The Rise of Vertically Integrated Women’s Imaging
Providing the full continuum of breast care earns the loyalty of the all-important female health care consumer, considerable downstream imaging, and the mammography annuity
More and more practices are casting an eye toward vertically integrated women’s imaging as a new way to attract family health care administrators—namely, wives and mothers—by offering an unparalleled standard of care. It’s not easy, though. It requires a multidisciplinary approach where there once was competition and sizeable investments in the requisite technology. What’s the thinking behind this strategy? How is it being executed in practices around the nation? What are the potential pitfalls, if any?
Advocates of integrated women’s imaging cite the need for a coordinated approach to breast cancer as the key motivator, and note that this approach is more easily achieved in a hospital setting. After abandoning mammography in great numbers earlier in the decade, outpatient imaging providers are also discovering this strategy.
Howard Berger, president and CEO of RadNet Inc, Los Angeles, says, “Right now, the market is underserved. Until we put the surgeon, the oncologist, and the imaging specialists together within one organization, any patient identified with possible breast cancer has to see multiple physicians, and it can take months until a conclusion is determined.”
Berger is so convinced that vertical integration is the correct approach that he’s betting on it with a new RadNet division called BreastLink. In business since April 1, 2008, BreastLink offers its patients access to women’s imaging specialists, oncologists, and surgeons within a single organization.
“We want to go out to the public and let them know that we have the resources to do both the mammography and any further treatment that’s needed,” Berger says. “Then we get the benefit of doing all their imaging in an integrated fashion. Rather than lose the patient to some other oncologist, medical group, or surgeon, we keep all that imaging inside. Our surgeon can refer patients to our oncologist, our oncologist can refer patients to our surgeon, and then both groups refer all of their imaging to us.”
Gary Wood, MD, of Radiology Associates of Albuquerque, NM, says that his practice has the only fully integrated women’s imaging site in the state—and gains close to 20% of its total earnings because of it. “We’re serving a special need in the community,” he says. “Fifty percent of the population is female. There’s a huge demand for women’s imaging and a huge demand for rapid turnaround. This is a high-visibility area for our practice.”
David Gruen, MD, director of the women’s center at Norwalk Radiology, Norwalk, Conn, says that his practice puts its money where its mouth is by offering women a standard of care previously only available to providers’ friends and loved ones who knew enough to ask for it.
“The standard of care, nationally, involves a woman seeing a gynecologist, the gynecologist calling the breast surgeon, the breast surgeon calling the radiologist, and, in the end, you’re talking about weeks between detection and finding out, the vast majority of the time, that it’s benign,” he says. “The VIP standard of care is not two weeks, but two to three days. Why shouldn’t that be the standard of care for everyone, if it’s the best?”
Mark Jensen, COO of Charlotte Radiology, Charlotte, NC, has set a similar benchmark for his women’s imaging services. “We don’t call a patient back until we have an appointment time immediately available,” he says. “When a woman needs additional studies done, she’s channeled to our schedulers, who make a phone call to the patient and offer her a couple of choices for appointment times. That’s been a big customer-service satisfier.”
Investing in an Annuity
Gruen is an enthusiastic endorser of supporting the entire continuum of women’s care within one practice, based on a single simple principle. “Women’s imaging is an annuity,” he says. “If a patient messes up his kneecap skiing, we get one shot at him. We may get his MRI, but then he gets his knee fixed and we never see him again. If we do a good job on your mammogram, on the other hand, where are you coming next year, and the year after that? Then, when your husband needs an MRI, or your kids need a CT, our practice is the one getting the referrals. You can’t measure the power of that.”
There are other compelling reasons to make women’s imaging a cornerstone of your business, according to Gruen, even if they’re a little less tangible. “Women make the health care decisions for their families,” he notes. “This wouldn’t work as a business model with 75-year-old men, but women decide where their husbands go and where their children go, and if they have a bad experience, they’re not likely to come back.”
