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.

Julie Kaufield, MA, RT(R)

Articles

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

Administrator Focus: Payment Models

Business Analytics Improves Operations, Quality, Clinical Performance

Reimbursement, Billing in Radiology: Updates and Issues