Richard Woodcock, MD

The monthly numbers. All businesses have them. And everyone worries over them. For radiology, everyone wants to see total study numbers, total billed dollars and reimbursement. It’s natural. But it is insufficient.

A few additional pieces will give you and your group much greater clarity about the practice’s health.

• Year to year comparison is essential. We commonly see a drop in reimbursement in January and August, and everyone is alarmed when they compare to the prior month. But when you look year to year, the numbers may actually be up. The numbers are down due to seasonal variation and contraction. In fact, business is good. Ideally these can be benchmarked with national trends for similar reasons. It is one thing if everyone in your region (or nationally) is losing ground; quite another if it is just your practice.

• Aggregate data is great. But some granularity is needed. Your practice might see growth overall, but where is it coming from? You may have a drop from one center and a rise in another, with a net increase. That’s great, but doesn’t help you figure out where to turn your attention and who is sending you more or less business.  Do you have in- and outpatient business? Give data for both. Do you provide service for independent outpatient centers? Hospitals? Both? Split out data for each.

• Exam numbers are also great. But can be misleading. We’ve had days, weeks or months with big numbers, but sometimes due to tons of plain films. Provide these by modality and center, if at all possible.

• Provide each group member with total reads for themselves and the group average. Each individual’s data need not be shared. Include gross studies, RVUs, billed and reimbursed dollars for the greatest breadth of understanding the meaning. Again, use of national benchmarks is ideal.

• Keep track of and include your payor mix - are you seeing a drop in one area? A rise? This can guide your marketing efforts and allow you to intervene if you’ve been dropped from a provider list.

• Show everyone reimbursement rates for different centers or contracts. Are you seeing growth in contracts with fixed reimbursement? Are those rates good compared to the reimbursement you are seeing for those you bill insurance? Are you getting increased numbers where you have slightly better (or worse) payor mix?

Seem like a lot of work? It is to set up, but once you have a methodology to extract the data, it actually is not onerous. You can’t make good informed business decisions on staffing, marketing and business development without data such as this. If you try to, you’ll just be lucky if you hit the mark. A well-run business is knowledgeable about itself.

Articles

To run your practice well, you need to know your practice well.

The Numbers in Radiology

Earlier this year, some of my neighbors asked me about an op-ed they had read in the 

. In it, the commentator made observations about the overuse of radiation in medical testing. For these friends the responses were, to me, both rational and irrational concerns and questions. One of them observed that she would never forgive herself if her child, who had a head CT after a concussion, developed cancer one day. So it’s good that it started a dialogue about an important topic, but also concerning that it might result in people being hesitant about getting necessary tests.

Lots of attention recently has been directed at the use of radiation in medicine. In part, this stems from increasing availability of information. It also stems, in part, from recent commentaries, like that op-ed piece earlier this year. The concerns are related to the noticeable increase in use of CT in particular, from several population studies suggesting possible increase in cancer rate from use of medical radiation, and from several cases of radiation injury. While it is true we image far more than we did 30 years ago, that is somewhat unfair given that CT is new, and CT scanners have improved in quality and geographic distribution, improving their availability and utility. In addition, pretty much all forms of technology are used way more decades after development, (are we over using airplanes? – we use them way more than we did in 1970 – and there are more accidents). But we also use radiation to diagnose aortic dissection, pulmonary embolism, intracranial hemorrhage and accurately diagnose diverticulitis, and appendicitis, earlier, with better outcomes, for patients with those diseases.

Looking at CT as an overused cancer-causing technology clearly only looks at one side of the coin. CT quite simply saves lives, cost and time. That has to be weighed against any potential risk. What we should not do is incite a general panic and resistance to use of the technology. What we can and should do, is be cognizant of its limitations, improve its safety – reducing its risk – and educate users, both patients and providers. You say you are not a policy maker or blogger? Maybe so, but that doesn’t mean you can’t have an impact. Here is a brief action plan anyone can follow.

• Support public education on doses and appropriate use of medical imaging with radiation

• Educate providers about non-radiation options and encourage them to engage patients who have had multiple tests as to further options

• Insist on patient advocacy to your colleagues and referring practices, and act as a gatekeeper

• Support society and national standards and regulation of same

• Promote and support research regarding radiation effects, especially in defining what is presently only a loose association between use of radiation and cancer in historical population data

• Remain vigilant and cognizant about overuse and be particularly sensitive to that in our youngest patients and in the chronically ill, who can accrue larger doses of radiation over time

• Continue to emphasize safe use of CT to your friends and patients, and its undoubtable importance in medical imaging as well as reduction in morbidity and mortality

• Hold society and politicians feet to the fire in forming reasonable malpractice standards to avoid the use of radiation-requiring tests for medico-legal reasons

• Be active in development of reasonable appropriateness standards, tied to outcomes that might form a basis for third party approvals or denials and reimbursement 

Radiologists need to play their part in educating the public about radiation. 

Radiologists Can Help Put Fear of Radiation in Perspective 

Many of you have heard of Schrodinger's cat. It’s the hypothetical physics problem that posits a cat in a box could be both alive and dead simultaneously, until you open the box, observe it and find out which is true. Like this, radiologists often send out reports to the netherworld of physician offices, never knowing if they are helpful or not, and thus not knowing how well we are doing our job - because we rarely observe the end product’s results.