Then there’s the word-of-mouth factor: a powerful marketing tool in the right hands. “Women talk,” Gruen says. “Men don’t talk. We don’t discuss our prostate exams on the tennis court, but women discuss health care in an educated, open way. If they have a good experience, they pass on the news.”
Berger backs this notion completely, adding that, unlike other forms of imaging, mammography is one modality where patients have the liberty to self-refer. “We can go out and market directly to the public because a woman doesn’t need a prescription for this procedure,” he says. “When women reach the age of 40, they get this on an annual or biennial basis, and they don’t have to go through their primary care physicians.”
Wood adds that reimbursement for mammography was unscathed by the Deficit Reduction Act of 2005, which makes it a commodity. “There’s even new stuff being proposed that would increase reimbursement on mammography, which is the opposite of all the trends we see elsewhere in imaging,” he says. “At least from the mammography standpoint, things could still improve.”
Jensen notes that mammography is one of the lone modalities that has not experienced significant turf encroachment from nonradiologists. “This is an area that allows us to remain competitive in a turf-battle marketplace,” he says.
Gruen agrees. “What can you develop as a service line that allows you to maintain some ownership over your patients?” he says. “Breast-imaging patients come here because no one else wants to deal with them.” Gynecologists and primary care physicians may claim those patients as their turf, but Gruen adds that radiologists know best how to perform their imaging and their mammography follow-up care. He says, “Capitalize on women as an annuity, take exquisite care of them, and you’ve got the right service line. The only thing you have to do is provide good care.” 
A desert palette runs throughout the breast center operated by Radiology Associates of Albuquerque Advanced Imaging: Friend or Foe? The next piece of the puzzle, according to Berger, is advanced imaging. He says that a vertically integrated venture like BreastLink would not have been fiscally feasible five years ago. “Everybody was pretty much of the opinion that efforts to channel all of these specialists into one organization would not have been successful in the past because the imaging piece was kind of a wild card,” he says. “With the emergence of things like breast MRI and ultrasound-guided and MR-guided biopsy, however, imaging has emerged as an absolute prerequisite for the proper diagnosis, staging, and follow-up of treatment.” Berger’s statement reflects Improving Breast Imaging Quality Standards,1 a 2005 Institute of Medicine report commissioned by Congress prior to reauthorization of the Mammography Quality Standards Act. That document issues a clarion call not just for better standards in mammography, but for more consistency in women’s imaging in general. “Mammography is only one component of a multi-step process in breast health care—quality care is thus dependent on performance standards across the cancer care continuum,” the report states. “The best possible care will result from effective communication and coordination among breast imagers, surgeons, pathologists, and primary and other care providers.” Berger adds that the emergence of digital mammography is a huge boon to improving women’s care. “The diagnostic capability of digital is superior,” he says. “At the moment, it has only penetrated about 30% of the market. We hope that women will find the benefit of going to centers with digital mammography, though they might have to travel longer distances to do so.” The increased reimbursement offered for digital mammography doesn’t hurt, either. Advanced imaging technology comes at a fairly high price, however, and not every practice has the financial leeway to upgrade its mammography units without consequences. “The investment in mammography is far more substantive when you’re digital,” Berger says. As Cynthia Rabalais, director of diagnostic imaging at Woman’s Hospital, Baton Rouge, La, recalls, “In 2005, we made the transition from analog to digital. We were delivering about 2,500 to 5,000 mammograms a month in our satellite offices, but you can’t put in a digital mammography unit and only perform 2,500 mammograms. You won’t be able to pay the bills.” In the end, Woman’s collapsed two of its satellite sites because of the volume problem. “We made those decisions in order to deliver the same technology for all of our patients,” Rabalais says. “We didn’t want to be part analog, part digital.” Wood injects a similar note of caution. “Like anything in radiology now, the only practices that are going to be able to begin to be viable with this approach are high-volume practices,” he says. “Our outlying sites want to go digital, and there’s no way we’re going to be able to underwrite the cost of that. You have to be high volume and very efficient in order to compete. If you