Dr. Shrestha is Vice President, Medical Information
Technology, University of Pittsburgh Medical Center, Pittsburgh, PA; and
Medical Director, Interoperability & Imaging Informatics,
Disclosures: Dr. Shrestha is on the
Medical Advisory Boards of Nuance, Inc., and Vital Images, Inc., as well
as on the Editorial Board of Applied Radiology, and the Advisory Board of KLAS Research.There is no doubt that change is coming to the world of imaging; both
in the very way we practice the profession, as well as in the way we
contribute value back to health care. The spiraling cost of health care
in the United States (U.S.) is unsustainable, and it has perhaps been
rightly stated, “advanced imaging is the bellwether for the excesses of
fee-for-service medical care.”1
Currently, the United States
spends more on health care services than any other country, exceeding
$2.6 trillion, or about 18% of our gross domestic product, yearly; yet
Americans have a shorter life expectancy than people in almost all of
the peer countries.2 What’s worse is that this cost is
increasing faster than inflation and the economy as a whole. While there
are many reasons for this, one of the key reasons cited is that we tend
to pay doctors, hospitals, and other medical providers in ways that
reward doing more, rather than being efficient, in the way health care
as a whole is delivered. Here’s what is not working: our predominantly
fee-for-service system that reimburses for each test, procedure or
visit, alongside medical systems that lack integration, propagate
unnecessary tests and over diagnosis. The U.S. did 100 magnetic
resonance imaging (MRI) tests and 265 computed tomography (CT) tests for
every 1,000 people in 2010—more than twice the average in other OECD
(Organization for Economic Co-operation and Development) countries.3
is a definite need to shift from a volume-based practice of imaging to
one that emphasizes value across the care continuum.
Health care reform and ACOs
Health Information Technology for Economic and Clinical Health (HITECH)
Act, implemented as part of the American Recovery and Reinvestment Act
(ARRA) of 2009, was signed into law on February 17, 2009, to promote the
adoption of meaningful use in health information technology. Now, while
radiology is no stranger to adopting and using digital technology, the
push to use electronic health records (EHR) and care coordination across
the full spectrum of health care delivery has wide-reaching
implications for radiology—and these implications have not been fully
understood or embraced by the radiology community. The Patient
Protection and Affordable Care Act (PPACA) of 2010 has provisions for
the development of accountable care organizations (ACOs) and happens to
represent one of the most significant regulatory overhauls of the U.S.
health care system since the passage of Medicare and Medicaid in 1965.
ACO initiative has the potential to remake health care delivery,
incentivizing physicians and health care providers of all
types—hospitals, clinics, long-term care facilities, and others—to work
together to improve outcomes and generate shared savings. Increasingly,
some integrated delivery health systems and large multispecialty groups
already consider themselves to be ACOs, or they have adopted many facets
of the notion of accountable care. While some of these newer models are
rehashing older hospital- and physician-managed care partnerships from
the 1990’s, the goal of reducing costs through better care coordination
is a noble one and certainly worth another try.
The Centers for
Medicare and Medicaid Services (CMS) began entering into agreements with
ACOs in January 2012. From late 2011 to early 2013, Medicare contracted
with > 250 ACOs nationally with 4 million total Medicare
beneficiaries. Another 100 to 200 ACOs are expected to be added in the
next 2 years. At the heart of the ACO model is a shared-savings program,
which reimburses participating physicians and providers for the
quality, efficiency, and appropriateness of the care they deliver. ACOs
must meet quality standards to ensure that savings are achieved through
improved coordination and provision of appropriate, safe, and timely
care. CMS has established 33 quality measures on care coordination and
patient safety, the appropriate use of preventive health services,
improved care for at-risk populations, and patient and caregiver
experience of care. If the ACO surpasses certain performance benchmarks,
CMS will effectively share those cost savings with the ACO.
The war against inappropriate overutilization of health care resources is on, and radiology is a prime target.
Understanding the climate to weather the storm
care may provide a framework to control costs primarily by reducing
avoidable, duplicative, variable, and inappropriate use of health care
resources. In this era of turbulent financial rumblings, fully
comprehending the climate is critical to weathering the storm.
leaders face many business and operational challenges. While some
perceive destabilizing effects of health care reform, the reelection of
President Obama ensured one thing for health care, regardless of party
lines: Reform is here to stay. It is now time to turn any question
marks into periods—perhaps even into exclamation marks. Understanding
the challenges affords us the chance to leverage the opportunities at
hand. In his most recent State of the Union address,4 the
President remarked, “We’ll bring down costs by changing the way our
government pays for Medicare, because our medical bills shouldn’t be
based on the number of tests ordered or days spent in the hospital—they
should be based on the quality of care.”
