Navigating New Payment Models: A Survival Guide | Health Imaging

Radiologist: How the ACA will impact medical imaging reimbursement – FierceMedicalImaging

Radiologist: How the ACA will impact medical imaging reimbursement

As healthcare reform unfolds, the Centers for Medicare & Medicaid Services is in the process of testing a number of payment policy options such as pay-for-performance, bundled payments and shared savings through accountable care organizations. In an article in the Journal of the American College of Radiology, Andrew Bindman, M.D., of the University of California, San Francisco, writes that radiologists should expect this will result in a change in the way they get paid by Medicare.

These different payment approaches or strategies each incentivize performance. Pay-for-performance, for instance, rewards or penalizes physicians financially in order to incentivize quality care. The Physician Quality Reporting System provides a 1 percent Medicare bonus that’s tied to reporting on quality health measures, and will over time be tied to actual performance. In addition, the programeventually will include penalties up to 2 percent for physicians who don’t participate or are unsuccessful.

Meanwhile, bundled payments for discrete episodes of care cover physician, hospital and post-acute care costs, including laboratory and imaging studies. According to Bindman, since the allocation of the bundled payment is at the discretion of the entity contracting, radiologists should be prepared to demonstrate the value of the services they are providing.

While bundled payments are being tested for groups of patients with specific clinical issues, an ACO is payment model for a broad population of patients.with a variety of clinical needs, Bindman says. These organizations are accountable for all of the costs associated with delivering care to their patient population, and consequently have a financial incentive to identify and treat clinical problems at an early, less costly stage. This means that within this kind of model, radiologists have the ability to demonstrate value by using imaging for cost-effective screening and prevention programs (such as CT lung cancer screening programs).

“How fast and how far ranging these changes ultimately will be is not predetermined,” Bindman says. “However, radiologists can anticipate that the basis for how they are paid will change and that they will need to play a greater role than has been required of them in the traditional fee-for-service payment system to demonstrate that imaging studies are used safely and efficiently.”

To learn more:
– see the article in the Journal of the American College of Radiology
– read about the Physician Quality Reporting System program

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A special board should regulate HMOs | BusinessWorld Online

High healthcare costs: How radiologists can avoid public backlash – FierceMedicalImaging

High healthcare costs: How radiologists can avoid public backlash

One of the country’s major news outlets reminds us that healthcare consumers still have the capacity to get riled up about the cost of healthcare–and the amount of money the people who provide that care get paid.

A recent article in the New York Times examined the case of an Arkansas history professor who went through an outpatient procedure at the Arkansas Skin Cancer Center in Little Rock that ended up costing more than $25,000. Throughout the course of the article, the writer explained that many specialists were “becoming particularly adept at the business of medicine by becoming more entrepreneurial, protecting their turf through aggressive lobbying by their medical societies, and most of all, increasing revenues by offering new procedures–or doing more of lucrative ones.”

As we know, medical imaging and radiology gets its share of abuse when it come to articles like this. Last spring, the Times published an article detailing the extraordinarily high costs of colonoscopies–and other procedures like MRI exams–in the U.S., particularly in comparison to the rest of the world.

We also know that despite the fact that radiology compensation levels have flattened over the last several years, radiology remains one of the mostly highly-compensated medical specialties. According to the latest American Medical Group Association compensation and financial survey, diagnostic radiologists–interventional and non-interventional–rank fourth and fifth among 30 different medical specialties when it comes to compensation levels.

As long as healthcare costs remain a major public policy issue, we will continue to see articles like the two from the Times mentioned above. So what can medical imaging professional do to avoid any potential blowback from this kind of publicity?

First of all, radiologists should be doing what they can to reduce costs, whether it involves focusing on imaging appropriateness or playing a role in helping hospitals provide better patient care and improved safety at lower costs.

They should also be doing more to increase the public’s awareness of the profession so that patients have a better understanding of what radiologists do and the critical role they play in their care. This could involve anything from taking steps to facilitate patient interaction to publicizing the profession through the avenues like social media.

The more radiologists are able to get those messages across–that they play a critical role in diagnosing and treating disease and also are doing their part of keep healthcare costs down–the better able they’ll be to deflect any criticism coming their way. – Mike (@FierceHealthIT)

Appropriate use criteria key to reining in health costs | Urology Times

Appropriate use criteria key to reining in health costs


Blogger Profile

Dr. Shore is medical director of Carolina Urologic Research Center,Myrtle Beach, SC.

Overutilization of diagnostic, prognostic, and therapeutic services not only contributes to excess costs within our constrained health care budget but, even more important, may also contribute to unnecessary patient morbidities.

