The Radiologist's Value: Measuring the Immeasurable?

Radiologists wear a variety of hats these days. As healthcare continues to evolve, the radiologist’s many roles boil down to one question: which role is the most valuable?

The physician role, including that of the diagnostic radiologist, is under the microscope as the healthcare industry seeks new ways to define and prove the value of their services, and the best way to pay for them.

“The huge paradigm shift going on now in all of healthcare delivery, is this transition from volume to value, and certainly radiology needs to find its space in it,” said Richard Duszak, Jr., MD, vice chair for health policy and practice, department of radiology and imaging sciences at Emory University School of Medicine.

The traditional model of paying per radiology study performed is falling by the wayside as payers, both private and government, look to new models using data-driven metrics based on outcome and quality, or at least that’s the ultimate goal. 

But value in healthcare has different definitions depending on whom you ask. For radiology, that might include imaging appropriateness and safety, efficiency, patient and referrer satisfaction, and quality.

“For me, value very loosely equals quality divided by cost. If I provide equal quality service at a lower cost, I’ve improved value,” Duszak said.

Where Are We Now?
Policy makers, payers, think-tanks and some medical groups are looking at how to implement value-based purchasing programs that compensate fairly for quality work and outcomes. “Conceptually getting from those ideas into reality and operationalizing it is a devil-in-the-detail situation,” Duszak said.

Fee-for-service payment does no favors in the quality realm, Duszak said. He gives an example of two chest X-ray reports, one written clearly and accurately, and one written as a single sentence replete with typographical and punctuation errors. The Centers for Medicaid and Medicare (CMS) pays both doctors $8.80 for the work. “This is the worst of fee-for-service,” he said. The movement toward value-based purchasing means that prices are dependent to some degree on service quality.

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Showing value as a radiologist can be trickier than for most other specialties, especially as it relates to clinical outcomes. Making a brilliant call on an imaging study won’t give you a good clinical outcome score if the patient gets a suboptimal surgeon with high postoperative infection rate, and fares poorly after, Duszak said. If the surgeon isn’t up to standards and the overall health system is getting graded, that team will eventually boot out the surgeon. But until the whole team is engaged and working together on quality measures, it’s harder to measure a specific radiologist’s impact.

Physician Quality Reporting System
While many believe the Physician Quality Reporting System (PQRS) metrics are flawed Duszak believes it is a work in progress.

By statute, CMS is required to implement a physician value-based payment modifier for all doctors by 2017. They already initiated the program for groups that employ 100 or more eligible professionals, including physicians and clinicians billing under the Medicare Part B fee-for-service schedule.

In 2013, CMS started implementing the value modifier by looking at quality and cost measures and getting composite scores in each of those areas, said Judy Burleson, senior advisor on quality metrics at the American College of Radiology (ACR). Quality is on one axis, cost on the other, with low, average and high rankings for each. The score determines the potential for positive, negative or zero impact on reimbursement for Part B services. “If you’re low cost and high quality, you’d be in the upper spectrum,” she said. The physician’s performance report is compared to other physicians reporting the same measures.

Cost measures in the modifiers are ranked by total per capita cost and per capita cost across a chronic condition like diabetes, congestive heart failure or chronic obstructive pulmonary disease, for example. The costs are attributed to physicians based on plurality of primary care service provided to beneficiaries. With that methodology, the measures are not attributable to radiology groups. “CMS recognizes that there are specialties where those can’t be attributed,” Burleson said. Since it’s not yet possible to allocate these per capita costs specific to radiology, CMS assumes, for reimbursement purposes, that the radiology costs are “average,” with no positive or negative impact on reimbursement.  Given the work CMS is doing to analyze costs per episode of care, it’s possible that in a few years they’ll be able to attribute specific cost measures to radiology.

In terms of value-based purchasing in hospitals, there aren’t any measures directly relevant to radiologists, but there are some involving radiology departments. For example, in emergency departments, there’s a measure looking at the time from when a stroke patient enters the department to how quickly CT exams are provided. “Obviously the radiology department has a part to play in that measure,” Burleson said.

She added that many states and regions have purchasing collaboratives which also implement value-based purchasing. For example, the Massachusetts Alternative Quality Contract bases some reimbursement on quality and cost performance.

The PQRS continues to roll out. In 2015, groups containing 100 or more eligible professionals must report the value modifier based on PQRS performance in 2013, or get penalized. In 2016 groups with 10 or more eligible professionals must report the value modifier based on PQRS and cost metric performance in 2014. For radiology groups with 10 or more eligible professionals, their PQRS rates reported this year could potentially earn them a bonus if they had high quality compared to others reporting the same measures.

