement project, from the front desk to the technologist and the physicist.

“Quality metrics are now externally imposed and we have an accountability to respond to them,” Kazerooni said. She named HCAPS scores, billing accuracy, developing high quality reports, and exam appropriateness as examples of quality drivers that are becoming directly tied to certain physician reimbursement models as well as referrer satisfaction.

Patients’ Perception of Quality is Different than Ours
“

Value in health care is quality plus service over cost,” she said, or more precisely, “value equals what you get for what you are willing to give or pay.” But what radiology providers’ perceptions of value are has not been aligned with what patients say is important to them. Ninety percent of what a patient finds valuable during their experience involves the non-medical aspects, according to Kazerooni’s work with the ACR’s Patient- and Family-centered Commission (PFCC). Defining value in today’s patient-centered world involves asking patients the right questions and involving them in solutions.

The PFCC has patient members consulting, advocating, and speaking openly about their experiences. Kazarooni said that most patients want to be able to speak to a radiologist about their results if necessary, they wanted to be engaged and a part of the decision making, and they wanted patient portal access to their health records electronically. Excellence in service is important, from interactive communication tools to follow up thank you notes from radiologists, patients want the level of customer service they would receive from other service industries.

What Will Radiology Patients Demand in the Future?


Looking to the future, James R. Duncan, MD, PhD, FSIR, vice chairman of quality and safety at the Mallinckrodt Institute, expects patients by 2025 to want more and better from every aspect of health care. Including better integration, better tailoring to the individual, more transparency, and more predictable outcomes.

Duncan said we will be working with more patient data than ever before, generated by electronic sensors including smartphones with attachments, wearables, and imaging bedside devices. “We will face a potential medical data overload with an anticipation of data doubling every 73 days by 2020,” he said, concluding, “health care has a big data problem. We are drinking from the firehose.” Automated data collection systems like Watson will improve how small, meaningful pieces of data can be grasped from such large sources to help make clinical diagnosis, he said.

“During stressful times, humans want to interact with humans because there is a need for empathy,” he said, sharing that improved machinery will combine forces with humans, not replace them.

Stronger predictive business analytics will be able to find value and quality encoded within patterns of care. Duncan predicts that future patients will demand itineraries that explain their health care journey with a series of expectations and predictions that provide a timeline back to normalcy.

Measuring quality and value in 2025, Duncan said: “we must look at care as a sequence of events, bring evidence that our message was accurately received, decoded, and used to solve the problem in an efficient and effective manner while having a direct impact on outcomes.

Experts predict radiology’s future is dependent on improving quality. 

Quality Improvement in Radiology

“When you think of your own physicians, it’s not that outrageously high of a number to think that 50% of your own practice may not even know what MACRA is,” Ezequiel Silva, MD, vice chairman, ACR Commission on Economics, said at RSNA 2016.

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 is a 

 (QPP) with two tracks beginning in 2017 for those practices that bill Medicare patients.: the advanced payment model (APM) and the merit-based incentive program (MIPS).

“We are being judged with all other physicians in medicine,” Silva said. He clarified that the statute recognizes two categories, patient facing and non-patient facing physicians. Radiologists must ask themselves which category they consider themselves to be in.

“We believe we are a patient-centered specialty, however, there are clearly advantages to the statute classifying radiologists as non-patient facing,” he said, noting that there were reduced measures more easily attained and focused solely on quality and improvement actions for those non-patient facing participants.

“Radiologists that report to CMS as an individual and have more than 100 patient-facing encounters within a year or report as a practice where 75% or more of the group has patient-facing encounters will be classified as patient-facing,”  Silva said. EM Codes are considered patient facing and certain procedural codes such as breast biopsy, paracentesis, TIPS, and other IR procedures may be considered under the category once CMS finalizes the statute.

Regardless of classification, in the first performance period of 2017, neither category will be judged on cost. The strongest weighting factors will be those focused on quality, making up 85% of the non-patient facing factors and 60% for patient facing.  Reporting will be judged on six quality measures, including one outcome measure, and can be reported through a claim or registry based system. [[{"type":"media","view_mode":"media_crop","fid":"56070","attributes":{"alt":"Ezequiel Silva, MD","class":"media-image media-image-right","id":"media_crop_8132763665610","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7039","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Ezequiel Silva, MD","typeof":"foaf:Image"}}]]

Discussing the other key component to QPP required by both categories, improvement actions, Silva shared, “

 is the next potential option for us. It is clinical decision support-based and educates physicians. There is no downside to putting this in place upfront.” This method or the use of 

Silva shared that radiologists should be asking themselves where they want to be within the program on day one given the opportunity granted by CMS for physician determined pacing. Looking towards the future of payment policy related to improvement actions, “we have to embrace patient-centeredness,” he shared concluding, “It is not just terminology. It is a requirement.”