Unfortunately, special interest groups with significant influence—including certain specialty societies, institutional health care entities, and proponents of nationalizing health care—are staunchly dedicated to marginalizing the independent practice of medicine. As important, practice-changing diagnostic and therapeutic services have emerged, physicians must be able to continue to have shared decision making and discussion directly with the patients they serve. Ideally, all health care decisions would be made between physician and patient and should be both clinically appropriate and cost effective.

Unfortunately, in an era of diminishing resources and economic constraints, policymakers and actuaries from the Centers for Medicare & Medicaid Services, spurred on by the aforementioned interest groups, have answered these challenges with blunt policy instruments, such as reimbursement cuts to medical imaging and the proposed elimination of the in-office ancillary services exception (IOASE).

Eliminating the IOASE will assuredly lead to a dramatic loss of patient access to care as well as a “hobbling” of the medical profession. Thoughtful policies—with the input of physicians and physician specialty expertise—should be enacted to successfully address inappropriate utilization and ensure more efficient pathways. Appropriate use criteria (AUC) is one such pathway policymakers should fully embrace.

As 2013 end-of-year budget negotiations concluded, it was encouraging that policymakers considered using evidence-based AUC as a vehicle for sustainable growth rate (SGR) reform. This provision would require ordering physicians to consult appropriateness criteria for advanced imaging services provided to Medicare patients in order to be reimbursed for that service. Well-constructed AUC will benefit patient care and avoid systemic waste and abuse of services, and must be designed and reviewed by community and academic clinician experts, patient advocates, and policymakers.

Implementation of clinical guidelines would not only guard against inappropriate over- or under-utilization of specific services, it would also restore medical decision making to expert physicians, rather than leaving it to Congress and actuaries to determine the best course of treatment for a particular patient. Moreover, the AUC readily emerges as a more balanced and efficient option when compared to proposals that would levy heavy operational burdens on doctors and concomitantly restrict patient access, such as eliminating the IOASE provision (thus preventing physicians from offering certain diagnostic and therapeutic services in their office) or the purely cost-based decisions issued by the narrowed representation of the Independent Payment Advisory Board.

Repeal of the IOASE would prohibit cancer treatment services from being provided by integrated medical practices, which allows a team of physicians to establish coordinate patient care. Appropriateness criteria would empower physicians and their patients to plan a course of treatment that is uniquely suited to the individual needs of that patient through shared discussion. Thus, the independent doctor-patient relationship is not only preserved but also enhanced.

While there is no one-size-fits-all solution to containing rising health care costs, Congress should pursue policy fixes that enhance patient access to coordinated care, encourage appropriate utilization of the most innovative health care technologies, and preserve the patient-physician relationship of independence. Inclusion of evidence-based AUC in SGR reform is a step in the right direction: a common-sense approach that both addresses concerns regarding utilization of services and preserves patients’ ability to seek care at their own doctor’s office, promoting the most convenient and affordable site of service for patients.

Policymakers should reject any modification or elimination of the IOASE in an SGR reform package, and instead advocate for inclusion of appropriateness criteria with broad clinician and patient representation.

– See more at:

Radiologists: Time to Aggressively Adopt ACR Select | Diagnostic Imaging


Radiologists must embrace imaging appropriateness early – FierceMedicalImaging

Radiologists must embrace imaging appropriateness early

Another big issue facing radiology as we head into 2014 is one seemingly left over from 2013: imaging appropriateness, ie, ensuring that every patient who needs imaging gets the right exam at the right time for the right indication, while avoiding care that they don’t need.

During a session on the “threats to radiology” at the 2013 meeting of theRadiological Society of North America in Chicago, Vijay Rao talked about the necessity of radiologists taking on the role of imaging utilization gatekeepers in order to reduce unnecessary imaging. “This is where radiologists have to take a leadership role in reducing unnecessary imaging,” she said.

In an interview with Diagnostic Imaging, Rao expanded on the subject, arguing that radiology residents should be taking on the role of “change agents” when it comes to imaging appropriateness. “You have to be at the front line making sure that only appropriate tests are being performed,” she said.

Unfortunately, in some cases this is easier said than done. In a study presented at RSNA a year earlier, researchers at Tufts Medical Center in Boston determined that imaging appropriateness isn’t exactly a priority in medical school training.

The study, which involved surveying medical school radiology directors, found that imaging appropriateness ranks behind interpretation when it comes to med school priorities, and that limited faculty time and short radiology clerkships are the biggest barriers to implementing imaging utilization curriculum.

