Adapting to Change
In a time of declining reimbursements and increasing government regulations, radiologists evolve to remain integral members of the health-care community.
No one remembers Camarasaurus. At 75 feet long and weighing 50 tons, the dinosaur thrived during the late Jurassic Period.
Subsisting on tough, fibrous plants, it dominated the landscape of the western United States, foraging in large herds. But then, in a relative blink of an eye, the species vanished. Other species, however, did not share the same fate. Camarasaurus' contemporary, the shark, adapted by diversifying its food supply, outlasting the dinosaurs and rising to the top of the food chain over the millennia.
What lessons can radiologists draw from this chapter of history? Whether in paleoclimatology or in business, only those who adapt to their surroundings will survive. Will radiology follow the shark or Camarasaurus? Radiologists currently face a sea change in health care that will require them to alter the way they do business in order to thrive as a profession. If they do not, they risk being left behind as health-care reform moves forward. Fortunately, the ACR has created a set of resources to help radiologists prosper in these changing times.
Endangered Species: Fee-for-Service
The way radiologists have traditionally practiced is under significant pressure. Several factors have contributed to this state of affairs, including payer attempts to control ever-escalating costs, which have resulted in reimbursement cuts for many providers, among them radiologists. Citing the perceived overuse of imaging, CMS and Congress have cut imaging payments to radiologists 12 times in the past six years.1
In addition, efficiency-improving technologies such as RIS and PACS, along with innovations like teleradiology, have reduced the visibility of radiologists and distanced them from referring physicians and patients. A recent survey of patients conducted by the Indiana University School of Medicine found that over half of respondents had little or no idea what radiologists do. Furthermore, in an effort to support an increase of payments to primary care physicians, policy-makers continue to make cuts to specialists, including radiologists.
Radiologists have already begun feeling the effects of these tectonic shifts in their profession. Examples include a tightening of the labor market as hospitals and practices try to do more work with the same staffing levels, a consolidation of smaller practices into larger groups to take advantage of a range of physician subspecialties, and hospitals forcing client practices to align with the electronic health record systems they use, threatening to take their business elsewhere if radiologists do not conform. In addition — and perhaps most harmful of all — radiologists have begun to see a commoditization of the imaging services they provide.
Commoditization Tar Pits
Bibb Allen Jr., MD, FACR, vice chair of the ACR Board of Chancellors, and a private practice radiologist with the Birmingham Radiological Group, PC at Trinity Medical Center in Birmingham, Ala., describes the threat commoditization presents to the specialty this way: "If radiologists can't figure out a way to save the health-care system money while providing good patient care, the only thing we'll be competing on is price." The danger inherent in commoditization is that if the price for providing an interpretation is the only factor that distinguishes one radiologist from another, then quality patient care will not be a high priority. This situation "represents a departure from the radiologist's full responsibility to not only generate a report but to all assure a safe, high-quality imaging environment," remarks Cynthia S. Sherry, MD, FACR, chair of the Department of Radiology at Texas Health Presbyterian Hospital Dallas. "Radiologists must stop considering themselves ancillary and embrace their role as central to the modern practice of medicine."
Some in the industry think that radiologists have no one to blame but themselves for the fact that commoditization looms on the horizon. "Radiologists have been their own worst enemy in terms of commoditization," notes James H. Thrall, MD, FACR, chair emeritus of the Department of Radiology at Massachusetts General Hospital in Boston. "They have gone to work for companies that arbitrage their professional fees, paying them a discount. Also, groups have outsourced their night work to corporations, which has basically taught people that what radiologists do is a commodity."
"If radiologists can’t figure out a way to save the health-care system money while providing good patient care, the only thing we’ll be competing on is price." — Bibb Allen Jr., MD, FACR
Commoditization has affected other areas of medicine as well, particularly in the field of pathology. In the early decades of the 20th century, pathology was widely seen as the "scientific foundation of medicine." However, because pathologists have infrequent patient contact, the role they play as key members of the health-care community is not always clear to patients and policy-makers. In addition, the automation of laboratory processes and the outsourcing of biopsy specimens have paved the way for the commoditization of the field based on price.
Time to Evolve
While some of the same forces that led to the commoditization of pathology are at work in radiology, the changes being wrought by health-care reform afford radiologists the opportunity to redefine themselves as leaders in value-based imaging care. Those radiologists not content to let their services be solely distinguished by price points can leverage their expertise to promote appropriate use of imaging services by providing imaging decision support to their referring physicians. This consulting role, proponents argue, will save the health-care industry money by utilizing point-of-care IT tools to cut down on inappropriate or duplicative imaging while ensuring patient safety through attention to radiation exposure. This initiative, developed to help practitioners evolve to take on a new role within the health-care team, is known as Imaging 3.0™.
Imaging 3.0 encourages radiologists to implement tools that bolster their position as unique caregivers, putting them in a stronger position to advocate for fair compensation in the shifting health-care landscape. Howard B. Fleishon, MD, MMM, FACR, former ACR Council speaker and medical director of North Mountain Radiology Group in Phoenix, says, "Utilization management is and will be a centerpiece of controlling costs. The right test for the right reason every time will be a value play. And that is what Imaging 3.0 is about." Decision-support instruments, such as the ACR Appropriateness Criteria® and its interactive component, ACR Select™, enhance referring physicians' ability to safeguard patient safety by providing an evidence-based methodology to ensure the right imaging examination is performed every time. In complex encounters in which the Appropriateness Criteria do not provide clear guidance or a referring physician wishes to override criteria for compelling clinical reasons, radiologists can serve as peer-to-peer consultants.
"Radiologists must stop considering themselves ancillary and embrace their role as central to the modern practice of medicine." — Cynthia S. Sherry, MD, FACR
In addition to ACR Select and the ACR Appropriateness Criteria, Imaging 3.0 encompasses many other strategies to help reinforce radiology's primacy within health care. Allen's practice has already implemented several such techniques to help position it for the future. For instance, he and his colleagues participate in the Physician Quality Reporting System, a reporting program that provides incentive payments and payment adjustments to eligible professionals who report data on quality measures for services provided to Medicare beneficiaries. They also take part in ACR's Dose Index Registry®, which allows facilities to compare their CT dose indices to regional and national values to ensure their radiation levels remain acceptably low. In addition, the practice's next PACS upgrade will include a radiation monitoring tool to enhance patient safety. "Radiologists have to convince policy-makers that our value to the system goes well beyond just image interpretation," notes Allen. "We also have to help them understand that continued fee-for-service payment reductions will not be the road to value-based care. Fee-for-service provides incentives to increase volume. To move to value-based care in medicine, payers and policy-makers need to provide incentives for physicians to reduce unnecessary care. By aligning these incentives, we can provide optimal care for patients and the population as a whole."
When preparing for the future, radiologists should look to the past for guidance. The commoditization of radiology will benefit no one, least of all patients. But to prevent this eventuality, radiologists must find ways to increase their relevance by improving patient care beyond just image interpretation. Since quality patient care is a radiologist's top priority, doctors can implement Imaging 3.0 strategies to transform their approach from a volume-based model into one that is predicted on offering value to the health-care system. In this way, future generations will know the benefits radiologists provide to health care without having to visit a museum to learn about them.
For more information about Imaging 3.0, please visit http://bit.ly/ACRImaging3.
1. Allen Jr. B. Presentation to the Association of University Radiologists. April 11, 2013.
By Chris Hobson