According to a recent
study that retrospectively analyzed a large group of CT and MRI
examinations for appropriateness using evidence-based guidelines,
approximately 26% to 30% of the imaging tests ordered were deemed either
unnecessary or inappropriate.5 The American College of
Physicians (ACP), the largest U.S. medical specialty group, found that
excessive testing costs a staggering $200 billion to $250 billion per
Another reality facing imaging leaders is that
of softening volumes amidst a climate of continued reimbursement
erosion. Despite an exceptional run in the late 1990’s and early 2000’s,
with Medicare outpatient imaging volumes experiencing growth rates from
10% to 15% annually, the growth of discretionary noninvasive diagnostic
imaging in the Medicare fee-for-service population has distinctly been
slowing since 2005, with the slowdown being most pronounced in MRI and
nuclear medicine.7 Current trends also point to declines in
hospital-based imaging in almost all modalities. The previous ‘age of
growth’ in imaging has given way to an ‘age of accountable care,’ with
increased scrutiny, greater price sensitivity, and greater focus on the
full cost-of-care that rewards imaging appropriateness.
also finalized the expansion of Multiple Procedure Payment Reduction
(MPPR), and this clearly will have an impact on reimbursement. CMS will
apply MPPR to the professional payments of certain advanced imaging
services, such as CT, MRI, and ultrasound, primarily in situations when
multiple imaging services are furnished to the same patient, in the same
session, on the same day, by the same practitioner. The imaging
procedure that carries the highest professional payment will be paid in
full, while professional payments for other services will be reduced by
However, the reimbursement battle rages on,
led by organizations such as the American College of Radiology (ACR).
Expressing strong opposition to further cuts in imaging reimbursement,
the ACR recently argued that imaging reimbursement has been cut 12 times
since 2006,9 and warned of adverse effects on patient care
resulting from these reductions, including a significant regulatory cut
to (noncontrast) lower- and upper-extremity MRI reimbursement in the
2013 Medicare Physician Fee Schedule. The ACR correctly argues for the
adoption of quality-based imaging utilization and management policies
that would mandate the use of appropriateness criteria in ordering
advanced imaging studies.
Imaging utilization, defensive medicine, and decision support
massive cultural revolution, incentivizing a move away from blind
defensive medicine, is needed to address a number of cascading key
trigger points in support of appropriate imaging. It is not just the
swell of patient demand for more imaging, triggered by consumer-directed
marketing of the availability and benefits of various procedures, such
as full body CT scans. Nor is it just the disturbing and proven
relationship between physician self-referrals and higher imaging
utilization,10 perhaps to offset costs associated with
acquiring expensive imaging equipment. Many physicians choose, and are
taught, to practice ‘rule-out medicine’ as opposed to actual ‘diagnostic
medicine’ in fear of liability and expensive litigation resulting from
missed findings. According to a recent survey,11 the cost of
defensive medicine is estimated to be in the $650 billion to $850
billion range, or between 26% and 34% of annual U.S. health care costs.
What prompted a New England Journal of Medicine paper, “The Uncritical Use of High-Tech Medical Imaging,”12
was an interesting observation the author makes: Imaging tests are most
valuable when the probability of disease is neither very high nor very
low but in the moderate range. Various imaging utilization management
systems have been enforced in various forms by insurance companies and
radiology benefit management (RBM) companies. Prior authorization,
prenotification, and various network strategies that focus on
examination costs, total quality, and practice guidelines have also had
varying levels of success. Beyond more tailored tort reform, and an
evolution in medical education and training, perhaps the most effective
antidote to this trend is data—intelligent, personalized data
based on solid, evidence-based medicine, tightly integrated into the
decision support and physician-order entry workflow. Ordering physicians
want to do what is best for their patients, and presenting them with
intelligent, personalized data around image-order entry appropriateness,
alongside easy access to relevant priors, will work wonders. This is
difficult, but not impossible—and is a critical step toward meaningful,
Continuous quality improvement
key enabler of value-based imaging is also to embrace a culture of
continuous quality improvement (CQI) that ensures both qualitative and
quantitative methods to assess quality. Value-based imaging needs a core
culture of continuous improvement in safety, performance,
appropriateness, and outcomes to stay competitive in today’s rapidly
changing health care environment. We need to thoroughly embrace the ACR
accreditation programs, which are based on the ACR Practice Guidelines
and Technical Standards13 and created through a thorough consensus process with collaborative efforts with other medical specialty societies.
quality tracking should be a core goal. Physician Quality Reporting
System (PQRS) certification and maintenance needs to be considered a
serious opportunity to embrace quality. The Affordable Care Act also
required CMS to provide physicians with the option to report data on
quality measures through a Maintenance of Certification (MOC) program
operated by a specialty body of the American Board of Medical
Specialties. An incentive payment of 0.5%, additional to the PQRS bonus,
is authorized for years 2011-2014 if certain requirements are met.
care entails a keen focus on quality, outcomes, and costs—and
continuous quality improvement is the linchpin that will enable better
clinical outcomes at lower costs.
Transparency and visibility
Accountable care will require radiology to function in an environment of increased transparency, while it requires radiologists to become more visible across the care delivery continuum.
transparency between the payer and the provider in terms of utilization
data, appropriateness, and costs will foster an environment of informed
decision making. A recent study14 that looked at price
transparency and its impact on imaging-order appropriateness found that
cost alone was not a determining factor in deterring high-cost imaging
procedures. However, with a focus on bundled payment models and
outcomes-driven treatment, ACOs will need to seriously enable
transparency of data available to radiology services. Successful
strategies that aim to reduce costs and increase collaboration across
clinical lines call for both insurers and providers to develop more
transparent policies and procedures for business, and to use clinical
data analytics so that these metrics are clearer and more visible as the
new models of care.