So what can be done to make sure that aspiring radiologists are getting exposed to this kind of training? The obvious answer is that teaching hospitals should be making it part of their curriculum.

But, there are other ways in which medical residents can start taking a leadership role when it comes to imaging appropriateness. For example, research published last summer in the Journal of the American College of Radiology found that having radiology residents participate in rounds with clinical teams could reinforce their role as consultants to clinicians on issues like imaging appropriateness.

Rao also pointed out that radiology residents can be proactive when it comes to this issue by taking advantage of resources available from organizations like ACR, or at annual meetings of the RSNA.

A recently published European Society of Cardiology position paper urges cardiologists to take efforts to reduce inappropriate radiation exposure. While I think such a position is a noble one, radiologists, more so, need to be the ones to embrace such efforts.

Significant changes are taking place in the specialty–particularly with regard to imaging appropriateness. Those just entering the field shouldn’t be bashful about taking a leadership role in effecting such changes. – Mike (@FierceHealthIT)

Limiting Radiation Exposure in Heart Exams | dailyRx

A medical-testing lesson from Minnesota: Less can be more | Star Tribune

More than 80 percent of imaging scans in Minnesota are now ordered only after doctors consult a standard set of guidelines to make sure the scans are recommended based on their patients’ conditions and medical histories.
Richard Tsong-Taatarii, Star Tribune

A medical-testing lesson from Minnesota: Less can be more

  • Article by: Jeremy Olson
  • Star Tribune
  • January 6, 2014 – 8:29 PM

A novel strategy that has saved Minnesota millions of dollars in unnecessary medical-imaging scans — and probably prevented dozens of patient deaths — might soon go national.

Leaders from Minnesota’s medical and insurance communities met Monday morning to celebrate the project — which has leveled off the skyrocketing growth of MRI and CT scans for back pain, headaches and other problems — and to promote legislation by Rep. Erik Paulsen that would bring it to bear on the federal government’s vast Medicare program.

Minnesota’s “decision support” strategy, enacted in 2006, created a single set of standards for doctors to follow in deciding when patients need the costly scans. It also created a green-yellow-red coding system to show patients when scans were recommended and when they weren’t. The use of such scans, which had been growing at a 7 percent annual clip, grew just 1 percent from 2007 to 2012.

“It happened immediately,” said Cally Vinz, a vice president of health care improvement for the Institute for Clinical Systems Improvement, or ICSI.

The Bloomington-based collaborative advises Minnesota health plans, physicians and other providers on ideal medical policies and practices. One recent ICSI project aimed at improving efficiencies was the so-called DIAMOND program to assist primary care clinics in treating patients with depression.

ICSI estimates that the medical-imaging protocol has prevented $234 million in questionable or unnecessary scans, and 96 cancer-related deaths that would have been expected due to the radiation exposure that comes with CT scans, had use of the scans continued growing at previous rates.

And although patients sometimes want more and better medical tests, ICSI officials said patients are often glad to receive the “good news” that they don’t need an imaging scan based on their condition, or that they should wait to see if other symptoms emerge first. Vinz recalled one woman whose doctor showed her that a proposed scan in her case would be in the “red” category, suggesting it wouldn’t be worth the risk and the cost.

“Well, I don’t want a red!” the woman exclaimed.

Paulsen, a Republican who represents Minnesota’s Third Congressional District and has authored several health-reform measures, said he hopes the evidence, combined with a favorable political climate in Congress, make the timing right for the Minnesota approach to be replicated in Medicare, the government health care program for the elderly and disabled. Medicare’s outlays have grown rapidly in the past two decades, reaching nearly $600 billion last year, making it a regular target in Congressional budget discussions.

Lawmakers are trying to reform the so-called sustainable growth rate formula, which determines how much Medicare pays physicians for services, and Paulsen said he believes his bill could become part of that effort.

“If you let this slip away,” he told the group Monday, “it’s going to be a lot more difficult to solve later.”

Vinz said she has talked with insurance and health care leaders in other states about this approach, in part because alternatives such as prior notification — which requires insurers to sign off on scans before they are performed — create adversarial relationships between patients, doctors and insurers. Minnesota health plans had adopted prior-notice rules in 2006, but phased them out due to the success with the decision-support tool.

But officials in other states often view Minnesota as “quite peculiar” because of its small, cooperative community of insurers and physician groups, and don’t believe its innovations can be repeated elsewhere, said Dr. Pat Courneya, medical director of HealthPartners, the Bloomington-based health plan.

Getting this type of approach to succeed in Medicare, on the other hand, would cause it to spread to other states, he said.

