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Radiology Appropriateness Criteria Might Be Inappropriate

Posted on October 7, 2014 by Sheila Sferrella

 

The appropriateness criteria included in this year’s Protecting Access to Medicare Act (Sec. 218) is hardly

appropriate, even as it aims to reduce unnecessary or duplicate radiology exams.

 

“Like many regulatory issues, the devil is always in the details,” says Sheila Sferrella, senior vice president

at Nashville-based Regents Health Resources. “No one’s denying the need to rein in costs and reduce

unnecessary CTs, MRIs or PET scans. But right now, there’s not a clear guide for what ‘ordering the right

test’ means.”

 

The new regulation requires that physicians ordering an imaging test must include information such as

diagnosis and symptoms to determine if it meets the criteria for the exam they have ordered.

Appropriateness software is designed to reduce unnecessary or duplicate exams in any setting:

hospital, outpatient center or doctor’s office.

 

The outpatient radiology community, Sferrella cautions, must pay attention because the  physician placing the order won’t be penalized for failing to comply – at least not yet. For now, the imaging provider is on the hook for the penalty.

 

For what is designed to save money, the cost of adding the software can range from $2,000 to $10,000 a month depending on the size and number of sites in a given imaging operation. Facing these higher costs, plus reduced volume and a sizable reduction in revenue, some smaller locations and office-based radiology services are likely to close. That limits access for patients and ups the hassle factor for physicians.

 

The silver lining is that although appropriateness software goes into effect January 2017, few expect it to hew to such an aggressive timeline. Delays will buy the industry – and the Center for Medicaid Services – the time they need to get the devil out of the details.

What’s the number one issue facing primary care providers nationwide?

Posted on August 14, 2014 by Daryl Demonbreun

 

We really don’t have to ask, we know. Most would simply say survival. It’s a common theme to hear

physicians say that they are working harder but making less. And the future looks bleak in regard to

both workload and income preservation.

 

A secondary issue resulting from the first is the scarcity of primary care physicians. With so many

leaving the field (or not going into the field in the first place) the burden left on today’s internist,

ob-gyn and family medicine practitioner is daunting. There’s just no one left to pick up the slack.

 

The third major concern, also tied to the first two, is the ever-increasing cost of doing business.

Reimbursements don’t come with a cost-of-living increase, and in many cases they are declining.

Combined with the difficulty of gaining approvals, the additional administrative burden is

depressing to practice margins and providers.

 

Is technology the key to efficiency? In talking to practices the conclusion is that the EMR economics just don’t work. Once a practice pays for the system, trains employees and suffers the loss in patient revenue during the transition, the payback never materializes. But just like changes to coding regulations, in order to remain in business, practices must meet EMR and other requirements.

 

To Be or Not to Be Independent

 

It’s tough out there. Faced with mounting costs, declining reimbursement, and increased complexity brought on by the Affordable Care Act, a growing number of physicians are feeling pressured to give up on private practice.

 

While being employed by a large hospital or network may be the right choice for some, many are seeking other options to survive and more closely control the fate of their practice.

 

What are the key criteria to remaining independent?  At Regents we tell our clients that independence requires these four key elements:

 

1. Run a lean, high-performing medical group.

2. Navigate changes from the ACA and other industry challenges.

3. Get paid more and capture available incentives.

4. Connect and clinically integrate with hospitals and other partners.

 

Survival Boot Camp

 

Many practices are at a crossroads, and it takes more than time to get in the game and get proactive. As a famous coach once said, “It’s all about blocking and tackling.”

 

Regents focuses on the fundamentals through a process that distills the key issues and problems faced by the practice. One-size-fits-all doesn’t really work in health care, as each organization is a unique entity with its own distinctive problems.

 

At Regents, we break things down by looking at the financial health of the organization, assessing all the processes and protocols as compared to industry standards and then getting a targeted action plan together to address the root causes, like this:

 

1. Financial Health

 

• Complete a financial analysis of practice.

• Benchmark it against national numbers so we know where you are (what are the outliers) to avoid chasing rabbits and wasting time.

• Avoid making decisions from a gut level and instead make data-backed decisions.  Gain agreement with the leadership team that you don’t know what you don’t know.

 

2. Examine Your Processes

 

• Look at process and protocols within the practice. You might think you have a billing problem but you may really have a coding problem. This can be a costly mistake.

• Get an unbiased third-party perspective on things as you and your partners may be too close to the practice to see things clearly.  

 

3. Get a Game Plan Together

 

• Firm up your marching orders and address greatest needs first.

• Get an action plan together that prioritizes issues and focuses the efforts using both internal teams and external support.

• In healthcare it’s common to throw bodies at the problem—an expensive strategy that may actually exacerbate the issues.

