Breast Imaging Paradox: It’s About the Annuity

In 2002, Norwalk Radiology—like many radiology practices across the nation—reached a crossroads. Prepare to invest in expensive new digital mammography technology or stop doing mammograms. In fact, more mammography centers in the U.S. closed than opened between 2001 and 2004, but in Norwalk, Conn, practice president Allan Richman, MD, rightly recognized that women would drive service line growth, and it was a good idea to take care of them. Given the proper attention, the mammogram is the engine that drives outpatient imaging, David R. Gruen, MD, radiologist, contended, during a presentation at the at the 2nd Annual GE Healthcare Outpatient Imaging Center Conference, July 27, Crystal City, Va. In an hour-long talk, Gruen, medical director for women’s imaging, described why Norwalk Radiology chose to grow its women’s imaging service, how it built that service, and its ancillary benefits. “Mrs. Jones is a mammogram annuity,” Gruen explained, “and if you take good care of her she will be there every year, from age 40 until she’s 88 and retires to her nursing home and doesn’t get a mammogram anymore. At the $6 annual profit for Mrs Jones’ mammogram, you are going to make $240 over a lifetime. But that is not why we are doing this.” In addition to performing her mammography, Gruen noted, the practice is positioned to be the first choice for all members of the family, adding up to a lifetime annuity of knee MRIs, carotid Doppler, coronary CTA, brain MRI, breast MRI, and so forth. “Their families are your annuity,” Gruen said of the mammogram patient. “If you don’t take good care of your mammogram patients—and you can’t measure all of that spin off—you know you are going to lose it if she gets her mammogram at the competitor across the street or goes somewhere else. And that’s the way to think about women’s imaging: It is the engine for your practice’s growth.” D2D48: Today is the Only Day that Matters Norwalk Radiology veteran breast imager David Gruen, MD, fully understand that for women who discover a breast lump or receive news of a positive mammogram, “Today is the only day that matters.” Norwalk Radiology made a decision to commit to results in 48 hours for women with a positive mammogram, and designed its 2007 marketing campaign around that promise, known internally as D2D48. Much to the surprise of many of the practice’s radiologists, the campaign is having a noticeable effect on local referring patterns. “We compete with other community hospitals in the surrounding towns, and the distances are not very great,” Gruen explained. “How do we really change referral patterns? Not an easy thing to do. We know referral patterns are made on the golf course.” According to Gruen, physicians in some of the surrounding towns who have heard about the D2D48 program through a lunch or physician marketing, are referring their patients who have had a positive screening mammogram elsewhere and are upset because they have to wait six days for their next mammogram and longer for their workup. “Their doctor is saying, ‘You know what, Norwalk Radiology says they can see you the same day’,” Gruen said. “Hopefully, she’ll tell her friends, but now we have made Dr Brown a referrer. That’s the annuity. We may not get those patients who have been going elsewhere for years, but when a new patient shows up, and asks where should I go for my mammogram, she’ll say, ‘You know what, the service is better at Norwalk Radiology’. And that is how we differentiate. Market Paradox There is no time like the present to jump into women’s imaging, Gruen said. A July 2006 report from the General Accountability Office found a 6% reduction in facilities between 2001 and 2004; 4% fewer machines; 3% fewer technologists; and 5% fewer radiologists who are doing breast imaging. The same report found that 865 counties in the U.S. do not have any mammography machines at all, and in 117 counties, the number of machines decreased at least 25%. “Here is the paradox, and this is why I still think there is great opportunity,” Gruen said. “The population is aging and the patient flow is going up. I am not an economist, but you have demand going up and supply going down. This is where there is a mis-match, this is where there is opportunity.” Since adding digital mammography technology and retooling its processes in 2002, Norwalk Radiology has grown its mammography volume from about 8,000 in 2001 to an anticipated 15,000-plus mammograms this year. Additionally, the following ancillary procedures are generated for each 1,000 mammograms the practice performs: 73 breast MRI 165 breast ultrasound 44 breast biopsies 200 DEXA scans 65 vein ablations The first thing Norwalk did in re-engineering processes for digital mammography is convert from a diagnostic mammogram model to a full-on screening