More than 80 percent of imaging scans in Minnesota are now ordered only after doctors seek out decision-support guidance to make sure they are recommended based on their patients’ conditions and medical histories.

Courneya said the initial guidelines were based on the clinical expertise and recommendations of Minnesota doctors. They have since been revised as studies refine when imaging scans should be used. Research, for example, has identified the types of patients who are suitable for scans to screen for breast or lung cancers.

Courneya said he hopes the “decision support” tool can grow to include genetic testing and other medical tests that doctors and patients don’t know for certain when to use.

Jeremy Olson • 612-673-7744

© 2014 Star Tribune

Its time to end diagnosis fragmentation – FierceMedicalImaging

It’s time to end diagnosis fragmentation

We’ve all heard about, discussed and lamented fragmentation of care. You know the scenario: A patient has 24 medications managed by eight separate subspecialists, gets multiple duplicative imaging studies ordered by different teams in different health systems at different imaging centers–all the while leaning on their primary care physician to organize and manage the mishmash of physician-to-physician correspondence (or lack thereof) to ensure the proper steps are taken to actually improve their state of health. Meanwhile, a patient with the same condition in a neighboring city is treated entirely differently.

There is no need to reiterate all the reasons this does not work.

Fortunately, a substantial amount of effort is being put into reforming the way patients are treated. Efficiency and efficacy are primary goals of modern healthcare. Surgeon and journalist Atul Gawande haseloquently written about standardization and systematic implementation of care for patients with certain diagnoses (such as osteoarthritis of the knee), and how length of stay decreases, costs decrease, and outcomes improve. Harvard Business School professor Michael Porter continues to push the concept of “Integrated Practice Units” which are multi-disciplinary teams organized around certain conditions (or closely related conditions), responsible for the full-cycle of care, and measure outcomes for every patient–therefore implementing constant feedback, learning, and improvement in how patients with certain conditions are treated. The bottom line? Many smart people have laid the grounds and drawn the map for the future direction of medical treatment.

But what about diagnosis? How do we know that patients who need knee replacements have osteoarthritis and not (although much more rare) rheumatoid arthritis? How do we know that the child who needs surgery has appendicitis, and not a Meckel’s diverticulum? There are many centers across the nation with excellent, streamlined, systematic cardiac and cancer care; but how did they find out their patients had heart disease or cancer in the first place? Diagnosis is expensive for our healthcare system. It is anxiety-provoking for our patients. Yet, we haven’t spent much time analyzing how patient symptoms are transferred to diagnosis.

In many (and most) cases, our approach to diagnosis has, unfortunately, been haphazard. The number, type and order of diagnostic tests often is very different, depending on if a patient is first seen in a primary care office or an emergency room. A patient’s work-up may primarily be driven by which service admits a patient, or which subspecialty is consulted first (before a definitive diagnosis is made). A hedgy suggestion from a radiologist for additional testing or confusing interpretation from a pathologist may lead to extra, unhelpful tests. I’m confident that if we studied how patients who present with dyspnea, hematemesis, and abdominal pain were “worked-up” in varying health systems across the nation (or even just in individual cities), we’d find enormous variation and huge cost and outcome discrepancies.

It is time for multi-disciplinary, diagnosis-focused teams. The lack of communication between multiple services participating in a patient’s diagnosis decreases accuracy and precision, and escalates the likelihood of the increasingly expensive “wrong-diagnosis.”

Radiologists and pathologists certainly are diagnostic-centric specialists who should lead this charge. But every specialty has diagnostic experts. Our GI and cardiology colleagues are examples of other subspecialty physicians that also are experts in diagnosis via modalities such as optics/endoscopy and echocardiography.

Barriers separating diagnostic subspecialties need to be broken. Conversations between diagnostic experts need to begin. Multi-disciplinary diagnosis-focused teams must be formed.

If patients could be referred to teams like this, the process for diagnosing ailments could be standardized with increasing efficacy, decreasing cost and improved efficiency. Systematic processes for diagnosing patients with dyspnea, hematemesis and abdominal pain could be established, rather than the diagnostic process being determined by which service was consulted first, or by established traditions at the hospital a patient visits.

As we continue to end fragmentation of treatment in our healthcare system, let’s also begin ending the fragmentation of diagnosis.

Matt Hawkins, M.D., is a vascular interventional radiology fellow at the University of Washington/Seattle Children’s Hospital. Follow him on Twitter at @MattHawkinsMD.

Prior articles by the author:
RSNA13: Business analytics, clinical decision support take center stage for radiologists