 

The process you go through to diagnose a medical issue with a patient is the same type of care we take in diagnosing business and operational issues. Practices need to refer to another kind of specialist. Asking for help may be difficult but can any U.S. practice really afford to stay in the dark?

 

We believe that for you, as an independent physician, the only people you should have to be accountable to are your patients and your staff. But that takes a thorough internal examination and an organization-wide commitment to changing “how things are done.”

Marketing Imaging Services

Posted on December 4, 2014 by Amanda Cecconi

 

At a recent AHRA conference Regents was asked to present a marketing strategy session for

hospital based imaging services. The content was well received and timely given the challenges

hospitals are facing in retaining and expanding services that contribute on average 40 to 60%

of the total hospital contribution margins in well run organizations. In our experience, the

C-suite often doesn’t appreciate the impact competitive and regulatory changes have on the

bottom line. Many healthcare organizations no longer invest in marketing for individual services

like imaging. However, senior leadership appreciates when imaging managers can quantify a

return on investment in imaging services.

 

Investing in profitable services, patients and physicians just makes good business sense for the

health of a hospital system. Treating all services the same on the other hand, erodes focus and

makes investments in marketing a very poor return.

 

Outpatient imaging is being overrun with a slew of new market entrants, mergers, acquisitions and successful competitors. If you don’t market to your target patient and physician base, you can be sure that a competitor already has. The latest threat is coming from mega-retailer Walmart who is actively expanding store healthcare services to include imaging. Walmart is a pure price competitor and does not differentiate its brand based on quality.  An Accenture survey that gathered patient perceptions of healthcare value found that this is not likely to be a hindrance. Patients are consumers, and with price sensitivity increasing for a variety of factors including higher deductible plans and increasing costs, value is likely to continue to migrate toward a combination of lower cost, and greater convenience at least for payers and patients.

 

So what’s a hospital to do?

 

Start by focusing on the services that consumers can self-select and the target group who has the greatest impact and influence on the purchase of a broader range of hospital services.  It is well documented that middle age women are responsible for 80% of all healthcare decisions for themselves, and their families. Services that can be purchased directly (or are less influenced by a referral process) include ED services for ambulatory patients, childbirth and mammography. For imaging, and the hospital at large, women’s imaging offers a conduit to target buyers creating a halo effect that lifts service volume across the board. During a recent client engagement, through a retrospective analysis Regents was able to show that although a women’s health center was barely at break-even, the introduction of the center was responsible for a 40% lift in volume for other imaging services. The client was ready to spin off the women’s imaging services unaware of the potential loss near and longer term.

 

Women’s imaging services gives radiology a face in the community and a reason to interact with a high value patient population on an annual basis. Now that we have focus, what do we offer that Walmart can’t? The same thing Uber offers: a better experience for which your target buyer is willing to pay a premium. This takes work and a laser focus on transforming healthcare into a retail model that includes, loss leader pricing for services like mammograms and 3D tomosynthesis, and the same level of equipment available consistently in all locations. A high-touch service experience includes a concierge delivery of proactive patient scheduling, registration, reminders and a process that walks them through the center rapidly but with the warmth that leaves a positive impression. Warm colors, current magazines, drinks/snacks and low lights are other ways to make imaging a positive experience. And when things don’t go well, a rapid communication process that minimizes the stress of the unknown is a requirement.

 

Is it worth it? Absolutely, and we can prove it.

How do we prove value in radiology/medical imaging?

Posted on December 16, 2014 by Bob Maier

 

Let me count the ways…

 

This is the dilemma that we grapple with today and was a major focus of this year’s RSNA meeting.  

New payer models are focusing on paying for outcomes and not for volume. Radiologists and

imaging administrators are feeling underappreciated and undervalued at every turn and are

turning to IT specialists to help them quantify and prove their value.  Hospitals are telling them

they can be replaced easily and at less cost with increasing rapidity. And yet, no other clinical

service provides the unique and necessary outcomes that almost all health care patients require

to set them on the right course of treatment and to validate the treatment process.  I know this to

be true from a unique perspective.

 

On October 8th my wife, Anne, went in for her annual physical with her PCP. Complaining of a minor stomach discomfort, she was sent for an ultrasound and her annual mammogram.  Within a couple of days the radiologist reported there were “suspicious findings” and recommended a CT scan for more definitive, conclusive results.  We waited two anxious days to get the CT scan and within four hours had the result.  “Probable cancerous cells in the omentum” was the conclusion and she was scheduled to see an oncologist which took another four days to get on the schedule.  The oncologist agreed that the suspicious findings were probably ovarian cancer but would have to conduct “Marker” testing and a CT biopsy to confirm.  Within 48 hours the CT biopsy was performed by a top notch interventional radiologist who came highly recommended by our friends in the radiology field.