have enough dedicated people, I think you can make women’s imaging a cornerstone, but it’s getting worrisome.” R. James Brenner, MD, immediate past president of the Society of Breast Imaging and a radiologist with San Francisco’s Bay Imaging Consultants Medical Group Inc, warns practices against biting off more than they can chew. “It’s tricky,” he said. “If you get really good, then more and more people want to see you, and it gets harder and harder to accommodate them in as timely a manner as you originally intended. Some places that set benchmarks as badges of pride find it difficult to attend to all these factors and still meet their goals.” Brenner cites what he calls the artificial economics of medical reimbursement as a major hurdle in dealing with advances in women’s imaging technology. “Depending on the level of reimbursement, we may or may not see a huge profit from screening MRI, for example,” he said in reference to a new California bill that would mandate coverage for annual screening MRIs for high-risk women. “If you look at the number [that the California legislature] assigned to the cost of an MRI, I think they’re grossly underestimating. Reimbursement schedules take a long time to change. In a fixed pie of funds, there’s only so much to go around.” Wood’s experience confirms this. “We knew we were going to lose money doing breast MRI, so we do general MRI on our system as well,” he said. “You can’t pay for the equipment doing breast MRI.” Hard Numbers What do the downstream imaging ratios look like for those bold practices embarking on a vertically integrated approach? “We’re probably doing around 40,000 exams a year,” Wood says. “Diagnostics are probably about 10% of that—4,000 or 5,000 ultrasounds a year. As for MRIs, it’s significantly less. As long as we’ve been doing breast MRI here, we’ve controlled it fairly stringently as to appropriateness, and there hasn’t been a lot of demand for screening MRI.” Jensen’s ultrasound ratios are slightly higher; he says that Charlotte performs around 150 to 160 per 1,000 screening mammograms. MRIs are done at a rate of about 15 per 1,000 screening mammograms, and biopsies hold steady at about 30 per 1,000. Rabalais reports that about 15% of Woman’s Hospital’s 46,000 annual screening mammograms result in ultrasounds, but the hospital only performs 600 biopsies a year—or 13 for every 1,000 mammograms—and 60 MRIs a month. “Our MRI system is only two years old this past March, so we haven’t really gotten into the groove yet,” she says. “Our volume on the MRI right now is for newly diagnosed breast cancers. We use it to look at the other breast and to stage treatment, and everyone has embraced that next step.” For every 1,000 mammograms at its women’s imaging center last year, Gruen reports, Norwalk performed 80 breast MRIs, 165 breast ultrasounds, and 44 breast biopsies—on top of 187 bone-density scans and 65 vein-therapy procedures. “This is the spin-off from mammography that makes its specific return difficult to measure,” he notes. “This doesn’t include other procedures the patient or her family may have.” For example, he says, several women per day have pelvic ultrasonography, chest radiography, ultrasound screening of the carotid or aorta, and other procedures in addition to their mammograms. Managing Multiple Disciplines Approaches to positive screening mammograms—and, therefore, to interaction with breast surgeons and oncologists—vary widely from practice to practice. Gruen and his team members, who have found so much success in other aspects of the women’s imaging business, are still negotiating the relationships between the practice and independent, private-practice breast surgeons in the community. “One of the things we heard from breast surgeons that prompted this program is that they were getting killed financially,” Gruen says. “They were spending too much time holding the hands of the worried well and not enough time operating on women with real findings. Quality breast surgeons are imperative to comprehensive breast care. We have tried to work closely with our surgeons, and frequently ask them how we can help them. One of our breast surgeons is very happy with us because she’s doing more procedures.” He continues, “If you get the patients into your office quickly and turn them around quickly, you’ve taken the high road of always providing the best patient care. If we can provide excellent patient care faster than others, whether they are competing radiologists or clinicians, we don’t worry too much about it. We need to work closely with them, and we don’t want to affect patient care negatively.” Norwalk also participates in a monthly multidisciplinary tumor board that includes radiologists, pathologists, oncologists, surgeons, plastic/reconstructive surgeons, geneticists, and others. “This has really helped show that our mission of taking good care of patients benefits everyone,” Gruen says . Charlotte Radiology takes a similar approach, participating in a weekly