“We always knew that the important thing that was going to incentivize us, make it scalable, and make patient-centered care last was going to be crafting meaningful incentives that we could support doing,” Geraldine McGinty, MD, MBA, of Weill Cornell Medicine, who works alongside Silva on the ACR Commission on Economics, said.

Discussing the evolution of patient-centered care within radiology, McGinty said there has been a culture change over the last four years from doing to and doing for, to doing with. With the ultimate goal being shared decision making, McGinty said, “We are now bringing patients into the discussion.”

The ACR introduced Imaging 3.0 as well as the Commission on Patient- and Family-Centered Care to educate and share information while increasing visibility and patient community collaborative efforts. “CMS now actively contacts the ACR to get feedback on policies,” she said, which opens up a new, more collaborative relationship with policy makers.

There are many patient-centered opportunities within both the quality and improvement outcome categories, shared McGinty, who stated even tying a relatively small percentage of the payment pool to improvement outcomes related to patient-centered care results in a seven-figure sum for her practice. “That really starts to give us energy about what we might do differently,” she said, noting that it is important to think about the metrics process, which will be ongoing.

“Developing metrics around patient engagement and satisfaction in radiology gives us a huge opportunity to craft meaningful metrics around the type of care we want to be giving our patients,” McGinty said. Sharing valuable tools including Image Wisely and R-Scan allows radiologists to be the stewards of imaging in the short term. Focusing on the long term, radiologists can continue to focus on the quality domains to drive visibility and change improvements that directly impact patients. Creating visibility through photographs and communication tools as a patient enters an imaging center, direct patient access to reports, fostering collaboration with patients through tumor boards, design teams, and advocacy, and having radiologists serve on hospital ethics committees increase value that will help define future metrics.

“Every time I talk to the patient, I get an opportunity to make sure the patient is getting the image they need as well as a conversation with the patient that is meaningful to them,” McGinty said, who noted that engaged patients statistically do better on metrics, including readmissions. She concluded, “nothing is more energizing than interacting with patients. It’s the right thing to do and it feels really good.”

Experts at RSNA share what radiology will look like with payment reform.

Radiology in the Era of Payment Reform

The integration of health information technology (IT) into the everyday practices of radiologists has paved a new pathway of entrepreneurship for a unique niche of physicians who have used their professional clinical expertise coupled with informatics savvy to produce solutions to key efficiency problems. Two successful radiologist entrepreneurs shared their journeys of success at RSNA 2016.

, acquired in August 2016 by Nuance Communications, is one example of a smaller start-up that began with an idea in 2009 when William Boonn, MD, CMIO at Nuance, used the real-world challenges of running a radiology department coupled with his own informatics background to develop a radiology data mining and analytics tool that could increase efficiency.

“I am motivated to solve problems and enable others to do the same,” Boonn said, sharing that Montage had its first customer in 2010, went through several rounds of funding and was eventually acquired this year after maturing to the size of seven employees, 148 customers, and over 300 million indexed reports across customers.

Boonn equated the successful growth and acquisition of his company to timing, the number one differentiating factor for success of start-ups according to a study serial entrepreneur 

 conducted. Combined with a trusted team of colleagues from the University of Pennsylvania and his professional network, Boonn said they had time to grow the product the way they wanted to initially. By getting a customer first and doing his own sales and presentations, he shared that this boot-strap method gave the team latitude and mobility to be flexible with no undue pressure from board members in the beginning.[[{"type":"media","view_mode":"media_crop","fid":"54970","attributes":{"alt":"Entrepreneurship","class":"media-image media-image-right","id":"media_crop_9134974023791","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6880","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Vector Goddess/Shutterstock.com","typeof":"foaf:Image"}}]]

Ultimately, entrepreneurship is a gamble, shared Boonn, who confessed that an idea is not enough and offered these helpful tips to his fellow radiologist-entrepreneurs:

“Especially if you are currently working within an institution, everyone will take notice if you begin to succeed,” Boonn said. Read and understand the employee handbook and understand what you can and cannot do within the confines of your role.

 Create a paper trail of emails and communications that demonstrate your actions related to your start-up are in line with the employee handbook.

