As a follow up to our first blog post regarding the 2017 Medicare Physician Fee Schedule highlights, you will find additional information and details below:
New Bundled Mammography Codes
CMS will also not make any changes to the technical component (TC) reimbursement for mammography with CAD, but CMS is changing the code definitions to match the 2017 CPT® codes. For example, code G0202 will now be defined as “screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed” to match code 77067. The G codes will be used for both digital and non-digital mammograms. CMS expects to switch over to the CPT® mammogram codes in 2018.
CMS accepted the mammogram work RVUs proposed by the RUC (Relative Value Unit Update Committee) but is not accepting the practice expense RVUs as this would result in drastic payment cuts. Instead, CMS will use the PE-RVUs from the G codes. CMS notes in the Final Rule that there will not be significant payment reductions for mammography in 2017.
Reimbursement Reductions for Plain Film X-rays
CMS has demonstrated over the past two years its commitment to getting digital images into the EMR. While some entities may choose to take a hit in 2017 rather than make the capital investment in digital radiology, the penalties in the coming years may warrant the investment.
Delayed CDS/AUC Implementation
After consulting the appropriate use criteria (AUC), the ordering professional must communicate the results of the AUC consultation to the furnishing professional (imaging facility) at the time the advanced imaging study is ordered. CMS stated in the Final Rule it does not intend to establish any requirements as to how this communication takes place.
The furnishing professional is in turn required to report the results of the AUC consultation on the Medicare claim for the imaging exam, and CMS expects this requirement to go into effect on Jan. 1, 2018. CMS is considering various mechanisms for this reporting, including HCPCS G codes and HCPCS modifiers.
By 2020, the Protecting Access to Medicare Act (PAMA) requires that CMS identifies “outlier” order professionals who consistently fail to follow AUC recommendations. These outliers will be required to obtain pre-authorization for advanced imaging exams.
Ordering professionals will be required to consult AUC for all advanced imaging services that are furnished in an applicable setting, such as office or outpatient, and paid under an applicable payment system, such as MPFS or OPPS. However, in the 2017 Final Rule CMS designated eight “priority clinical areas” that will be the focus for identifying outliers:
Coronary artery disease (suspected or diagnosed)
Suspected pulmonary embolism
Headache (traumatic and non-traumatic)
Low back pain
Shoulder pain (to include suspected rotator cuff injury)
Cancer of the lung (primary or metastatic, suspected or diagnosed)
Cervical or neck pain
CMS is decreasing the RVUs of codes that previously included moderate sedation, which will now be separately reportable with all procedures including those that were previously listed in Appendix G of the CPT® manual. For example, interventional radiologists who provide moderate sedation in conjunction with lower extremity revascularization or percutaneous biliary procedures should report the sedation service separately beginning on Jan. 1, 2017 using new sedation codes 99151-99157. Note that CMS has also created an HCPCS code (G0500) for moderate sedation, but this code is used only in conjunction with GI endoscopy.
Preliminary Comparative Analysis
We have performed a preliminary comparative analysis of 2017 versus 2016 with the “Imaging Cap” (lower of OPPS or MPFS) for all affected technical component CPT codes. There have been rumors in the marketplace that some MRI codes experienced cuts up to 58 percent in 2017 versus 2016. We do not see such drastic cuts in our preliminary analysis, but we do see certain MRI, CT and Ultrasound codes with reductions in the technical component from as low as .8 percent to as high as 19 percent (selected MRI codes). We also see some slight increases in technical component rates as well.
When a more complete analysis has been performed, IRP will publish the results. The full impact of the changes in the 2017 MPFS to practices will only be fully understood based upon their historical utilization volume by modality, by CPT code. It will also be important to factor in any changes to practices’ locality Geographic Practice Cost Index (GPCI).
To learn more about the 2017 MPFS Final Rule’s impact on radiology and other medical specialties, please contact us.
/wp-content/uploads/2014/05/Logo_header_vs21.jpg00admin724/wp-content/uploads/2014/05/Logo_header_vs21.jpgadmin7242017-01-06 22:56:112017-05-15 21:08:19Medicare Physician Fee Schedule Final Rule: Impact on Radiology, Part 2
Last month, the Centers for Medicare and Medicaid Services (CMS) released the 2017 Medicare Physician Fee Schedule (MPFS) Final Rule, which updates policies and payment rates for services provided on or after Jan. 1, 2017. CMS released the Proposed Rule for comment on July 7, 2016.
Overall, CMS estimates a 2017 conversion factor of $35.8887, a slight increase from the current conversion factor of $35.8043. This change reflects the .5 percent update included in the Medicare Access and CHIP Reauthorization Act of 2015, and will result in an estimated one percent decrease in radiology and interventional radiology payments. Radiation oncology and nuclear medicine payments will remain unchanged.
While this is an improvement from the proposed seven percent reduction in interventional radiology payments, starting in January, certain interventional radiology codes will be bundled, reducing reimbursement for some procedures. For example, cerebral arteriograms are currently reported with component codes, allowing doctors to receive payment for each vessel studied. Instead, procedures performed in 2017 will be reported wholesale, probably resulting in a lowered payment for half of the codes.
