Tailoring Access to Care
The business case for reducing missed care opportunities.
Recently, a patient walked away from a meeting that included her primary care physician (PCP) and her radiologist and declared she had just received "a mini lesson in medical evaluation and reasoning."
She told her radiologist that she was fascinated to see the images and hear how her doctors assessed the significance of what they revealed. And, above all, she "walked away having a much better grasp of the findings."
A growing number of patients are asking for this level of understanding when it comes to their medical care — and physicians are responding with new care models that involve the patient more closely and promote collaboration among providers. In addition to boosting the quality of care, these patient-centered measures impact reimbursement and enable radiologists to maintain their foothold in the wider health system.
These efforts are paying dividends among early adopters. Practices are seeing seemingly small efforts bring about big changes in their practices, hospitals, and health systems. Patient-centered care models can help radiologists maintain competitive standing, build stronger relationships with referring clinicians, and increase awareness across all parties involved in diagnosis, treatment, and follow-up care.
"Historically, and not uncommonly, in radiology practices, the attitude was if you build it they will come," says James A. Brink, MD, FACR, chief of radiology at Massachusetts General Hospital (MGH) and chair of the ACR Board of Chancellors. "We'd open our doors and say, 'We're open for business.' Patients would arrive and have their imaging care provided." But that is no longer the case, Brink asserts. Patients now have more say in where and how they receive care.
Better patient care also translates into improved relationships with primary care physicians. "In the past, the primary responsibility for ensuring that patients got the care that they needed was left to the primary care doctors," says Brink. "Some of their contracts with payers measure their ability to get patients in for procedures such as screening mammograms. If radiologists can connect with PCPs to make sure that patients are actually getting the imaging tests that are ordered, it alleviates some of the burden the PCPs are used to shouldering. If there is anything we can do to help connect with their patients, just a little bit of effort on our part goes a long way toward improving patient care and our reputation with PCPs."
A small team of radiologists at MGH is exploring use of virtual radiology consultations to redefine physician collaboration to improve patient care. These "virtual consults" connect a patient along with his or her PCP to a radiologist, who reviews the images and explains the results. All three parties have the opportunity to evaluate findings, ask and answer questions, and collaborate on the best course of treatment and follow-up.
The experience so far has been a good one, according to Dania Daye, MD, a radiology resident at MGH. "It started a few years ago with an in-person consultation clinic," Daye says. From there, she and her faculty mentor and lead on the virtual project, Dushyant Sahani, MD, came up with the idea of building on the initial program's success by launching the virtual clinic as a pilot. "This pilot emphasizes the importance of a radiologist's role and gives the patients more accessible information when reviewing images, often clarifying what their primary care doctor has already told them," says Daye.
The virtual consult pilot won funding late last year and the radiologists plan to expand access to as many patients and interested physicians as it can accommodate. So far, the program has received favorable reviews from the approximately 25 patient participants and their corresponding radiologists. "Patients appreciated their experience and weren't anxious or confused by the images they were shown," Daye says. The virtual meeting helps patients understand the imaging findings in the context of the rest of their care, she asserts, and also allows the radiologists to explain any incidental findings, potentially allaying the fears of the patient and the uncertainty of the PCP.
Seizing New Opportunities
"No matter how you slice it, an empty appointment slot is a terrible thing," Brink says. Developing programs that can increase patient engagement and reduce missed care opportunities (MCOs) actually increases health care efficiency and revenue, notes Efren J. Flores, MD, director of Radiology Community Health Improvement at MGH. "MCOs result in delayed diagnoses and negatively impact short- and long-term patient outcomes," says Flores.
MCOs can occur for a variety of reasons. Patients with unmet social needs, for example, are more likely to miss cancer treatment appointments, have fewer mammography screenings, and have prolonged follow-up than those who are socially active, says Flores. MCOs are more prevalent in low-income populations, African-American and Hispanic patients, and among patients whose first language is not English, he notes. Health disparities like these act as barriers to culturally competent and equitable care, Flores says. "These disparities arise from a number of complex causes, including demographic and social determinants of health, such as race, education level, physical disabilities, and logistical constraints," he says.