interdisciplinary conference of representatives from practices around the city. “It’s gone a long way toward improving patient treatment options,” Jensen says. “Because you’re communicating on a particular patient, it just makes sense that those patients would wind up in the same network. We’ll get patients referred to us for second opinions, and the same mechanism goes into action for them.” Radiology Associates of Albuquerque also started a tumor board that includes medical and radiation oncologists, breast surgeons, and radiologists. The board meets once a week to discuss all of the practice’s cases. “When we’re all here together, and we’re working as a team, we’ve got one unified philosophy that everyone follows,” Wood says. “That’s a big deal for us. It’s difficult for patients when everybody’s on a different track somewhere.” Meanwhile, Rabalais and her team members allow the patient’s primary care physician to make the referral to a breast surgeon, knowing that Woman’s Hospital is the obvious choice in the community for cancer care. “Ninety percent of the time, the patient will have her surgery and follow up care here,” she says. “If the patient would benefit from being in another environment—for example, if the patient suffers from heart disease or would benefit from being in a closer-to-home medical facility—then the choice of another facility for surgery may be made.” Berger is taking the most direct approach, working directly with surgeons and oncologists under the aegis of RadNet. Berger makes no bones about why he thinks this business tactic will work. He says, “We think we can run the oncology and surgical portions of the practice better than the doctors could on their own, and we’re very pleased with the first results we’ve seen. We think it will only get better.” Many Happy Returns In the end, only time will tell whether vertically integrated women’s imaging is an effective approach, but there’s certainly ample reason to believe it is, Gruen notes. “Providing a new standard of care for women was a culture change,” he says. “It was a culture change for our radiologists and for our technologist staff to say, ‘If we can do it today, then why not do it today?’ We’ve gone right to the limit, and it has grown our market share.” Jensen, whose practice is built on a hub-and-spoke model of screening and diagnostic breast centers, has seen Charlotte Radiology expand in years when other practices have been forced to scale back, and he attributes this growth in part to women’s imaging. “Breast services are a significant component of our overall portfolio, and at the present time, drive a significant amount of our investment dollars,” he says. “Women’s imaging is a significant component of our business, and because of it, we’re now getting opportunities outside of Charlotte to help groups and hospitals with their service.” Berger is also planning to expand, and BreastLink has only been in business for a few months. “There are probably four or five other areas in Southern California where we hope to roll out a similar platform under the BreastLink model over the next year,” he says. Brenner expresses measured optimism. “This is not a new strategy,” he says. “Mammography isn’t always very profitable, but the profits and proud outcomes come from the successful treatment of breast cancer. As an entry into the system, it has a very useful role.” Additional Reading - MQSA: Numerically Speaking
A desert palette runs throughout the breast center operated by Radiology Associates of Albuquerque Advanced Imaging: Friend or Foe? The next piece of the puzzle, according to Berger, is advanced imaging. He says that a vertically integrated venture like BreastLink would not have been fiscally feasible five years ago. “Everybody was pretty much of the opinion that efforts to channel all of these specialists into one organization would not have been successful in the past because the imaging piece was kind of a wild card,” he says. “With the emergence of things like breast MRI and ultrasound-guided and MR-guided biopsy, however, imaging has emerged as an absolute prerequisite for the proper diagnosis, staging, and follow-up of treatment.” Berger’s statement reflects Improving Breast Imaging Quality Standards,1 a 2005 Institute of Medicine report commissioned by Congress prior to reauthorization of the Mammography Quality Standards Act. That document issues a clarion call not just for better standards in mammography, but for more consistency in women’s imaging in general. “Mammography is only one component of a multi-step process in breast health care—quality care is thus dependent on performance standards across the cancer care continuum,” the report states. “The best possible care will result from effective communication and coordination among breast imagers, surgeons, pathologists, and primary and other care providers.” Berger adds that the emergence of digital mammography is a huge boon to improving women’s care. “The diagnostic capability of