Whether it is an internal champion such as the chairman of your department or early customers and industry experts, Boonn said that support is invaluable.

 “Customers are willing to pay for a product that works,” he said. Montage had customer users, a prototype, and could demonstrate measurable success which made it attractive to investors.

 With most start-ups ending in failure, Boon said that differentiating what your goal is from the beginning will help define the trajectory of the product. Some prefer “intrapreneurship” where one prefers to work within an organization without having to quit their day job, while others may be seeking the opportunity to change the world or receive a big payout.

On a much larger scale, Paul Chang, MD, vice chairman, radiology informatics, University of Chicago Medicine, is a self-professed, “accidental entrepreneur,” that had no intent to sell or create a company. Working at the University of Pittsburgh Medical Center in the 1990s, Chang was put to the task to help his organization go digital. What would result from those efforts was 

, a multi-million dollar company acquired by Philips Electronics in 2005 as one of the leading PACS systems on the market.

“Deep down, this was an impossible task but I was too young and arrogant to know that I couldn’t do it,” Chang said, who shared he had $15 million to play, over 2 million annual studies that needed digitizing, and a short-sighted plan. Chang said he achieved digitalization but failed to understand enterprise imaging. As a result, the department lost money through continual film costs because of the inability to distribute images to clinicians throughout the rest of the hospital.

Adopting an R&D approach, Chang went back to the clinical areas, researched clinician needs, and came up with a distribution solution that was ultimately a huge success. It saved U of P millions annually, and was adopted by many organizations within a short time frame.

“Back then it was a lot harder to build useful things,” said Chang, who shared from his own early mistakes that successful start-ups require a market-driven product versus a technology-driven one. Agreeing with Boonn that “you must be able to reproduce success,” he shared, Stentor ran successfully for three years prior to acquisition. Rigorous validation is a must.

“The product must also be transformative,” said Chang, noting it should be a “must have” not a “nice to have.” Great ideas can fail due to many reasons including dependencies on local systems. “There is no one right way to succeed,” he said, noting the overestimation of value, lack of intellectual property protection, or the use of shortcuts during build are pitfalls to avoid.

“The real success of a company is not your idea, it is those you trust to run it,” Chang concluded. “Maintain as much influence as you can but know when to let go of your baby.”

From the trenches of radiologists-turned-entrepreneurs, as told at RSNA 2016.

A Tale of Two Radiologist-Health IT Entrepreneurs

“There is fatigue around the word ‘value,’” Richard Heller, MD, national director of pediatric radiology, Radiology Partners, said at RSNA 2016.

Citing colleague frustration with overuse of the buzzword in medical journals and conferences, Heller said there is a reliance on value and what radiologists should care about is the measures used to quantify value.

“I think we are in the first mile of a marathon and we have just begun,” he said. Today, talks surrounding value should concentrate on the details and how the stressors in a radiologist’s world directly affect value. From payer and hospital consolidations to change in payment models and disruptive technology, there are many stressors that can diminish value and create further inefficiencies, Heller shared, who spoke about the role value plays in reimbursement.

Value-based payment models cover an increasingly larger volume of patients each year, including many of the 73 million Americans who utilize Medicaid annually as well as other governmental and private payers, he said. “This is clearly the trend on both the public and private sides of the fence and affects every radiology practice,” Heller said. “The value-based payment ship has already sailed and we are on it.” Using metrics to quantify value is essential.

He discussed further the two current value-based payment models most practices use related to the Medicare Access and CHIP Reauthorization Act (MACRA) passed in 2015, Merit-based Incentive Program (MIPS), and the alternative payment model (APM). Current systems are often homogenous and focused more on primary care, he said. Radiology’s uniqueness requires a pay-for-performance model that would ideally be meaningful to patients and outcomes, realistically measured, and under radiology’s direct control.

While Heller acknowledged that most radiologists currently use the MIPS scoring model under a non-patient facing category that incentivizes through the two measures, quality (85%) and improvement (15%), “MIPS has confusing rules, an asymmetric field of play, and there are ways to game the system by altering templates,” he said.

