Define Value, Save Radiology

It doesn’t really matter what you think about value, you’re going to have to provide it to get paid, according to Richard Duszak, MD, vice chair for health policy and practice, department of radiology and imaging sciences, Emory University School of Medicine, at ACR 2015.

Duszak referenced Sylvia Burwell’s recent piece in the New England Journal of Medicinein which she outlined her targets of having 30% of Medicare payments tied to quality and value in 2016, jumping to 50% of payments in 2018.

“We can’t have a CMS person reviewing every chest radiograph or every CT scan that you interpret, so we’re going to have to come up with some metrics,” Duszak said. “We can either let the agency do it, and we all know how that works, or we can do it ourselves.”

Most important, however, is how we think about value, Duszak said.

“If you figure out what your consumer wants, not what they articulate they want, but what they really want, you win in the value game,” he said.

How you measure value depends on who you ask, but Duszak likes the conceptual equation of quality/cost.

“What we’re really talking about is bang for the buck,” he said. “Better quality, lower cost, ideally you can do both.”

He cited the 2013 Harvard Business Review article that defined value as “health outcomes achieved that matter to patients.”

“I would submit to you that it’s even more than just patients,” Duszak said. “It’s all stakeholders in the health care delivery system to whom we need to be defining value.”

It requires a big picture look at all of the little people involved, though. For example, you’d measure cost from your payer’s perspective, but that could be one-sided.[[{"type":"media","view_mode":"media_crop","fid":"37901","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_3877274098683","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3763","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Richard Duszak, MD","typeof":"foaf:Image"}}]]

“A woman comes in for a screening mammogram which is entirely paid for under the ACA,” Duszak said. “You bring her back for a diagnostic, not sure if you really need it, but that patient is going to be paying the first dollar on that study.”

What about the quality definition? Duszak uses another conceptual equation, this time by Gary Kaplan, MD, where quality = outcomes + service/waste × appropriateness.

Duszak likes this more granular equation because it embodies what might be important to each individual patient.

Waste had an easy definition. Facilities waste money, they waste scanner time, and they waste patient’s time.

“If you make a patient sit for a couple of hours, you have provided lesser quality services than your competitor across the street,” he said.

Appropriateness also plays an extremely important part.

“You could do the best job interpreting a study,” he said. “But if that patient had the same CT two days ago, was the study you interpreted necessary if there was no change in the patient’s medical care? What’s the incremental quality you provided?”

“If the appropriateness of the additional scan is zero,” Duszak said. “The whole equation turns to zero.”

Duszak noted the challenge with measuring outcomes. He encouraged radiologists to think outside the box when determining value and to embrace the integrated practice unit.

“Joining and being a leader in integrated practice units is the way we, as a team, will provide services that can collectively improve outcomes and also measure meaningful outcomes that is attributable back to the team rather than you as an individual,” he said.

“In my opinion, this is the strategy that saves radiology,” Duszak said.