Article – Imaging Shift to Hospital Outpatient Facilities Concerns Radiologists

Following my post on consumer choice in imaging services, in which I asked how do we use quality—and not just cost—to help consumers make choices, I found some observations in this article on the shift of imaging being done in imaging centers to outpatient facilities to be quite interesting.

For example…

“groups at imaging centers may struggle to upgrade or get new equipment, which could affect image quality and interpretation”

So, how do I, as an imaging consumer know which provider has modern, safe, calibrated equipment, operated by qualified and skilled operators when making my choice of where to get imaging done?

I don’t ask my dry cleaner about what equipment they use, or when it was last serviced, or how much experience the person in the back doing the work has. Nor to I ask these questions about my car wash.

I often make choices in dry cleaning and cash washing based on cost, but more so convenience.

But this is my health and it is my body going through that device, not my clothes or my car.

I wonder how many people will simply trust that a friendly receptionist, flowers and nice magazines in the waiting room at a facility near where I work means quality and safe imaging. If I have a good experience during my imaging appointment, but they miss important findings due to low quality images (or lack of sub-specialty knowledge/training), how will I know?

Unlike a spot that doesn’t come out of my shirt or a still dirty section of my car, the consequences can be severe.

Putting the Power of Choice in the Hands of Healthcare Consumers

As reported in this Healthcare Informatics article, The Health Care Cost Institute, a non-profit organization based in Washington D.C., is making data on healthcare costs from 40 million insure individuals available for use by consumers to help them understand pricing information for common health conditions and services.

As I have blogged about in the past, providing the consumer, referring physicians and employers with tools to help them make choices about where to get affordable and market competitive healthcare services will be a growing trend.

Of course, to measure the value of something based purely on the cost assumes the product or service is a commodity. In the world of medical imaging, this is not the case.

Should an imaging service provider that has 15 year old equipment, no radiation dose tracking or optimization program, no sub-specialized Radiologists, and no peer review program (for quality assurance and ongoing learning) be paid the same for a procedure as a service that has all of these things (and more)?

Unless there is some consideration of quality in calculating the value of the money spent on a service, like medical imaging, then prices will be driven down to a commodity level and there will be no funds available to invest in the tools and resources required to provide quality. The math of economics is pretty unemotional about this stuff.

Creating Practical Value in Practice (of Radiology)

There is a lot written these days about the shift from volume-based to value-based in Radiology (and other medical specialties).

The thing is: volume is real easy to measure. And what gets measured, gets managed.

So, how do we measure value?

One can measure the time it takes to complete the report, sign it, and make it available to physicians and other members of the care team. Radiology practitioners call this Turnaround Time (or TAT). This is pretty easy to do.

We could try to measure whether the report is correct. In other words, is what the Radiologist concludes actually what is wrong (or not wrong) with the patient? This can be harder to measure, as it may take a lot of work to correlate many different data points, or a lengthy period of time for proof to be found.

There are a couple of activities that Radiologists, and other people working in the department, can do to improve the perceived value of Radiology.

In this article, a number of suggestions are made as to how to increase the visibility of Radiologists, as well as improve relationships and trust among other physicians and even patients.

And this WSJ article focuses on simply improving the clarity of the report by improving the language and writing skills of Radiologist. Seems obvious as to the value this would provide, when you read it, but how many Radiologists routinely attend training on how to communicate better?

While improving how Radiologists interact with the outside world—whether through better interactions or better writing—will help the Radiologist’s career, one would hope that it would also improve care. Better communication certainly couldn’t hurt.

Article – Who is the better radiologist? Hint, it’s not that easy.

I really enjoyed this article. It gets into the specifics of what we could mean by quality of Radiology reading.

I think it gets to the crux of the problem in any domain when quality is desired—a trade off is necessary. It may be cost, or it may be the experience of the user, but it will be somewhere.

Let’s use a similar evaluation in software development.

Coders that are fast are lauded as innovative and bright and creative, until their barely-tested and unscalable application fails in operations, or a security hole results in a data breach. These folks are often called “hackers” (but generally in a positive way).