Also new this year is the Qualified Clinical Data Registry option, including radiology measures to report. The ACR National Radiology Data Registry (NRDR) qualified for the program, giving radiologists the opportunity to successfully participate in PQRS with a broader range of measures relating to their practice that might be more meaningful than existing ones. These will be used as the quality aspect of the value modifier. The NRDR allows physicians to compare their facility’s practice performance to other similar practices nationwide, for benchmarking and use in quality improvement programs. The NRDR contains a number of ACR registries which collect data on CT colonographies, dose indexes, pediatric CT scans, mammography and others.

Other Metrics
The PQRS metrics are primitive, Duszak said, which doesn’t mean they’re bad, just early versions. “There’s a real disconnect between what the metrics are and how much physicians think they impact care,” he said. For example, one metric written to promote radiation awareness requires physicians to report fluoroscopy time, or some metric of exposure in the report. As long as it’s reported, the metric counts, even if it doesn’t incentivize the physician to reduce the exposure rate. “One could say six hours, and the patient got radiation burns. Nominally following the letter of the law would suffice,” he said.

Duszak added that things that are easy to measure usually aren’t worth measuring. “While there are a lot of exceptions, if it’s something you can drill down to the billing statement, it really doesn’t capture the nuances and flavors of clinical care. To move to the next levels, we have to move to more data-driven metrics,” he said, including the need to add more registries capturing the complexity and breadth of care over a number of years.

As for radiology groups participating in Accountable Care Organizations (ACO), “I really have yet to find a radiology practice that has perfected their relationship in doing this model,” Duszak said. This also remains a work in progress, and there have been reports that in a lot of the pilot ACOs, some haven’t been as successful as they’d like. Using an analogy, ‘it’s hard to reengineer the plane while it’s flying,’ he said.

Imaging 3.0 was introduced last year by the ACR as an effort to reengineer radiology, said Duszak, to develop a framework for radiologists to move from volume to value. “If you’re going to be providing value, it’s not good enough to say it, you have to prove it. Imaging 3.0 is the concept of why we need to provide value and start developing some of these toolkits.”

While toolkits are helpful, Duszak said his approach to metrics involves talking with practices and investigator collaborators, and asking that each practice comes up with a few initiatives, and share failure and success stories to help move the standards forward. “Find out from pilot tests and promote what worked for CMS,” instead of CMS using metrics that measure things that aren’t meaningful.

Where Are We Going?
The end game, said Duszak, will be a bundled payment for patient care given to accountable care organizations – in lower case. These would be organizations responsible for a patient’s care but not specifically the current ACO program. “Usually they would be networks of providers, facilities with hospitals, who will get a specific price with a goal to do it well and reasonably.” He likens it to paying a contractor one fee to renovate your kitchen, based on certain conditions.

Developing better data systems to capture meaningful information showing value is a huge and resource-intensive project, Duszak said. These systems need to have few participation obstacles. Since they require clinical input, information technology, money, maintenance and legal advice to develop, it would be hard for health systems to drive their development. “They’ll require for-profit entities or the role of organizations like the ACR,” he said. “These are going to be, in part, under the umbrella of professional societies that have the teams that can put these together in meaningful, useful ways.”

The most successful registries for capturing meaningful data should be as seamless and integrated as possible, and don’t have to involve physician entry. Templates and natural language process systems could capture important information, automatically transferring it to the registry, Duszak said.

Radiology’s Role in Value
Generally, radiology is not the primary point of service provider for the patient, so the radiologist must be part of the team and not the leader. “It requires a level of partnership that is unprecedented for the specialty,” Duszak explained.

That said, radiologists shouldn’t idly sit by waiting for directives to be handed down. “We are at a disadvantage, but the ones who win come up with creative ways to demonstrate our value,” he said.

The ACR metrics committee is looking at methods to attribute cost measures to radiology groups, said Duszak, who is a member of the committee. At this point, they’re in high level discussions about how to compare groups to one another, which goes along with work the ACR Health Policy Institute (HPI) is doing to look at bundling codes and episodes of care for distinct services, like breast imaging and breast care. To date, though, there are no cost measures attributable to radiology groups in the CMS value-based program.

The HPI is looking at utilization and cost, but not quality, since as a nonclinical think tank they don’t have access to clinical information, Duszak said. “Ultimately the answers will come from the clinical area, and those in reimbursement,” he said. Since hospital in-patient encounters already get bundled diagnosis related group payments, the construct exists. For one project, they’ve been looking at several years of CMS claims data to see how the payments get divided up for various diagnoses, and what radiology’s role is in that.

Some radiologists are embracing these concepts, Duszak said, and some are waiting. “The markets are moving very quickly,” he said. “They do need to buy into the culture and move in that direction. Those taking a watch and wait approach may find themselves suddenly in an unfavorable disadvantage in these communities.”