At the same time, however, visibility is key
for the often-lonesome radiologists. Radiology as a group is facing
increasing threats of commoditization. The inordinate level of focus on
metrics, such as report turn-around time (TAT) and fee-for-service, has
made the radiologist an invisible commodity ready to be traded freely on
price. This is directly contradictory, however, to the notion of
value-based imaging, where quality and care coordination are just as
important as costs. Radiologist-outreach programs must be put in place,
and radiologists should be incentivized to forge meaningful
relationships with referring physicians.
Visibility should also be
fostered through improved intradepartmental and cross-specialty
collaborations that highlight the value that radiologists bring to the
care continuum. Improving communication with referring clinicians in
both a synchronous and asynchronous manner is critical to sustaining the
value of the full radiology service to the health care organization.
The era of accountable care calls for radiologists to be fully engaged
with emergency physicians, hospitalists, and primary care physicians
(PCPs) as part of a collaborative solution toward appropriate image
utilization and improved outcomes. Radiologists have always served as
strong, albeit silent, patient advocates around imaging appropriateness.
But as health care organizations move from fee-for-service to
fee-for-value models, the value needs to be quantifiable and measurable
to really matter. In guiding and defining the future of radiology, the
ACR continues to seek to affirm the role of radiologists as physician
consultants.15 The ACR’s “Face of Radiology” campaign conveys
to patients that the “radiologist is the physician expert in diagnosis,
patient care, and treatment through medical imaging.”
a doubt, there is a steady march away from the practice of volume-based
imaging to that of value-based imaging. In anticipation of these newer
care models that bring with them payment changes and a redefinition of
the measures of ‘outcomes’ associated with the very practice of our
profession, it is critical for radiologists and all associated with the
industry to better comprehend the rationale and intricate workings of
accountable care. The challenges ahead also call for developing
innovative information technology investments or strategies to support
key priorities and well-thought-through informatics solutions that
intelligently enable the realization of value-based imaging from the
Becoming accountable for the total quality, cost, and care
of patients while embracing evidence-based medicine, coordinated care,
and shared savings can be a tall order. But these are exactly what we,
as an industry, now need to focus on so we can weather the storm of
payment reform, redefine service excellence in radiology, and explore
new models of hospital-radiologist partnerships.
The Boy Scouts have it right: “Be prepared.”
- Iglehart JK. Health insurers and medical-imaging policy—a work in progress. N Engl J Med. 2009;360:1030-1037, s.l.
U.S. health in international perspective: Shorter lives, poorer health.
Institute of Medicine.
January 9, 2013. Accessed February 19, 2013.
- Kane J. Health
costs: How the U.S. compares with other countries. PBS Newhour.
Updated October 22, 2012. Accessed February 11, 2013.
of the Union 2013. The White House.
http://www.whitehouse.gov/state-of-the-union-2013. Updated February 12,
2013. Accessed February 15, 2013.
- Lehnert BE, Bree RL.
Analysis of appropriateness of outpatient CT and MRI referred from
primary care clinics at an academic medical center: How critical is the
need for improved decision support? J Am Coll Radiol. 2010;7:192-197.
Sherman D. Stemming the tide of overtreatment in U.S. health care.
2012/02/16/us-overtreatment-idUSTRE81F0UF20120216. Updated February
16, 2012. Accessed February 11, 2013.
- Levin DC, Rao VM, Parker L, et al. Bending the curve: The recent marked slowdown in growth of noninvasive diagnostic imaging. AJR Am J Roentgenol. 2011, Vol. 196:W25-29.
Services, Centers for Medicare and Medicaid. 2012 Medicare Physician
Fee Schedule Final Rule. http://www.cms.gov. Updated January 7, 2013.
Accessed February 19, 2013.
- Medical imaging has been cut 12
times since 2006. American College of Radiology.
Updated February 7, 2013. Accessed February 11, 2013.
Stensland, Ariel Winter and Jeff. Impact of physician self-referral on
use of imaging services within an episode. Medicare Payment Advisory
Updated April 8, 2009. Accessed February 2, 2013.
- A costly
defense: Physicians sound off on the high price of defensive medicine.
Jackson Health care. http://www.jacksonhealth
care.com/media/8968/defensivemedicine_ebook_final.pdf. Updated May 27,
2011. Accessed February 14, 2013.
- Hillman BJ, Goldsmith JC. The uncritical use of high-tech medical imaging. N Engl J Med. 2010;363:4-6.
Radiology, American College of. Accreditation. American College of
Radiology. http://www.acr.org/Quality-Safety/Accreditation. Accessed
February 14, 2013.
- Durand DJ, Feldman LD, Lewin JS, Brotman DJ. Provider cost transparency alone has no impact on inpatient imaging utilization. J Am Coll Radiol. 2013;10:108-113.
- Paz D. The radiologist as a physician consultant. J Am Coll Radiol. 2010;7:664-666.