The more thorough developer is criticized for taking too long and keeping the application in the lab (instead of the “real world”) for too long. They spend significantly more time in the design and testing and documentation areas, so to outsiders, they are slow. Their products take more time (missing some early opportunities seized by hackers), but the applications are much more reliable and supportable in operations. They are professional software developers.

As someone that has managed R&D teams before, you always want both behaviors (and results), but as the article posits, you often cannot have both. You certainly shouldn’t expect to get both.

I often say: Decisions are easy (I decide I want innovation and reliability, and I want it fast), but Choices are hard. I value people that can make choices, and live with them, much more than so called “decision makers”.

Article – CDC on EHR errors: Enough’s enough

In this article, the CDC has issued a warning on the issues of user interface design when presenting patient information in EHRs.

As the examples in the article illustrate, having information in digital form is not enough. It needs to be presented in an effective way to ensure comprehension. After the current wave of information digitization and consolidation (moving information from disparate, departmental clinical information systems into a single large enterprise system), the next wave of effort needs to be on privacy/security, accessibility/reliability, and usability, or the incredibly high potential gains will not be realized.

Users need to trust the system, it needs to be there when they need it (wherever that is), and they have to want to use it.

P.S. Here is an infographic on EHR adoption.

Revenue Revolution in Radiology

I have been reading a lot recently about trends in healthcare and imaging around costs and revenues. There seems to be a perfect storm of changes in the market that will have a fundamental impact on diagnostic imaging service providers. I find this topic interesting because, unless you understand how the money is moving, you won’t understand why things are happening. Here is a summary of what I have discovered.

Medicare Reimbursement Cuts

This one is obvious. If you lower the amount of money paid for something, your revenues will go down (unless volume goes up proportionally). Here is an infographic from MITA on the cuts made since 2006.

Fewer Medical Imaging Exams being Ordered

Here is an article from MITA on the decline of the total number of CT exams being done in the U.S. Here is another one citing data published by the American College of Radiology (ACR). It states: “…physicians are calling for less, not more, imaging tests.” This shows a measurable reduction in the volume of exams performed in the U.S. And here is an article indicating a steady decrease in imaging studies being ordered for patients in the ED, following a steady increase up to 2007.

Image Sharing

The sharing of patients’ clinical records across facilities is a key part of Accountable Care, and is generally a good thing for patient care. So is sharing imaging records. With reliable options now available on the market, sites within a local referral area are rapidly launching or signing up to services to share images. The clinical benefits of comparing new imaging exams with priors are well understood, but this practice will often result in avoiding the need to perform a repeat exam. This benefits the patient (less radiation and anxiety and delay), and the operations of the receiving organization (less schedule disruption, less costs due to CD importation). The other impact, of course, is that the receiving organization loses some revenue from that avoided repeat exam. This will result in a reduction in volume of exams performed.

Adoption of Clinical Decision Support

Starting on January 1, 2017, imaging exams will require the use of Clinical Decision Support (CDS) to ensure that physicians are following Appropriate Use Criteria (AUC). In addition to clinical evidence, factors such as relative radiation level and cost of the exam are used to determine what is appropriate. All things being equal, the lower cost exam is likely to be recommended. The adoption of CDS may result in a reduction in volume of exams performed, or a recommendation to a lower cost (profit) exam.

Preauthorization Requirements

In some insurance plans, preauthorization is required before certain exam types can be ordered (even when CDS is used, in some cases). This may require a consultation with a radiologist or Radiology Benefits Management (RBM) company. Here is an article from 2011 on the use of preauthorization and CDS. The larger the burden on the ordering physician, the less likely they are to order the exam, which may result in a reduction in volume of exams performed, or a recommendation to a lower cost (profit) exam.

Patient Steerage

Last year, I did a blog post on an article on the trend of “patient steerage”. The original article is here. Essentially, patient steerage is when a payer incents a patient to use a provider that offers the imaging service at a lower cost. If a service provider is not price competitive, this will result in a reduction in volume of exams performed.