 

Needless to say that this process and timing raised our anxiety levels by 1,000% over the course of three weeks.  The interventional radiologist could not have been better or more comforting in his manner.  He visited Anne before and after the procedure assuring her that everything was fine and the results would be available as soon as pathology could process the specimens.   He even called me that evening to see how she was doing post biopsy. Personal service!

 

Next stop, the gynecological surgeon who scheduled and performed surgery based on these findings.  A kindly and experienced soul, the surgeon explained the findings of the radiologist and pathology reports to Anne and said “how lucky she was to have found this in early stages.  Because there are very few symptoms we usually find ovarian cancer when it’s too late and has grown to stage 4” (The five year, ovarian cancer survival rate is 44% according to the National Cancer Institute).  After surgery he even said, “I don’t know how the Interventional radiologist found and biopsied these cells since they were only 2-3 millimeters in size.”  Do you know how small that is?  Less than 1/8 of an inch!  Thank God and Radiology for early diagnosis!

 

Obviously, none of this process would have been possible without the radiologist’s and technologists’ expertise in imaging procedures and interpretation and that we have the technology and the systems in place that makes all of this possible.  Luckily the PCP was thoughtful and experienced enough to order the first ultrasound.  From there, the first CT and subsequent CT biopsy were absolutely essential to diagnosis and surgery.  This process is something that we in the medical imaging “business” take for granted, as it happens many times every day to patients with far worse conditions and yet we still don’t know how to “prove value” to our constituents.  I can tell you that value can’t be overstated when you or your loved one’s life is hanging in the balance.  

 

I would be terribly remiss if I didn’t mention the great physician and nursing care Anne received in the process.  Their caring, support and understanding truly helped her get through some of the more physically demanding and psychologically scary times.  I would also add that the speed of diagnostic testing (time from order to results) is critical not only in the patient’s mind but also in getting quickly to the most appropriate surgery and therapy.  Delays in getting on schedules are nerve racking to patients and their families while they wait for unwelcome results. Perhaps we can do better.

 

Medical Imaging has been the golden goose that keeps on giving.  We sometimes get caught up in the financial benefits medical imaging has provided to its stakeholders. In our haste to prove value let’s make sure we don’t kill its’ real value where it is most important, to the patient.  This year’s RSNA meeting was the 100th year of showcasing the progress of the medical imaging field and it has had a truly remarkable history. This was my 30th year of attending RSNA.  I won’t be around for the next 100 but I can’t wait to see what’s next.

Are you ready to retire? If not, five things you need to do now...

Posted on February 13, 2015 by Bob Maier

 

Well here we are in early 2015, five years after the PPACA health law was signed into law.  We are now facing

the most disruptive changes in medical imaging delivery and reimbursement since the advent of managed

care thirty years ago.   Utilization has been declining or flattening and hospital based reimbursement is next

on the chopping block.  How are you preparing for these changes?  The Advisory Board in its’ most recent

program has stated that there is a “...dramatic shift in the perception of Imaging, from profit center to

commodity and cost center” and that its’ “value and position in the institution is under threat.”

 

“HHS is doubling down on provider-sponsored risk.”  CMS pronounces of its push toward value based reimbursement will only accelerate these changes.  Medicare’s new goal is to increase value-based payment models to 30% by 2016 and 50% by 2018. As Medicare goes, so goes the private payer market.  If anything, the private payers are moving faster towards adoption of this risk based model.  This will affect how you deliver and get paid for your imaging services.

 

What does this mean for medical imaging in hospitals and outpatient settings? If you are unprepared, it certainly will mean reduced reimbursement and profitability.  For you it will mean doing less with less resources or increasing marketing and market share to make up for the loss of utilization.  You can also expect a continued loss of hospital based outpatient referrals to lower cost providers in your markets.

 

If you and your team are not getting ready for these changes now, you need to be addressing these as soon as possible!  Here are five things that you should be doing now.

 

1.    Evaluate your market, identify your outpatient market share, and conduct a competitor analysis to identify possible consolidations, joint ventures, acquisitions, etc.  

 

2.     Re-evaluate your outpatient service lines, to become more competitive, improve market share and eliminate hurdles in the patient access process. Understand your contribution margins by modality.

 

3.    Conduct an analysis of the operational efficiency of your services to expedite care and maximize throughput.

 

4.    Perform a referring physician survey specific to medical imaging and your radiologists to understand the strengths and weaknesses of your services and be responsive to your customers’ needs.

 

5.    Set performance targets and measure against national and regional performance standards.

 

Regents can help you conduct a strategic plan for medical imaging and address these issues and more!  Be proactive and be ready!  

 

No charge for a call with our senior consultants, call us today 800-423-4935.

 
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