model. Previously, each patient was greeted by the radiologist in the screening room and guaranteed results that day, a process that produced two studies per hour. In contrast, each digital scanner now at Norwalk produces six digital screening mammograms per hour. “We want women to be comfortable, we want them to tell us it is spa-like, but we don’t want them to linger in our procedure rooms,” Gruen said. “The actual acquisition time for a digital mammogram is about 56 seconds. A mammogram is typically four views, and we do two views of each breast. The 56 seconds includes the time it takes the technologist to walk over, change the angle of the machine, put the compression down and say, ‘Hold your breath’, beep. Under, a minute, maybe two minutes if the technologist isn’t quite so fast. So why are you doing two an hour? We were doing them at a very slow pace because I used to say hello to every patient, and I thought it was really nice if Mrs. Jones remembered me from last year.’ Out went the chairs in the examining room, and in came technologist aides who escorted the patient to and from the procedure room. “After the exam, they can linger in our waiting room, read magazines, drink herbal tea, and do whatever they want to do,” Gruen said. “And they will get their results quickly. We’ve committed to them that they will get results for their screening mammogram by the next morning. If they haven’t heard from us by the next day, everything’s fine and they will get the letter in the mail.” Norwalk went beyond that commitment with its 2007 marketing campaign, “Detection to Diagnosis in 48 Hours,” a program that Gruen believes has helped change referral patterns in its competitive market (see related story in box). The Five Imperatives For imaging center operators who want to make the commitment to women’s imaging, Gruen’s advice comes in the form of six key points. Imperative No. 1: Focus on customer service excellence. Patients. Norwalk Radiology was very concerned about the impact of the new screening model on how patients would perceive the mammography experience. In fact, the practice hired a public relations firm to guide it through the transition and help promote Norwalk Radiology as a center of excellence for breast imaging. The advice of the PR firm: While you are doing this, make sure you change your environment. “Has anyone ever been through the back door at the hotel where you check in?” Gruen asked? “No. We took all of our revenue qualification and the pre-certification people away from the front desk, so the people checking in didn’t have to hear the staff fighting with Oxford to get a CT scan pre-certified. If you have the chance to do it, think about the Four Seasons, think about Disney World, think about the spa experience. Remember, women make the health care decisions for their families. Women are the engine of an imaging center’s revenue stream. They are an annuity, they make the health care decisions for their spouse, their parents, and, more and more, their children.” Referring physician staff. Norwalk Radiology has created a concierge program for referring physicians and their staff. ‘Who makes the decision of where your patients go?” Gruen asks, rhetorically. “We have a liaison/concierge type of system. We assign our schedulers and secretaries to have a liaison relationship within a speciality. Esther is our breast liaison, and she is on a first name basis with the breast surgeon’s staff. Not the breast surgeon. Their schedulers their pre-certifiers and their ancillaries, Esther knows them all. She goes there with our marketing people and she takes lunch with them and hears their problems. So when Dr Smith needs a breast MRI on a patient quickly to get to the OR, Pauline, Dr Smith’s assistant, calls Esther directly. She doesn’t get, ‘Thank you for calling Norwalk Radiology, press one for billing, press 2 for scheduling, please hold.’ It’s Esther directly, that is the contact level, We’ve done it for urology, and we’ve done it for orthopedists, and we’re doing it for neurology. We create this hand holding contact, someone in our practice who can make your job easier.” Your staff. Reward good behavior and do not tolerate bad behavior. “If three consecutive women leave the digital mammography machine and say, ‘Boy that hurt more than last year’, that’s bad for business,” Gruen said. “You’ve got to make sure your staff is doing a good job. Reward them for it, bonus them for it, award part of their annual pay based on customer service surveys. Find a way to reward good behavior. Conversely, if you have someone who is doing a bad job, make sure you are writing them up, talk to your HR person, document it, but find a way to get those people out of your practice, because they are hurting it. The biggest mistakes we all make is we hire quickly and fire slowly. Hire slowly and