The Castlight Effect

This company received a lot of attention because of the size of its IPO, but it is also notable for what they actually do. As this article explains, they provide healthcare provider cost information for a range of healthcare services to employee health plans. The intent being that, given the choice, consumers will choose lower cost options. This is very likely to happen when the patient has a significant co-pay (e.g. 20%) and they will personally benefit from lower cost options. If a service provider is not price competitive, this will result in a reduction in volume of exams performed.

Wait, but what about Quality?

With all the talk about the shift of reimbursement from volume of procedures to quality or outcomes, I found this tweet on Castlight interesting… Castlight Tweet If we shift away from volume incentives/payment, reduce the prices paid (through policy or competition), but don’t recognize quality, the service of diagnostic imaging has been commoditized, and I don’t think that this will benefit patients, in the end.

Consolidation

I have heard a couple of opinions that believe that the strong trend of consolidation among healthcare providers will allow the largest of providers to dictate terms and pricing to payers. As it was explained to me, it works like this: The big, well-known healthcare provider, which has bought up many of the facilities in the area, tells the insurance payers, ‘If you don’t give me preferential pricing for my services, I won’t accept your insurance plan at my facilities’. If the healthcare provider is big enough and well respected, the insurance provider will have a tough time selling insurance plans to companies and individuals when the buyer learns that they can’t go to the big provider. This is called leverage. If this is true (and I think that it is), this will result in isolated areas of reimbursement stabilization or even increases. Here is an article talking about what the impact of provider consolidation means to private payers. It cites a steady increase in the number of physicians becoming employees of hospitals (vs. independent private practices)…

“…the number of doctors employed by hospitals increased to over 120,000 from 80,000 between 2003 and 2011. About 13 percent of all doctors are now employed directly by hospitals.”

A Necessary Change in Revenue Cycle Management Systems

Here is an article on the need for an overhaul of Revenue Cycle Management (RCM) systems in the U.S. It includes some stats on administration costs per transaction (compared to financial services transactions) and consolidation trends, as well as the value of analytics. Some excerpts…

“…the number of hospitals per integrated delivery system took a big jump last year from 6.4 to 7.1…”

“…the physicians who go into practice do not want to be entrepreneurs as much as they used to. When 52 or 53 percent of residents today become employees of integrated delivery systems, it tells you that the whole market has changed.”

Using Analytics to Maximize Revenues

Here is an article on using analytics and their reports to optimize financial operations.

So, what do you think?

P.S. Here is an interview that goes into the details of payer vs. provider, along with a case for more bundled payments. And here is a blog post that goes into more detail on bundled payments, including the shift from retrospective to prospective bundles.

P.P.S. Here is an article explaining the difference between charges and costs.

P.P.P.S. Here is a notice of rule changes proposed by CMS on the method by how physicians fees will be determined. “…we are updating our practice expense inputs for x-ray services to reflect that x-rays are currently done digitally rather than with analog film.”

P.P.P.P.S. Here is an article on a study on the disparity of costs for a Mammogram in the L.A. area. $60 to $254 for self-pay, with a bill of $694 to the insurance company for the same procedure elsewhere. 30% of Mammograms in the study were self-pay.

P.P.P.P.P.S Here is an article, with a nice infographic, on 5 common medical practice denials and remedies. Spoiler alert: Radiology made the Top 5 list of unexpected denials.

P.P.P.P.P.P.S Here is an infographic on the declining employment demand and income of Radiologists by a medical recruitment firm.

New JDI Article Published – Informatics Challenges—Lossy Compression in Medical Imaging

An article I co-authored with Kinson Ho on the implications on informatics and information management when applying lossy compression to medical images in DICOM has been published. Check it out here.

It also explores whether wavelet-based compression (e.g. JPEG2000) still provides the value that it once promised. A comparison of different approaches to preserve system and network resources is included.

It is available in Journal of Digital Imaging.