In reaching vulnerable populations, Brink cites three commonly accepted pillars of academic medicine — clinical practice, teaching, and research — and adds one more tenet physicians may want to consider. "In our hospital, we have a fourth pillar called 'Community Serivce' designed to address diverse issues related to the community we serve," Brink says. "And a key element of providing services to the population at large is to acknowledge the diversity of that community." Examples of community service might include education campaigns or enhanced access for at-risk populations.
When hospitals and practice seek to lower MCOs and bolster patient access to care, they must consider cultural, economic, and age-based differences. One way to assist patients in getting needed services, for example, is to implement text messages for non-English speaking patients as the preferred method of appointment reminders and instructions. For these individuals, it is easier for them to translate a text message than it is to translate a voice message. Practices can add further value by offering reminders and instructions in additional languages other than English, depending on the makeup of their patient population.
Transportation to and from appointments can also be a burden for many patients and a reason for MCOs. One solution in metropolitan areas is to offer transportation alternatives for patients to go to and from their imaging appointments. MGH uses a van shuttle to transport patients to appointments among different MGH facilities. (Before utilizing an unaffiliated transportation service, you should discuss any potential liabilities with your legal counsel.)
Frustration with wait times can also lead to MCOs. Available openings may be too far off, for example, and spots that are finally secured may conflict with tight work schedules or aspects of family life. Offer some flexibility by encouraging patients to visit less-crowded satellite branches, if available, instead of waiting for long periods of time at the main facility. Also, if your practice is in a rural area, be prepared to spend an appropriate amount of time with the patient to review images or answer questions, bearing in mind the time and trouble that may be involved for the patient to get a follow-up appointment.
Is the patient elderly? Older patients present with unique symptoms and conditions compared to their younger counterparts, and radiologists should be mindful of age-specific findings during examinations and try to ensure that the patient is comfortable and relaxed during assessments. Physicians must also keep in mind that older patients (and disabled patients) are often more challenged with transportation options, may be feeling poorly, and tend to miss appointments more often than younger patients.
In disadvantage communities, educational initiatives focusing on the benefits of screening can go a long way in encouraging patients to follow recommendations. And, as Flores points out, partnerships between care coordinators, PCPs, and specialists can help ensure that patients make it to their appointments. Staff availability can make such partnerships challenging, but the effort can ultimately save time and reduce missed appointments.
Brink says his facility is developing a program to better enable care coordinators to identify patients who may be more likely to miss an appointment. From there, the primary care physicians may be brought into the conversation to get their input about the patient's history of care and planned treatment. "Providing even just a little personalized care," he says, "can make the difference in a patient being there or not."
Reaping the Benefits
Many practices may want to implement measures to reduce MCOs, but this can be a hard sell without payment incentives in place, says Ezequiel Silva III, MD, FACR, radiologist with the South Texas Radiology Group in San Antonio and chair of the ACR Commission on Economics. "They may not, for example, be ready to compromise volume in favor of individual consultations and more longitudinal, consultative care. But this is changing as we see more and more quality metrics tied to patient experience and to the overall cost of care," says Silva.
The Merit-Based Incentive Payment System (MIPS) is a current example of value-based metrics. "Fast forward a few years to the emergence of true alternative payment models," Silva says, "and the shift could be even more dramatic. There should be a move away from purely volume-driven care to broader value-driven care."
Flores agrees that ensuring the best access to appropriate care is good business. Some of the simplest steps a practice can take are not terribly expensive to implement. The cost to develop and implement patient assistance programs is relatively low.
Survey data has shown that the way patients view their radiology experience boils down to elements including the way they are treated by medical staff, the accuracy of the information they are given, the timeliness of services, safety, comfort, and cleanliness. Ultimately it is the health care provider's responsibility to engage patients to improve perceptions of care.
The PCPs who have participated in MGH's virtual radiology pilot have been pleased with the consults and have noticed an improved relationship with their patients. They say it gives them more confidence in their management decisions when moving forward with a treatment plan. Daye reports extraordinary interest in the pilot program, which is expected to include many more physicians as it expands.
"We need to start thinking about how the new health paradigm has shifted focus to a shared responsibility among PCPs, specialists, and patients," says Brink.
By Chad Hudnall, writer for the ACR Bulletin