Thus, Heller said he sees the future shifting to a special subset APM known as an advanced APM that removes radiologists from MIPS requirements, offers a 5% bonus annually for many years followed by a future annual increase that is three times the size of other physicians who are not participating in an advanced APM.[[{"type":"media","view_mode":"media_crop","fid":"54748","attributes":{"alt":"Richard Heller, MD","class":"media-image media-image-right","id":"media_crop_5557944777911","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6858","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 242px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Richard Heller, MD","typeof":"foaf:Image"}}]]

“CMS is trying to use a particular kind of carrot that is clearly trying to incentivize us to go this way,” Heller said. He noted, to CMS’s credit, they recognized that the starting point of an advanced APM is primary-care focused and that they needed to get other specialties involved. Creating a pathway that radiologists will most likely follow, Heller said physician-focused payment models (PFPM) in which Medicare is the payer to a physician or physician practice that’s finding a new way to deal with quality and/or cost.

If you have a PFPM that can fulfill the criteria required for an advanced APM including the active use of certified electronic health record technology, quality measures in place, and some level of financial risk, Heller said your PFPM automatically becomes an advanced APM with all the benefits associated with it, which is a goal radiologists should strive for.

Physician-Focused Payment Model Technical Advisory Group

 (PTAC), made up of 11 committee physician members, has developed a criteria for PFPM models that will help broaden APM’s to include under-represented specialties, such as radiology, Heller said. “We are kind of the belle of the ball,” he said. PFPM’s that are creating bundled payment initiatives can satisfy their requirements by including radiology where it is relevant, as well as identifying radiologist’s contribution to cost with the 

“APM is where the future wants to go and I think it is where it probably should be going,” Heller said. He offered two ways to look at where radiology currently stands in relationship to value-based payment: “You can see this as the view in the rearview mirror with the sun setting, it was a great run but that day is over,” he said, or alternatively, “You can look at the road ahead, the sun is rising and it is a new day. Yes, I expect there to be significant challenges, but I also expect wonderful opportunities for us, for our patients, and for the system.”

Seeing ‘value’ for the buzzword that it is in radiology, from RSNA 2016.

Making Sense of ‘Value’ in Radiology

“The radiology report is the clinician’s primary gage of our value and sometimes it is the patient’s only interaction with us,” Curtis Langlotz, MD, PhD, medical informatic director for Radiology at Stanford Healthcare, said during a standing-room-only session at RSNA 2016. “In the end, it is what we are paid for,” he said.

Providing a brief, clinically relevant, and consistent report is the goal. Developing best practices around precise and accurate reporting include establishing a routine, using short, declarative sentences, and providing summaries within the report that can stand alone.

 expert on radiology reports, Langlotz confirmed that only 38% of clinicians actually read the entire report. “It is important for the summary to be good because very few people will go through and read the rest,” he  said, so it should contain a list of significant findings in their order of importance, as well as integration between findings, and it should answer the clinical question.

The summary should also eliminate lengthy explanations and information that is not relevant or supported by clinical information. “There is a cost to extraneous information,” said Langlotz, who believes report readers are in a hurry and need the most efficient information.

Word or phrase usage is highly important and certain phrases don’t always give a strength and direction to findings, such as saying “findings are consistent with a specific disease”. Likewise, the use of post-test probabilities is not wise if there is not a comparable pre-test probability to relate it to.

Inversely, when a radiologist is certain of a finding, “normal is a powerful word,” said Langlotz.  “It means that all abnormalities have been considered and excluded, it’s a definitive answer, and it’s good for the patient,” he said.  It offers no additional medical or legal risk and is much more effective than the use of the words “unremarkable, within normal limits, or essentially normal.”  

Using the word “normal” also helps to answer the key question a clinician is asking, “how is this exam different than normal and should I care?” he said and ultimately saves them time.

Additional tips to creating a high-quality report included:

Anatomy such as the aorta for which there is clear literature to indicate risk is one example of an important measurement. In cases in which there is not a clear reason or methodology to measure quantitatively, there should be a consistent expression of size such as “trace, small, moderate, large, extremely large,” Langlotz said, noting to stay away from words like “tiny, prominent, chunky, or inconspicuous.”[[{"type":"media","view_mode":"media_crop","fid":"54442","attributes":{"alt":"Curtis Langlotz, MD, PhD","class":"media-image media-image-right","id":"media_crop_2737946844286","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6815","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Curtis Langlotz, MD, PhD","typeof":"foaf:Image"}}]]

“I personally have trouble distinguishing even five points of severity,” he said, noting “mild, moderate, and severe,” as key points of reference. Linking severity to specific imaging features or to literature that establishes a grading scheme establishes consistency.

Langlotz is not a fan of using this term in a report. He shared that clinical correlation is what a clinician does, like radiologists looking at images. “Think about whether clinical correlation can actually solve the diagnostic dilemma before using it,” he asked, offering the ability to suggest diagnostic options based on clinical correlations instead when relevant.

