Suiting Up for Value-based Payment

Many radiology practices got their first taste of value-based payment in September with the arrival of their Quality Resource Use Report (QRUR) from CMS for performance year 2015—and found it a bitter pill to swallow. As basis for the 2017 Value Modifier, the 2015 QRUR will determine whether practices qualify for an incentive payment of up to 4% of Medicare payments, or a negative update of as much as -4% in 2017, or no adjustment at all.

CMS announced an aggressive goal to link 30% of physician payment to quality by the end of 2016 and reached that goal just three months into this year. In October, CMS released the final rule for payment reform called for in the final rule to implement the Medicare Access to Care Reforma Act.

With momentum gathering, Radiology Business Journal communicated separately with two radiologists for their thoughts on how radiology should suit up for value-based payment. (VBP). Jonathan B. Kruskal, MD, PhD, radiology chair at Beth Israel Deaconess, Boston, Mass., whose experience under accountable care began when Massachusetts implemented health care reform in 2006, generously agreed to represent academia as well as contribute to a different article in this issue (see page 18); several invitations extended to leaders of private practices were declined, but Lawrence Muroff, MD, a radiologist and consultant, agreed to talk with us.

What are the most immediate steps every radiology service must take to prepare for VBP? 

Kruskal: Having lived in an accountable care environment for a number of years, the most important lesson we have learned is that it is no longer a case of either being in a fee-for-service environment or being in a value-based environment.  We now live in that central gray zone where we are mostly receiving fee-for-service but under the new value-based rules. 

The second most important lesson we have learned is that radiology is one cog in a large wheel. While we can place intense focus on the well-recognized contributors to value—in other words quality, outcomes, appropriateness and stakeholder satisfaction over costs—we have to do this within the larger framework. 

What this means is that reducing our report turnaround time is not going to immediately impact radiology value-based payments, but is one component that contributes to length of stay. If the length of stay, as a whole, exceeds the accountable care organization’s target, radiology will take exactly the same hit as all other departments when any of the withholds are distributed. 

The same goes for customer satisfaction, where somebody might have a wonderful experience during an imaging study or procedure, if the overall experience is negative, radiology will be impacted as much as all other provider services.  The lesson from this—and the very first step that one should take—is to fully understand how the organization works; what radiology’s role is and how it can contribute effectively; and how radiology can most impact distributions of withholds and what the target processes are for doing this. 

The only way to achieve this is to be at the organization’s table.  So, the most immediate step that every radiologist should take is to ensure that they are well represented at the decision-making table as it is many decisions that will impact the expectations, the goals and the ultimate value-based payments for radiologists.

Muroff: Radiologists really need to lean on two organizations, the American College of Radiology and the Radiology Business Management Association. That would be the best way of getting the most complete and comprehensive information quickly. Right now, very few people understand what this is, what it means and what might be expected of them.

How much of the work that needs to be done is likely to be done by radiologists and how much will be done by practice employees?

Kruskal: Radiologists must be at the table, but certainly effective practice employees must also be engaged in managing and measuring metrics and driving increased radiology performance.  Such practices, we have found, are optimally achieved through informaticists and data science managers, effective operations directors and experts in performance improvement. 

Muroff: Most private practice radiology groups will be relying on their business management team and their hospital’s information system for appropriate reporting. If the hospital is not providing the appropriate information, you may not be in a position to participate at all, particularly if you are a small group.

If you outsource your billing, you will expect your billing company to provide you with information, with assistance in doing what is correct. I don’t see, for example, retraining  of radiologists. I’m very worried about small practices and how they will be able to comply with whatever comes down the road.

Will employees with different competencies need to be hired to accomplish these tasks? 

Muroff: You could argue that entities like the Radiology Leadership Institute (RLI) or the Academy of Radiology Leadership and Management—the RSNA and Roentgen Ray society equivalent of the RLI—that those entities that provide nonclinical skill-set education will be relied on more, but that is something I haven’t seen.

There should be thousands of people—even thousands of radiologists—seeking leadership training, communication skills and negotiation skills. People talk a good game, but I am not seeing people signing up for these courses, it’s a very small minority.

Radiologists need to be, in a figurative way, hit over the head with a two-by-four and made to realize that there are going to be big changes coming down the pike. We have a wonderful specialty it’s intellectually stimulating, the technology changes continually, the quality of life is great and, by the way, it is pretty financially rewarding—it’s worth fighting for.

Do you think the fundamental work of radiologists will change and, if so, how?

Kruskal: We have certainly seen a fundamental change in the patterns and types of work that radiologists do.  Of course we are ultimately in the business of effectively managing medical image information and we need to do this far more effectively. 

There needs to be a full understanding that the work of a radiologist extends well beyond simply interpreting diagnostic studies or performing procedures, but in managing the entire patient experience and answering to the needs of all stakeholders. The value-based contributors of appropriateness, efficiency, outcomes, quality and stakeholder satisfaction all need to have an intense focus placed on them. The practices and departments that are most successful in this new environment are placing resources and full attention into these important domains. 

Muroff: Radiology is still radiology. A large part of it is the interpretation of imaging studies and the performance of imaging and interventional procedures. More and more, we are going to have to function as a consultant, as a team player in the approach to treating populations of patients.