digital is superior,” he says. “At the moment, it has only penetrated about 30% of the market. We hope that women will find the benefit of going to centers with digital mammography, though they might have to travel longer distances to do so.” The increased reimbursement offered for digital mammography doesn’t hurt, either. Advanced imaging technology comes at a fairly high price, however, and not every practice has the financial leeway to upgrade its mammography units without consequences. “The investment in mammography is far more substantive when you’re digital,” Berger says. As Cynthia Rabalais, director of diagnostic imaging at Woman’s Hospital, Baton Rouge, La, recalls, “In 2005, we made the transition from analog to digital. We were delivering about 2,500 to 5,000 mammograms a month in our satellite offices, but you can’t put in a digital mammography unit and only perform 2,500 mammograms. You won’t be able to pay the bills.” In the end, Woman’s collapsed two of its satellite sites because of the volume problem. “We made those decisions in order to deliver the same technology for all of our patients,” Rabalais says. “We didn’t want to be part analog, part digital.” Wood injects a similar note of caution. “Like anything in radiology now, the only practices that are going to be able to begin to be viable with this approach are high-volume practices,” he says. “Our outlying sites want to go digital, and there’s no way we’re going to be able to underwrite the cost of that. You have to be high volume and very efficient in order to compete. If you have enough dedicated people, I think you can make women’s imaging a cornerstone, but it’s getting worrisome.” R. James Brenner, MD, immediate past president of the Society of Breast Imaging and a radiologist with San Francisco’s Bay Imaging Consultants Medical Group Inc, warns practices against biting off more than they can chew. “It’s tricky,” he said. “If you get really good, then more and more people want to see you, and it gets harder and harder to accommodate them in as timely a manner as you originally intended. Some places that set benchmarks as badges of pride find it difficult to attend to all these factors and still meet their goals.” Brenner cites what he calls the artificial economics of medical reimbursement as a major hurdle in dealing with advances in women’s imaging technology. “Depending on the level of reimbursement, we may or may not see a huge profit from screening MRI, for example,” he said in reference to a new California bill that would mandate coverage for annual screening MRIs for high-risk women. “If you look at the number [that the California legislature] assigned to the cost of an MRI, I think they’re grossly underestimating. Reimbursement schedules take a long time to change. In a fixed pie of funds, there’s only so much to go around.” Wood’s experience confirms this. “We knew we were going to lose money doing breast MRI, so we do general MRI on our system as well,” he said. “You can’t pay for the equipment doing breast MRI.” Hard Numbers What do the downstream imaging ratios look like for those bold practices embarking on a vertically integrated approach? “We’re probably doing around 40,000 exams a year,” Wood says. “Diagnostics are probably about 10% of that—4,000 or 5,000 ultrasounds a year. As for MRIs, it’s significantly less. As long as we’ve been doing breast MRI here, we’ve controlled it fairly stringently as to appropriateness, and there hasn’t been a lot of demand for screening MRI.” Jensen’s ultrasound ratios are slightly higher; he says that Charlotte performs around 150 to 160 per 1,000 screening mammograms. MRIs are done at a rate of about 15 per 1,000 screening mammograms, and biopsies hold steady at about 30 per 1,000. Rabalais reports that about 15% of Woman’s Hospital’s 46,000 annual screening mammograms result in ultrasounds, but the hospital only performs 600 biopsies a year—or 13 for every 1,000 mammograms—and 60 MRIs a month. “Our MRI system is only two years old this past March, so we haven’t really gotten into the groove yet,” she says. “Our volume on the MRI right now is for newly diagnosed breast cancers. We use it to look at the other breast and to stage treatment, and everyone has embraced that next step.” For every 1,000 mammograms at its women’s imaging center last year, Gruen reports, Norwalk performed 80 breast MRIs, 165 breast ultrasounds, and 44 breast biopsies—on top of 187 bone-density scans and 65 vein-therapy procedures. “This is the spin-off from mammography that makes its specific return difficult to measure,” he notes. “This doesn’t include other procedures the patient or her family may have.” For example, he says, several women per day have pelvic ultrasonography, chest radiography, ultrasound screening of the carotid or aorta, and other procedures in addition to their mammograms. Managing Multiple Disciplines Approaches to positive screening mammograms—and, therefore, to interaction with breast surgeons and oncologists—vary