A style issue to avoid at all costs is the use of phrases such as “is seen,” “identified,” “appears to be present,” or “is known to be made of,” because they imply, “if there was a better radiologist in the room they might see it but I didn’t,” Langlotz said.

Phrases including “non-specific, cannot exclude, cannot rule out, and consistent with,” Langlotz said to steer clear of due to their ambiguous nature. “Now that patients increasingly see their own reports electronically,” he said using emotional content within a report, including stating a patient’s disease has “surprisingly” not spread, is unnecessary.

“Not much has changed within the last century with radiology reports,” concluded Langlotz, who said the form is fundamentally the same despite new technology trends.  It is important to ask, “As we move from measuring volume and being paid by how many reports we do to being measured by value and quality, what is the role of the radiology report in a post fee-for-service world?” he asked, pondering ways information could be delivered differently versus reporting on each singular study.

How to ensure a meaningful radiology report, from RSNA 2016.

Radiology Report Best Practices

Navigating through the skills required to succeed as a new radiologist reaches far beyond the interpretation of images and begins even prior to landing that first job, Michael Veronesi, MD, PhD, said at RSNA 2016.

Currently in his second half of a neuroradiology fellowship, Veronesi ssaid that burnout is a real problem in medicine and over 50% of radiology trainees suffer from at least one symptom of burnout. The culture of expectation, emotional intelligence, and onboarding support that imaging practices offer new radiologists can make all the difference.

Asking the right types of questions during job interviews leads to higher job satisfaction downstream and offers ways to find the right fit while maintaining a level of personal control. Veronesi suggested asking the hiring team about the safety of the practice, work/life balance, practice stability, and individual contributions. These can offer insight into the dynamics of each potential position and decrease the risk of burnout.

Sharing an ACR Imaging 3.0 initiative that each radiologist has the ability to affect the culture and success of the group whether he or she holds a leadership position or not, Veronesi said ideal prospective employers offer leadership development, understand physician wellness, and cultivate emotional intelligence.

“Each time a new radiologist joins a practice, it is an opportunity to reexamine the work environment and how everyone is treating each other,” He said. Burn out can be salvaged through good emotional support and a team that brings out the best in each other.

Brent Wagner, MD, West Reading, PA, agreed that matching the appropriate radiologist to the right circumstance is imperative for success. Having been a leader in private practice for over 15 years, Wagner said: “I wish I had more people to advise me along the way. I still consider myself a developing leader. I make mistakes. I’m imperfect and evolving.”

Onboarding takes time and patience and there should be communication upfront between practices and their new radiologists regarding cultural expectations as well as inclusion and transparency regarding financial reports and decision making.

To create a successful onboarding process for new radiologists, Wagner stated practices should have these key attributes:

The practice should have a history of fair treatment. Providing the same formal contracts and bylaws for each employee, fairness should be the goal culturally in the group.

Both new hires and seasoned members of the team need to be patient with one another. New hires need to know that their ideas are important but there is a balance between innovation and disruption. Employers also must empathize and realize that both teaching and learning are hard.

 There should be group governance in place from chairman to president and beyond that form a democracy and recognize each individual role along with the unique qualities they bring to the group.

Offering new radiologists a well-selected contemporary who is approachable and relatable to discuss common struggles openly and honestly.

Once hired, practices need to understand there are currently four active generations in the work force with very different generational values, from the older traditionalists and baby boomers to the younger gen X and millennials is essential to sustaining career success,” according to Anastasia Hryhorczuk, MD, pediatric radiologist, Tufts Medical Center.

“Leaders may expect younger radiologists to have similar work styles,” she said, acknowledging that older generations are known to be more loyal “company men” or “workhorse” types and less focused on lifestyle balance. This can end up being reflected in department hours, promotion hierarchy, and call distribution.

Despite generational differences, Hryhorczuk said new radiologists can improve their work environment by clarifying expectations with their employers from the beginning, such as call, daily hours, and work/life balance.  Considering other generations’ perspectives and learning from them is key. “Play to your strengths both clinically and professionally,” she suggested, and look for areas of openness to implement gradual change or gain efficiencies.

“It’s not a 4-week rotation,” said Hryhorczuk, whose motto during residency was to just keep swimming. “Sometimes the pool gets a little small, sometimes you are a fish out of water, but eventually you can turn your job into a home where everyone can be happy.”

How new radiologists can find the right practice, from RSNA 2016.