That is going to be difficult for a lot of radiologists. We have been accused of self-selecting ourselves for avoiding contact with referring physicians and patients; indeed, in many parts of the country and many hospitals, it is very difficult to find a radiologist. That’s going to have to change.

Radiologists are going to have to be visible, they are going to have to be available, because their compensation—while tied somewhat to the performance of interventional procedures and the interpretation of imaging procedures—also is going to be tied to their contributions to keeping people well and in treating people who get sick. If they are not going to do that, then I think we will find that large portions of radiology will be, basically, stolen from radiologists.

If you can’t provide value under these alternative payment mechanisms, whether they be quality mechanisms or just episode payments per diagnosis, then somebody else can do what we do. The pulmonologists might say, “We’ll read our chest x-rays, we’ll read our own CT scans.” We’ve got to provide value either as a consultant or a team contributor under these scenarios.

Are you taking steps to prepare your radiologists for VBP?

Kruskal: Over the last couple of years, we have invested in employees with expertise in performance improvement, in informatics and data science and in stakeholder engagement. We also have hired radiologists with interests and expertise in health care economics and policy, in health services research, and in informatics, all essential domains that we are finding are contributing to us being able to succeed in this new environment.

From the perspective of a consultant who meets with multiple private practices, do you have any suggestions for how radiology practices can prepare for VBP?

Muroff: One of the byproducts of declining reimbursement in a fee-for-service environment is that some radiology practices, in an attempt to compensate for declining reimbursement, have ramped up productivity. These practices sort of lock their members away and become almost hamster-wheel practices, where they are trained to grind out more and more studies. As a result, relationships are not cultivated, and radiologists have lost contracts.

Some large practices are taking steps to make the shift, but those practices are atypical and more prepared than most. Rank-and-file practices are just going on cruise control, and they wonder why they are having problems; many don’t even know they are having problems until it’s too late.

What are the projections for medical imaging volumes—how will practices keep up with increased volume on top of new responsibilites?

Muroff: If there is some assumption that volumes will go down, I don’t believe that is true. Bottom line, I can’t think of a scenario where volume will go down in an alternative payment universe.

There are three major drivers of medical care costs. The first is the ability—or not—to prevent unnecessary admissions. The second is the ability to shorten the necessary hospital admissions. The third is to prevent recidivism, people bounding back to the hospital for noncompliance.

Of those three drivers, radiology, and imaging particularly, can influence the first and the second. I don’t think we can do much about recidivism, but we certainly can prevent unnecessary admissions—or many of them—through early diagnosis. I believe you are going to see CT scanners, and in many cases MR and ultrasound, cranking around the clock because they are there, they are in the hospital and people will take even more advantage of them.

Kruskal: This question, in essence, summarizes why big data, data science and machine learning are rushing down the tracks and why so much attention is now being focused on them. Radiologists now are experiencing much burnout and stress in the work environment for a variety of reasons, including trying to keep up with the growing volume of studies and images, and in managing the medical imaging information. 

The solution to this is more effective use and embrace of informatics and data science, and most effective practices are already embracing tools to facilitate these processes, including voice recognition systems, decision support processes both for input as well as for managing reports, processes for managing abnormal results and following up on recommendations, and processes for seeking effective feedback that is managed. 

Our world has changed, but these new opportunities are exciting, leading to the reinvigoration of many radiologists. They are providing new career opportunities in our field, placing us at the table with our colleagues and showing exactly to what extent we can contribute to the patient experience and outcome.

Long-term, how should radiologists prepare for what is ahead?

Kruskal: Radiologists have to be embracing their many tools to allow ourselves to succeed, and I believe that most are.  Practices need to broaden their scope in terms of skills of new recruits. I believe that young radiologists entering the job market are well-aware of the new career opportunities that are now available. 

The concerns about machine learning should not exist given our need to embrace machines and data science to become even more effective.  At the same time, it would certainly help if radiologists could get together at the national level, so that we don’t all need to reinvent the wheel. We can be much more thoughtful and smart about developing tools and processes that we can share.  I know that this already happening at the national level. 

Are these new priorities impacting how you assess individual radiology productivity?

Kruskal: Across the country, we are all seeing increasing productivity, with wRVUs going up across the board. Of the many reasons for this, one is the growth in imaging networks and successful efforts to keep patients within networks and restrict out-migration.

Another challenge we all face is the inverse relationship between wRVUs and revenue, so we are all working harder to keep up and sustain income. This  harder work is compounded by technical advances presenting us with many more sequences and images to interpret, greater demands for timely access and reads and, of course, an increasingly demanding regulatory environment.

Put all of this together, and no one should be surprised at the stress and burnout levels that radiologists are experiencing. As we aggressively seek solutions to mitigate the stress and improve satisfaction at work, the last thing I want to be doing is holding my very hard-working radiologists accountable to productivity metrics.  For this reason, we look to reward the many excellent contributions that our radiologists make to benefit our patients and other stakeholdersthat extend well beyond traditional wRVUs.

It is very difficult to reward individual radiologists in a large academic practice. To preserve and drive team effectiveness—and recognizing that ranking and rating different contributions is far too subjective (and time consuming)—we reward everybody the same based on current metrics endorsed and supported by the healthcare system, such as reducing inpatient MRI (to help drive hospital length-of-stay down), compliance with critical results notification policies, turnaround times for inpatient MRI studies and section participation in extended service-hours programs.