widely from practice to practice. Gruen and his team members, who have found so much success in other aspects of the women’s imaging business, are still negotiating the relationships between the practice and independent, private-practice breast surgeons in the community. “One of the things we heard from breast surgeons that prompted this program is that they were getting killed financially,” Gruen says. “They were spending too much time holding the hands of the worried well and not enough time operating on women with real findings. Quality breast surgeons are imperative to comprehensive breast care. We have tried to work closely with our surgeons, and frequently ask them how we can help them. One of our breast surgeons is very happy with us because she’s doing more procedures.” He continues, “If you get the patients into your office quickly and turn them around quickly, you’ve taken the high road of always providing the best patient care. If we can provide excellent patient care faster than others, whether they are competing radiologists or clinicians, we don’t worry too much about it. We need to work closely with them, and we don’t want to affect patient care negatively.” Norwalk also participates in a monthly multidisciplinary tumor board that includes radiologists, pathologists, oncologists, surgeons, plastic/reconstructive surgeons, geneticists, and others. “This has really helped show that our mission of taking good care of patients benefits everyone,” Gruen says . Charlotte Radiology takes a similar approach, participating in a weekly interdisciplinary conference of representatives from practices around the city. “It’s gone a long way toward improving patient treatment options,” Jensen says. “Because you’re communicating on a particular patient, it just makes sense that those patients would wind up in the same network. We’ll get patients referred to us for second opinions, and the same mechanism goes into action for them.” Radiology Associates of Albuquerque also started a tumor board that includes medical and radiation oncologists, breast surgeons, and radiologists. The board meets once a week to discuss all of the practice’s cases. “When we’re all here together, and we’re working as a team, we’ve got one unified philosophy that everyone follows,” Wood says. “That’s a big deal for us. It’s difficult for patients when everybody’s on a different track somewhere.” Meanwhile, Rabalais and her team members allow the patient’s primary care physician to make the referral to a breast surgeon, knowing that Woman’s Hospital is the obvious choice in the community for cancer care. “Ninety percent of the time, the patient will have her surgery and follow up care here,” she says. “If the patient would benefit from being in another environment—for example, if the patient suffers from heart disease or would benefit from being in a closer-to-home medical facility—then the choice of another facility for surgery may be made.” Berger is taking the most direct approach, working directly with surgeons and oncologists under the aegis of RadNet. Berger makes no bones about why he thinks this business tactic will work. He says, “We think we can run the oncology and surgical portions of the practice better than the doctors could on their own, and we’re very pleased with the first results we’ve seen. We think it will only get better.” Many Happy Returns In the end, only time will tell whether vertically integrated women’s imaging is an effective approach, but there’s certainly ample reason to believe it is, Gruen notes. “Providing a new standard of care for women was a culture change,” he says. “It was a culture change for our radiologists and for our technologist staff to say, ‘If we can do it today, then why not do it today?’ We’ve gone right to the limit, and it has grown our market share.” Jensen, whose practice is built on a hub-and-spoke model of screening and diagnostic breast centers, has seen Charlotte Radiology expand in years when other practices have been forced to scale back, and he attributes this growth in part to women’s imaging. “Breast services are a significant component of our overall portfolio, and at the present time, drive a significant amount of our investment dollars,” he says. “Women’s imaging is a significant component of our business, and because of it, we’re now getting opportunities outside of Charlotte to help groups and hospitals with their service.” Berger is also planning to expand, and BreastLink has only been in business for a few months. “There are probably four or five other areas in Southern California where we hope to roll out a similar platform under the BreastLink model over the next year,” he says. Brenner expresses measured optimism. “This is not a new strategy,” he says. “Mammography isn’t always very profitable, but the profits and proud outcomes come from the successful treatment of breast cancer. As an entry into the system, it has a very useful role.” Additional Reading - MQSA: Numerically Speaking