Radiology’s Role in Integrated Health Care Systems

For most of you, diving into radiology practice meant joining an academic department, launching a private venture, or signing on with a teleradiology company. Those three practice models consume the lion’s share of all radiologists reading studies today.

However, another model exists – the integrated health care delivery approach most widely touted by Kaiser Permanente. Through this multi-physician, multi-specialty design, Kaiser Permanente offers health care services, including radiology, through networks of medical centers.

It’s a system that places significant weight on preventive care and positive patient outcomes. To meet that goal, said Bruce Wollman, MD, associate medical director for the Mid-Atlantic Permanente Medical Group, all providers, including radiologists, proactively work together with radiology playing a big role.

“Radiology is the center of the medical universe. In a system, like Kaiser, in which patient care is first and foremost, radiology has a very prominent voice,” he said. “But, Kaiser is a big group. We’re not just a big radiology practice, but thousands of doctors of all specialties all working together on the same team.”

And, just as the system design is a little different, so are the reimbursement and referral models.

Reimbursement
In private, academic, and teleradiology practice, the overarching reimbursement model is still fee-for-service in which you are paid for the number of studies you read. Kaiser’s integrated health delivery model is different, Wollman said. Instead of being paid per scan, Kaiser physicians are salaried. Just like surgeons aren’t paid for the number of operations they perform, and radiologists’ salaries are not based purely on the number of studies they interpret.  

The outcome, he said, is optimized patient care.

“There’s no financial incentive for us to recommend additional imaging or surgeries or other things,” he said. “The financial incentive of the organization is to keep our patients healthy, so there’s no need for us to do things just for the sake of additional billing.”[[{"type":"media","view_mode":"media_crop","fid":"54053","attributes":{"alt":"Integrated health care","class":"media-image media-image-right","id":"media_crop_362270103038","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6770","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":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Gorobets/Shutterstock.com","typeof":"foaf:Image"}}]]

Referrals
Kaiser’s referral model is also different, and referring physicians and patients may find it easier to navigate.

From the referring provider’s perspective, there’s no need to call and get pre-authorization for a study. Kaiser radiologists work with only one partner insurance company, and studies can be ordered and scheduled at the same time. The physician salary model takes away any turf wars among specialists, Wollman said. Radiologists don’t fight with vascular surgeons over who will perform angiograms because no one is paid via fee-for-service.

Patients also benefit under the Kaiser referral model. Because the system focuses so heavily on preventive care, every provider, regardless of specialty, is expected to make sure a patient has received all of his or her preventive care services, giving radiology a strong cadre of partners. For example, a middle-aged woman who sees an orthopedist for knee pain could leave her appointment with a scheduled mammogram. In fact, any patient can leave any appointment with a scheduled, needed diagnostic study. 

Work Flow
Unlike teleradiology or even some private practices seeing a patient for the first time, Kaiser has an integrated electronic medical record system that allows providers to see patient notes from throughout its system, Wollman said.

Consequently, at the work station, a radiologist has access to the patient’s prior medical record, including lab results or clinic notes. If a patient experiences an injury during travel and gets care in another Kaiser facility, all the data is readily available for the radiologist to make a fully-informed diagnosis.

“We’re not necessarily better radiologists,” he said. “But, we do have more of the patient’s story at our fingertips to render a more useful diagnosis.”

Challenges
But, like all other practice models, Kaiser presents obstacles for its providers to overcome.

According to existing salary data from GlassDoor, if you’re a Kaiser radiologist, you can expect compensation comparable to your academic colleagues, roughly in the $200,000-to-$300,000 range. This figure amounts to roughly 50% of your possible earning potential as a private practice provider.

Other main drawbacks, according to a GlassDoor’s physician satisfaction site, centers on provider autonomy. Kaiser’s digital system keeps close tabs on how much time any provider, including radiologists, spends handling an individual patient’s file and case, focusing strictly on the time and not on case complexity. An electronic stamp marks the minute the file is opened, how long a provider reviews a study, what other clinical information is viewed, and when the file is closed. Providers are also tracked on how quickly they respond to patient emails.