For years we’ve thought of measuring ourselves by productivity. Doing this with the number of studies read, or RVUs or billed or reimbursed dollars and comparing them internally or to statistical norms very well may still be a valid part of determining value; I think it is. But that is not the whole story, and may not provide the right incentives all the time. Quality of care, communication skills and relationship creation and management, administrative and business task completion and leadership, all form parts of the value of a radiologist. The days of “I just want to come in and do my work” (ie, read films), may have passed. Those that want to work that way better be really productive, or they are a liability. For your practice, that can be a challenge, as those providers who read a lot often see themselves as most valuable, and have a hard time seeing or measuring the benefits indirect or non-clinical care can offer. It is critical for practices to emphasize that in the end, it is not the amount of work done, or technical proficiency, (what you might call our ‘input’), but actually how useful the work we do is to our patients and clinicians that is our true value (what you might call our ‘output’). Like the cat, what we are, is how we are looked at after the report arrives and the patient is managed.

When analyzing the totality of contribution, some metric for direct work productivity is a necessity, and a combination is probably best. Again, number of studies read, reimbursed dollars or RVUs are important. Quality metrics are critical too. They include basics like turnaround time (TAT). Other factors must be included but are tougher to come by. Measuring the quality of care in those direct interactions is trickier but doable. Data on peer review is a start. Whatever the scale, keeping track of how each provider measures against others with regard to minor and major disagreements is helpful. Information on quality of communication is also a challenge but available for those who want to get it. For instance, survey referring physicians - how often does the provider call you when you think they should? How are your interactions with them? How would you grade the usefulness of reports? So too, must there be feedback on interactions with imaging partners such as hospitals and imaging centers with which you work. Measuring administrative tasks has always been contentious in my experience. Some things are more banal and might be amenable to measurement as simply ‘hours worked.’ But for most things, there should be some effort to regularly determine how effective the administrator is. Measure business growth year to year, but use industry comparisons as benchmarks to account for business cycles. Survey the practice partners to assess communication skills, innovation, confidence and leadership for one another. Ask how useful and necessary certain administrative tasks are felt to be.

This is only a start and a meager one at that, I’d guess. In the long run, we should be looking to find out what measurable impact our radiology work and practice efforts have on improving the care of patients, something we have a very poor handle on at present. A system that accrues data for when a radiology report alters care might help us determine this clinically. Measuring our benefit in less clinical ways is also challenging at present. We have, as a surrogate, how useful our work seems to referring providers and colleagues by qualitative methods as I mentioned above.

So why is it valuable to do this? Because not evaluating it leads to stagnation. Like Schrodinger’s cat, when we look at something, it becomes defined for us. The ‘something’ here is our output (ie, or usefulness, not our input, ie, effort). Once any aspect of our output is measured, there is natural human instinct to improve on the measurement. That measurement has to go beyond the easy direct stuff. Because including indirect components validates the methodology for everyone, and vests people of more diverse productivity types into the process. Refining it will only help us all continually improve our usefulness. That should be the goal for us all.

Our original measurement of productivity no longer defines how useful we are.

How Do We Determine The Radiologist’s Value? 

Two financial news items grabbed the attention of many of us recently. First, an annual salary survey showed that radiologist salaries are declining. The reasons for that are myriad and we’ll talk about them another time. Second, CMS released physician payment data. Of course, at these times I reflect on why I chose medicine and radiology. I chose medicine because I honestly think my role is to make the lives of others better and easier. I probably chose radiology for several reasons: intellectual stimulation, interest in technology and its increased use in healthcare and a little hesitancy about how I’d handle close personal relationships with patients. We’ll leave the last one for a blog on psychology.

Right now I keep refocusing myself on the other reasons I chose medicine and radiology; that is, non-monetary rewards. It definitely frustrates me at times to see that there are industries where it is apparently fine with society to suck the financial life from the rest of us. But when it comes to medicine, that is frowned upon. I stared at my Medicare average pay per patient the other day (yes, if you haven’t done it, it is super easy to see your CMS data) and didn’t know if I should laugh or cry. It was $50–$60 per patient. I had just had a repair guy come to fix my garage door. He “required” $75 just to look at the door - you know, a diagnostic evaluation. Seriously, the system allows him to charge more than I do?

After paying back $120K in debt, and giving up 20 percent of my adult earning years to training, I’m pretty confident that this is not financially right. So what does that mean? Why am I doing this? The answer is back in why I started doing this. I’m not going to pretend I didn’t expect (and get) a good salary. But I knew when I started this, it wasn’t the easiest or best way to make a buck. Rewards come in all sizes and shapes. I get them from professional respect from patients, peers, friends and co-workers. I get them from job and intellectual satisfaction. I get them from knowing I tried to help someone every day, really and tangibly. I get them from integrity - staying true to myself.

I’m not suffering financially... and I’m not soaking every penny I can from society either. That doesn't mean I won’t try to get paid every dollar I’m worth in society’s eyes, using the current system. But it does mean the yardstick I compare myself to isn’t the electrician, the investment banker or anyone else.

Radiology might not be the best way to make a buck, but its rewards come in all shapes and sizes.

Richard Woodcock, MD

Articles

The Numbers in Radiology

Radiologists Can Help Put Fear of Radiation in Perspective

How Do We Determine The Radiologist’s Value?

The CMS Data - Should I Laugh or Cry?