Defining Quality and Value in Imaging 3.0

Radiologists and hospital administrators are finding common ground when it comes to one significant conundrum, according to Richard Duszak, MD, CEO of the ACR’s Harvey Neiman Health Policy Institute. “We are moving from a system where we got paid for doing procedures to one where we will get paid for taking care of patients,” Duszak said in a presentation at the 2013 conference of AHRA: The Association for Medical Imaging Management, held July 28-31 in Minneapolis, Minnesota. “The big word is value, and it’s going to be a real challenge for physicians and hospital administrators.” Duszak outlined the key paradigm shift faced by imaging, which is progressing from a volume-based approach to value-based care. As he puts it, “Right now, we do things to patients. In the future, we have to do things for patients.” To prepare for a future in which health care incomes are based on outcomes, how should radiologists, and the hospitals they work with, change? “We need to face reality as it is, not as it was or we wish it to be,” Duszak says. “Fee for service is over. If you think it’s going to stick around, you will find yourself a loser.” Regulatory Influences Some of the key regulatory influences driving the new paradigm were outlined in a presentation given at the same conference by Zeke Silva, MD, chair of the ACR’s Value-Added Committee. Contrary to popular opinion, Silva sees a promising future for imaging in the coming era of accountable care. As he explains it, accountable care organizations (ACOs) will, by their nature, have to reduce utilization of procedures with high variable costs, as well as procedures that are easily avoidable or replaceable or involve a limited number of physicians. It will be in the best interest of ACOs to focus on procedures with low variable costs, procedures that can be replaced with lower-cost options, and procedures that involve or influence many members of the care team, encouraging collaboration. In other words: imaging. “The profit from not doing an MR is less than the profit from doing it,” Silva notes. “We need to be sharing that information with ACOs. We need to show them that on a nuts and bolts level, imaging is not a problem for them.” Ongoing Challenges The obstacles to creating a sustainable, value-based future for imaging are both tangible and philosophical, according to the two speakers. Silva noted that imaging is currently under-valued in Medicare’s Hospital Outpatient Prospective Payment System as well as its inpatient analog. The reasons for this are complex, he noted, and include ongoing inaccuracies in hospital charge-masters resulting from hospitals treating high-tech imaging equipment as hospital fixtures when developing charges. “We need to protect payment for hospital-based imaging, more so than we ever have before,” Silva says. “We need to get engaged in watching payments closely across all settings and improving hospital cost reporting for imaging.” On a more intangible—but equally problematic—level, the cultural underpinnings of medicine need to shift, Duszak says. “Fee-for-service is a transactional approach to the delivery of imaging,” he observes. “It’s the lowest life form on the evolutionary chain of radiology. The incentive is to do things fast and not do them well.” Incenting quality will require a shift in payment mechanisms. Duszak envisions a future in which pay-for-performance, bundling/population management a la the ACO model, and a limited amount of fee-for-service are mixed. “We need to be thinking of all these spaces and have a fundamental understanding of them to be nimble as we move forward,” he says. “Being at the table is not enough. We don’t just need to figure out what is our slice of the pie; we need to re-examine how the pie itself is configured.” Looking Forward Quality reporting initiatives are a step in the right direction, Duszak believes, but programs like the Physician Quality Reporting System (PQRS) have a fundamental flaw in that they emphasize process over outcomes. To put outcomes at the core of the value equation will require data. “The way to get from volume to value in these new systems is data and information,” he says. “The data may not currently exist, so we have to create it. The imaging 3.0 value chain has data mining and analytics at its center.” Though Duszak makes no specific prescriptions for how to manage the change to come, he notes that it will require collaboration. “Smart practices and health systems will do these things together,” he says. “Physicians and administrators, working together, should come up with credible standards. It doesn’t have to analyze terabytes of data—you just need to find a way to evaluate physician performance for yourself.” Silva summarizes his recommendations simply: “Do the right thing, make the right decisions, take the right actions—and do it for the good of patients.” Cat Vasko is editor of HealthIT Executive Forum.