Patients can also present a challenge to Kaiser’s health care mission when they demand services and studies they don’t need, Wollman said. Educating a patient on why the CT scan or MRI they want might be unnecessary – and changing his or her mind – can be difficult. Doing so isn’t always possible, making it difficult to avoid overuse of diagnostic imaging.

Teleradiology
Unlike most radiology practices or departments, Kaiser does offer a radiology model that provides teleradiology services within its own system. There’s no need to contract out overnight reads to another company.

Instead, medical centers associated with Kaiser who take advantage of the teleradiology services send their overnight reads to regional centers where Kaiser-employed radiologists provide initial CT, MRI, and ultrasound scans for connected emergency departments. The system, which began in 2002 in South California, has spread nationwide.

Overall, the system is relatively simple. One teleradiologist is assigned to receive overnight read requests from a certain number of emergency departments. Departments are grouped based on their historical read needs, so no single teleradiologist receives an inordinate number of requests. An established, programmed router automatically sends requests to the appropriate teleradiologist based on the call schedule, and an internal Web application ensures safe, secure communication of all diagnostic notes and images between the teleradiologist and the referring physician.

The system is extremely efficient, according to a 2014 The Permanente Journal study. The turn-around time has dropped significantly.

“Clinicians who utilize the teleradiology service have been highly satisfied with the responsiveness of the service,” the authors wrote about the system. “Median time between performance of an exam and availability of a wet read is 19 minutes.”

In addition to cutting read time, the system has improved workflow. It also helps emergency departments manage and work through their study needs while maintaining high quality. In fact, Kaiser implemented a multi-step quality assurance program. After the teleradiologist submits the wet read, a staff radiologist confirms the findings. A quality assurance radiologist notes any diagnostic differences. Quarterly, all studies are reviewed, and teleradiologists are informed of their performance.

Standardized Reporting
More than five years ago, Kaiser also stepped out as a leader among radiology practices looking to streamline reporting. It implemented a standardized templating and speech recognition system in six of its South California facilities as part of the nationwide effort to help radiologists speak in one diagnostic language.

“Radiologists are accustomed to communicating in a certain way, and this is evidenced in how they dictate,” said Alan Rubenstein, a business consultant in Kaiser Permanente’s information technology division. “Techniques for dictating are often learned from observing the habits of other clinical users.”

And, that’s where problems often occur industry-wide. Instead of developing a uniform system for dictating diagnostic results, many practices or departments rely on their own systems for identifying findings, leaving some dictation notes up to interpretation.

Kaiser’s initiative side-stepped this common issue. As a speech-driven, rather than PACS-driven, workflow, Kaiser’s radiologists found the new system more flexible and easier to navigate. Providers have access to simple or highly-complex worklists, depending on the type of study conducted. The paperless system is also easily searchable through Boolean terms.

To date, the standardized reporting system has been a success, Rubenstein said, as turnaround times have dropped from days to hours.

Overall Design Impact
Although Kaiser shares the ultimate goal of high-quality patient care with traditional private, academic, and teleradiology practice, it tackles this objective in slightly different ways. Radiologists don’t spend long hours, trying to increase their read volume. They don’t devote out-of-clinic time to in-depth research efforts. And, they don’t necessarily experience maximum schedule flexibility.

But, they do offer the same round-the-clock care that’s available in any hospital nationwide. Patient coverage is 24-7-365, and it’s assumed that all providers pitch in and contribute. What makes the model so attractive, particularly for radiologists, Wollman said, is that all providers have an equal stake and equal voice in the success of patients and the medical centers.

“We’re physician led. Everyone on the team is a physician, and that’s good,” Wollman said. “There’s always opportunity. Most radiologists want to come in and do good clinical work and go home. But, for those who want to do more, the sky’s the limit.”