Value Above All

The ACR Annual Conference on Quality and Safety assesses radiology's value in an ever-changing health system.

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The importance of demonstrating and expanding value as radiologists was the central theme of the ACR Annual Conference on Quality and Safety, held in Boston this past October.

Jonathan B. Kruskal, MD, PhD, FACR, chair of the department of radiology at Beth Israel Deaconess Medical Center in Boston and chair of the ACR Commission on Quality and Safety’s Quality Management Committee, opened the conference by discussing the present state of radiology. “We currently exist in a disconnected state,” he said. “We are a small cog in the wheel of value-based healthcare, and we cannot afford to overestimate our contributions nor how others perceive our value proposition.”

Despite some early adopters and initiatives emphasizing the improvement and recognition of this value, many have not embraced the act of cultivating radiology’s value, according to Kruskal. Why? Given the current political climate, many are justifiably uncertain about the future of the Affordable Care Act and how it will impact healthcare, reimbursement, and the fee-for-service paradigm. Another, perhaps less complicated, reason is that many don’t know how to define value and are unsure how value truly impacts their organization’s outcomes.

The Big Picture

Providing a perspective on the U.S. government’s role in healthcare, Gregory N. Nicola, MD, vice president of the Hackensack Radiology Group in New Jersey, presented in a session titled “What’s Driving the Shift to Value? Our Economic Imperative.” Nicola described the economic forces behind radiology’s overall move away from fee-forservice. The U.S. spends more of its gross domestic product on healthcare than any other country, he noted, but it ranks lowest in health system performance overall among advanced countries, according to data from The Commonwealth Fund (available at

To rein in spending and establish measures for value, CMS has incentivized the move from volume to value through its MACRA program, its endorsement of public-private partnerships, and the “massively complex” Quality Payment Program (which encompasses the Merit-Based Incentive Payment System and alternative payment models). In addition, payers, such as Anthem, are attempting to control costs themselves by placing blanket restrictions on specific imaging services.

Defining Value

To help define value, David B. Larson, MD, MBA, associate professor of radiology at Stanford University Medical Center, during his presentation titled “Creating and Capturing Value for our Stakeholders,” stated that value is something that provides worth to an individual to fulfill a need or desire. Value often depends on what recipients must sacrifice versus the quality and service they receive. Therefore, the receiver, not the provider, determines value. In such an environment, he noted, understanding the receiver’s perspective is critical.

Larson noted that radiologists may find it difficult to understand the perspective of the end customers (patients) because radiologists are so far removed from them. It may be equally difficult for radiologists to understand the perspective of the direct customers (referring providers), because specialists, emergency providers, and primary care providers have such disparate needs. In addition, technology can be a disruptor in the care continuum because of variables such as staff changes, preferred methods of communication, and even changes to the technology itself.

Creating a Strategy

To overcome these obstacles, Kruskal recommended several strategies designed to help radiology thrive and increase its value in today’s healthcare system.

Engage your customers. Radiologists must understand and show their customers — referring providers and patients — how they contribute to patients’ health. To do so, radiologists must understand how health is defined and measured and establish ways to collaborate and become more customer-centric. “We don’t get to define the metrics that reflect our value proposition, but we still have the opportunity to manage them,” Kruskal noted.

Deliver excellent service through continuous quality improvement. Implementing continuous quality improvement requires time and resources. It cannot be delegated or outsourced, and it should not be viewed simply as performance and quality improvement checkboxes, a committee, or a line item in the annual operating plan. “Service excellence cannot and should not be purchased or outsourced. Own the service that your customers expect, or they will outsource you!” Kruskal admonished.

Provide data-driven care and know how to measure value. Radiologists should ask themselves, “Is radiology improving human health?” What metrics do radiologists have for determining the answer to that question? Measuring value is not easy because there is no single metric that fits all situations, customers, and stakeholders. Also, effective metrics will continuously evolve. Nevertheless, the value equation can be defined as a vision statement that encompasses such themes as appropriateness, outcomes, experience, quality, and cost.

Communicate unambiguously. The imaging report is the radiologist’s “product.” There are ways to standardize reports and provide more value to customers. For example, the phrase “satisfactory biopsy” is vague, whereas “adequate diagnostic material” conveys a more specific impression.

Engage in appropriate and efficient care. Sometimes the best care for the patient is to do nothing. It is important to determine if a study is necessary and will answer the specific clinical question being asked.

Be available, accessible, and affable. Radiologists should “leave the basement” and go to “the floor where care is provided,” explained Kruskal. They should find their patients and encourage their clinical colleagues to visit the reading room.

Learn and improve, always. Radiologists should be transparent about reporting, analyzing, and sharing their errors and near misses. “Any process that minimizes, delegates, or obscures this legitimate improvement effort and culture should be avoided at all costs,” Kruskal said.

By Brett W. Hansen, CAE, Assistant Director, ACR Press

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