The Final Rule also confirmed that any relative value unit (RVU) reductions greater than 20 percent will be phased in annually; therefore, a code faced with a 50 percent RVU reduction would be limited to a decrease of 19 percent in total RVUs each year.
Below are additional changes and announcements from the Final Rule:
New Bundled Mammography Codes Starting in January 2018, codes for digital, film screen and computer-aided detection (CAD) mammography will be bundled into one set of three mammography codes. In 2017, CMS will continue using existing G-codes (G0202, G0204 and G0206). CMS will also not make any changes to the technical component (TC) reimbursement for mammography with CAD.
Practice Expense Inputs for Digital Imaging Services CMS will price the professional PACS workstation at $14,616.93, and has provided a list of 426 radiology codes to which the professional PACS workstation will be added. They have also requested comment on additional codes. This change should result in a bump in TC.
Reimbursement Reductions for Plain Film X-rays Reimbursement for X-rays taken with plain film will be reduced by 20 percent in 2017 and all subsequent years. In addition, reimbursement for computed radiography will be reduced by seven percent between 2018 and 2022, followed by a 10 percent reduction in 2023 and all subsequent years. To implement the plain film X-ray reduction, CMS has established a new modifier (modifier “FX”) to be used on applicable claims.
CMS has demonstrated over the past two years its commitment to getting digital images into the EMR. While some entities may choose to take a hit in 2017 rather than make the capital investment in digital radiology, the penalties in the coming years may warrant the investment.
Delayed CDS/AUC Implementation CMS has delayed the implementation of the clinical decision support (CDS)/appropriate use criteria (AUC) program to Jan. 1, 2018 as policymakers continue to debate what CDS vendors will qualify as CDS solutions as well as the role radiology will have in the CDS process. CDS implementation will apply to orders for all advanced diagnostic imaging services, not just priority clinical areas.
The final list of priority clinical areas includes coronary artery disease (suspected or diagnosed), suspected pulmonary embolism, headache (traumatic and non-traumatic), hip pain, low back pain, shoulder pain (to include suspected rotator cuff injury), cancer of the lung (primary or metastatic, suspected or diagnosed), and cervical or neck pain.
CMS also finalized the requirements for the CDS/AUC reporting delivery mechanism. CMS will begin to accept the first applications for CDSMs immediately, with an application deadline of March 1, 2017. The qualified CDSMs will be announced by June 30, 2017.
Moderate Sedation Medicare frequently pays for anesthesia services provided by an anesthesiologist or CRNA in conjunction with procedures that are defined as including moderate sedation. In order to eliminate this double payment, CMS is decreasing the RVUs of codes that previously included moderate sedation, and moderate sedation will now be separately reportable with all procedures, including those that were previously listed in Appendix G of the CPT® manual. For example, interventional radiologists who provide moderate sedation in conjunction with lower extremity revascularization or percutaneous biliary procedures should report the sedation service separately beginning on Jan. 1, 2017, using new sedation codes 99151-99157. Note that CMS has also created a HCPCS code (G0500) for moderate sedation, but this code is used only in conjunction with GI endoscopy.
Preliminary Comparative Analysis We have performed a preliminary comparative analysis of 2017 versus 2016 with the “Imaging Cap” (lower of OPPS or MPFS) for all effected Technical Component CPT Codes. When a more complete analysis has been performed, IMP will update our blog with the results.
Overall, the Final Rule presents several benefits to the specialty of radiology. In addition to phased-in RVU reductions and the delay in CDS implementation, the rule upholds the mandate to lower the existing professional component multiple procedure payment reduction (PC MPPR) from 25 percent to five percent effective Jan. 1, 2017.
To learn more about the 2017 MPFS Final Rule’s impact on radiology and other medical specialties, please contact us.
/wp-content/uploads/2014/05/Logo_header_vs21.jpg00admin724/wp-content/uploads/2014/05/Logo_header_vs21.jpgadmin7242016-12-19 20:00:202017-05-15 21:09:01Medicare Physician Fee Schedule Final Rule: Impact on Radiology, Part I
While most physician practices and health systems implemented ICD-10 with only minor snares along the way, some groups did report a decline in productivity as coders rushed to become familiar with the new code set. Fortunately, the specialty of radiology only uses about 4 percent of the 68,000 codes within the ICD-10 set, significantly narrowing the learning curve for radiologists and radiology-focused coders.
The year-long grace period offered by the Centers for Medicare & Medicaid Services (CMS) served as another aid in the transition. For many payers, the use of unspecified ICD-10 diagnosis codes would lead to many claim denials for failing to meet medical necessity or the payer’s specific policy for the procedure performed. For this reason, CMS gave physicians and coders one year to become familiar with the new ICD-10 coding set and the greater level of specificity it required.