hire the right people.” Gruen recommended the book “If Disney Ran Your Hospital,” by Fred Lee, to put your staff on the customer service excellence track. Imperative No. 2: Commit to product quality. This piece of advice may appear to be simple, but it is all in the execution. “Our only product is the radiology report,” Gruen emphasized. “How it is delivered could be a positive or negative differentiator.” Imperative No. 3: Invest in good technology. Technology matters, Gruen believes. “Digital mammography has penetrated only 20 percent of the market,” he said. “There is huge upside potential there. It’s a market differentiator.” Other market differentiators are computer-aided detection software for mammography and breast MRI. Gruen carries the abstracts from the peer-reviewed literature, as well as comparative images on his laptop on visits to referring physicians. “Breast MRI is in for huge growth,” Gruen added, citing recent articles recommending breast MRI for women at high risk for breast cancer as well as those who have recently been diagnosed with breast cancer. “The surgeons in our community, at least the good ones, will not operate without a breast MRI in advance,” he said. The criteria for becoming a source for breast MRI in your community is a 1.5 T magnet, the ability to image both breasts, and the ability to do breast biopsy under MRI. However, an investment in the technology and software to perform breast MRI is contingent on a practice’s mammography volume. “In the DRA setting, when you are talking in your group about what are the nice-to-have versus must-have technologies, this is a key question,” Gruen said. “If you don’t do enough mammography, you can’t buy the MRI yet to do breast MRI. You’ve got to grow the mammography volume before you can pay for the MRI, just like we had to grow our digital mammography volume before we could embark on biopsies under MRI.” Imperative No. 4: Market aggressively, use resources appropriately. Develop a plan for growth, work the plan, and measure the results, Gruen advised. “This is what our marketing has been and this is what I think is one of the few ways of changing referral patterns: If a patient has a breast related problem, today is the only day that matters,” Gruen stated. “If someone has found a lump, we get patients in the same day, and, frequently, we biopsy the same day.” Gruen believes that in a market in which mammography facilities are backed up two to three months that this approach is a market differentiator. “Everyone is backed out two or three months for screening mammograms,” Gruen said. “Diagnostic mammograms in the town next to us are booked out 5-7 days. What does that mean? More than two weeks to get the results of the biopsy that more than 80% of the time is benign. You’ve ruined almost 3 weeks of this women’s life to tell her she has a fibroid adenomoa.” “This is what we do,” he added. “Same day, 24-48 hours, they have their answer, they can go on with their lives. If you take good care of your patients the rest will follow.” Imperative No. 5: Engage your radiologists. Doctor-to-doctor contacts are more effective than any number of dollars you can invest in advertising, Gruen said. “We always overlooked the fact that radiologists are a unique brand message,” Gruen said. “We provide committed time to get our radiologists out of the office. Grand rounds, journal clubs, CME lectures, association meetings, events like this in our community, we give them dedicated time, we get them out of the office It’s not a big demand: One contact per quarter per radiologist within their specialty.” Because the idea was greeted with some resistance from the radiologists, the practice devised a system. Practice management developed a list of top referrers, and each radiologist picks who they want to visit once a quarter, The radiologists also choses the forum (usually a lunch) and the topic. Practice staff handles the details, including making the appointment and handling reservations or take-out lunch. “I go see the gynecologists and the breast surgeons in my town and in the towns where we want to increase market share,” Gruen reported. “I talk about what I like to talk about: breast MRI. I help gynecologists understand the indications for breast MRI, I hand them the NEJM abstract, and I’ve highlighted the key lines so the take home points are this for your patients. This results in more than 50 direct doctor-to-doctor contacts annually.” Gruen believes these personal relationships are more valuable and cost effective than any dollar amount the practice could spend putting an ad in the paper. “At the end of the day, each of the physician groups is either stable or has increased, were not getting complaints, and we are getting phone calls at a doctor to doctor level asking for advice,” he said. “We are becoming their experts.”