Juggling Priorities

Radiologists must weigh the benefits and penalties when prioritizing health care reform initiatives.


In the classic Road Runner cartoon, it's hard not to feel a bit sorry for poor Wile E. Coyote. Every time he thinks the Road Runner is within reach — BAM! — something happens that makes the coyote wonder whether he'll ever catch the long-legged bird.

It's a scenario that many radiologists are familiar with. While they're not chasing the Road Runner's signature "beep-beep," they are pursuing the myriad changes facing radiology in this era of health care reform. And for many, just when they think they are close to grasping the requirements, a new initiative is introduced that leaves them wondering how they can ever keep up.

In addition to maintaining their day-to-day operations, radiologists are being challenged to implement several new initiatives — each with its own acronym and laundry list of hurdles. They are expected to implement the Physician Quality Reporting System (PQRS), Meaningful Use, clinical decision support, and new International Classification of Diseases (ICD-10) codes. Radiologists are also being urged to join accountable care organizations and increase their value to patient care teams by adopting quality improvement programs for which no standard strategies currently exist. Some of the initiatives are optional, but many are mandated by CMS and carry financial penalties for practices that do not implement them.

With so many initiatives and limited resources to implement them all, radiologists must determine which programs meet their needs and which they can realistically adopt. From there, they must develop plans and engage their teams to execute the programs. "It's easy to become overwhelmed as these regulations change and evolve so quickly," says Ezequiel Silva III, MD, FACR, director of interventional radiology at South Texas Radiology Group and vice chair of the ACR Commission on Economics. "Radiology practices must be proactive about implementing programs that improve their financial status and position them well as the industry moves toward value-based care."

Poised for Change

Many of the initiatives take time, additional personnel, and upfront costs to implement, making it difficult for most practices to adopt them all at once. Therefore, practices must take a systematic approach to enacting the programs. "As practices make the philosophical commitment to do these quality initiatives, it is important to be mindful of the extra expense they will incur," Silva says. "They must have the resources available and be smart about how they deploy those resources." For instance, implementing ICD-10 may require additional staff training, while installing clinical decision support software is an obvious technology cost.

John H. Lohnes Jr., MD, FACR, president and chief operating officer of Wichita Radiology Group, says that practices should consider where they stand in the marketplace as they weigh which initiatives to invest in. "Like any business, radiology practices have to evaluate where they are in their local community, where the community's heading, and which players are driving various changes within the community," he says. To conduct such an evaluation, practices must stay abreast of the current trends by maintaining communication with referring physicians and other members of their health care system. "Once they have this background information, practices can determine which initiatives will help position them in a positive manner and advance their goals," Lohnes says.

As they begin prioritizing the initiatives, radiologists will notice that many of the programs require input from referring physicians and hospital administrators. Gathering that input and implementing those initiatives takes a significant amount of time, but Silva says that radiologists shouldn't shy away from them. Instead, they should use those initiatives to engage their health care partners and highlight the value that radiology brings to patient care. "I love that radiology's presence is evolving so quickly, and we are having a role in a number of immediate initiatives such as clinical decision support that impact the larger health care team," Silva says. "But initiating all of these things takes effort. The practices that do it right are the ones that are going to come out on top, regardless of how payment reform evolves."

Priority One

One initiative radiologists say all groups should adopt is PQRS. When it was introduced in 2007, PQRS (formerly the Physician Quality Reporting Initiative) was an incentive-based program that paid practices 1.5 percent of their estimated allowable charges for Medicare Part B in exchange for their participation. Silva says that although the incentive wasn't significant, his group implemented PQRS in 2007 as part of its mission to be a premiere radiology group. "From a philosophical perspective, we thought we couldn't call ourselves a quality group if we weren't participating in the quality initiatives that CMS was asking us to take part in," Silva says.

PQRS has since changed from an incentive program to a payment-adjustment initiative. That means that beginning in 2015, groups that don't participate will incur a financial penalty. Max Wintermark, MD, chief of neuroradiology at Stanford University, says PQRS is relatively easy to implement, so all groups should adopt it to avoid the penalties. "PQRS is completely in our control to implement and doesn't require a lot of assistance from other departments, so that's a good one to start with," Wintermark explains. "From there, you can make a priority list of the initiatives that are a bit more complex and that require buy-in from referring physicians, hospital administrators, and patients."

Practices considering how to prioritize other initiatives to implement after or alongside PQRS should examine the consequences associated with each initiative. For instance, practices that aren't ready for ICD-10 when it takes effect in October 2015 stand to lose a lot of money. "Groups want to be proactive because they don't want to have their claims denied and their revenue stream suffer while they try to figure out what is wrong with their ICD-10 codes," Silva says. He adds that all practices should also be prepared for a delay in payments as the new codes take effect late next year. "I hate to be crass and say that everything is about money, but you owe it to your group, patients, and practice to remain financially viable through all of this," Silva says. "You need to make sure you have either a line of credit or some cash in the coffers to pay your staff and maintain your operations in the event of claims processing delays."

Embracing the Future

Once practices establish a plan of action, they must get their staffs on board with the changes. Wintermark says that one of the best ways to ensure everyone is committed to the changes is to include everyone in the planning discussions early on. "The practice leaders need to sit down together to look at the needs of the practice, its patients, and its referring physicians," he says. "It's much easier to engage colleagues and staff if everyone is involved from the start in selecting which initiatives the group is going to participate in."

Still, it's unlikely that everyone will welcome the changes right away. Practices can take a variety of approaches to get their staffs and radiologists to comply with the new workflows. For example, Silva says that when his group implemented PQRS, it created what it called a dictation clarification system. Every time a radiologist submitted a report that failed to meet the PQRS parameters, the system automatically sent an email asking that the report be corrected. "We saw the number of inadequate reports decrease dramatically in a short amount of time thanks to the system," Silva says. "That's important because whatever your cynical thoughts are about these CMS mandates, they are still the law and you still have to comply with the statutes."

While opinions about the usefulness of the initiatives vary, embracing the programs rather than working against them can help radiologists demonstrate their value to the care team. "We're in the best position to define our patients' needs, so radiologists need to take the lead in these initiatives and be actively involved in them," Wintermark says. In concurrence, Silva says that radiologists should use the initiatives as icebreakers to inject themselves into the health care reform discussion. "These initiatives are gifts that are being handed to radiologists, and we can use them to establish and solidify ourselves as experts — from traditional imaging all the way to clinical support as consultants in patient care," he says. Practices that leverage the initiatives successfully will be more likely to turn the tables — becoming the Road Runner rather than the coyote.

 By Jenny Jones, freelance writer for the ACR Bulletin



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