As of Oct. 1, 2016, however, that grace period came to a close. If there is an established policy in place (Medicare National Coverage Determinations (NCD) or Local Coverage Determinations (LCD)), Medicare may now deny certain unspecified diagnoses. If other payers offered a similar grace period, they also may follow suit and deny these claims.
To mitigate the impact this change may have on practice revenue and coder productivity, it is critical to develop and implement an advanced analytics platform to track and cut down on unspecified codes. Many industry leaders have already realized the potential of analytics to generate positive changes in healthcare: In a 2012 executive report titled “The value of analytics in healthcare,” the IBM Institute for Business Value states: “Using analytics to gain better insights can help demonstrate value and achieve better outcomes, such as new treatments and technologies. Information leading to insight can help informed and educated consumers become more accountable for their own health. Analytics can improve effectiveness and efficiency.”
Analytics can help to significantly reduce the number of unspecified diagnoses and therefore protect practices’ cash flow. Radiology groups should aim for unspecified codes to account for less than 10 percent of gross charges, keeping in mind there are times when radiologists do not have additional information regarding the patient’s condition or medical history, and that there are a few unspecified ICD-10 diagnoses that do not provide a more specific diagnosis option.
Achieve a 360-degree practice view An advanced analytics platform that can leverage both structured and unstructured data can help physician practices better prepare for life in a post-grace period world. Because between 60 and 70 percent of all radiology exams are normal, it is critical for radiologists to obtain full clinical history to optimize the quality of care and minimize the use of unspecified codes.
Analytics are able to filter data by provider, modality, payer, location, place of service and referring provider, granting physician leaders and administrators a 360-degree view of their coding performance. These types of platforms can also help highlight areas of improvement down the line.
Gain recommendations to reduce unspecified codes Analytics platforms can also sort the top 10 or 25 unspecified ICD-10 codes used by practices and make helpful recommendations to improve dictation and coding while reducing denials. These unspecified diagnoses are often missing anatomical- or morbidity-related information, such as laterality, body location and severity.
For example, the I65.29 code for occlusion and stenosis of unspecified carotid artery merely requires providers to document the affected carotid arteries (right, left or bilateral). By adding this piece of information, physicians can reduce claim denials and help drive uninterrupted cash flow.
While ICD-10 did not cause the turmoil many industry leaders anticipated, it did increase the workload of physicians and coders alike. To learn more about the power of analytics to reduce unspecified ICD-10 codes and increase practice and coder productivity, please email us at ContactIRP@IntegratedRP.com.
When President Barack Obama signed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) into law, he effectively transformed U.S. healthcare into a system in which value trumps volume. With a new reimbursement framework in place, providers must adjust their business and care models accordingly.
Beginning in January 2017, the Merit-based Incentive Payment System (MIPS) will begin assessing Medicare physicians’ performance by developing a Composite Performance Score (CPS) based on four elements: Quality (weighted 50 percent of total score), Advanced Care Information (25 percent), Clinical Practice Improvement Activities (15 percent) and Cost (10 percent). This new payment system aims to streamline and simplify the three previous CMS quality programs known as the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VBPM) and the Electronic Health Record Meaningful Use (MU) program, and will affect payments beginning in 2019.
While the transition to value-based care will accelerate come January, we have already seen swift progress toward adopting this new model; by 2018, 90 percent of fee-for-service payments are expected to be tied to quality and value programs. But how does this directly impact the radiology department, and what can radiologists do to better prepare for these upcoming changes?
Radiology’s unique position
With this increased focus on providing higher quality care more efficiently and cost-effectively, the specialty of radiology is uniquely positioned to play a pivotal role in the U.S. healthcare system’s transformation. Imaging touches nearly every major disease and is often the first step toward diagnosis, therefore playing a critical role in patients’ entire care and treatment process. Unsurprisingly, according to a 2015 Malpractice Report by Medscape, more than two-thirds of the medical malpractice lawsuits faced by the radiologist respondents stemmed from a failure to diagnose.
In addition to being the first step toward an accurate diagnosis and effective treatment plan, radiology is a costly burden on the overall system: According to the American Academy of Orthopedic Surgeons (AAOS), the United States spends $100 billion on diagnostic imaging annually, making it the second-largest—and fastest growing—item for healthcare payors. The AAOS also estimates that $30 billion of this spend is unnecessary, caused by inappropriate utilization of imaging or duplication of studies.
In an era of value- and quality-based reimbursement, radiology groups can reduce costs and waste while improving patient outcomes through greater access to trained subspecialists.
Subspecialty access is key
Greater access to subspecialists has become crucial to providing the highest quality of care to the hospitals, surgery centers and communities that radiology groups serve. Research proves subspecialists provide more accurate diagnoses for certain tests, therefore leading to improved patient outcomes and reducing the need for timely and costly duplicate tests. For example, a study published in the Radiological Society of North America (RSNA) Radiology journal found that radiology subspecialists made more true-positive and fewer false-positive interpretations at screening mammography, with significantly higher cancer detection rates than their general radiologist counterparts.
And yet, a 2006 study published by the American College of Radiology (ACR) found that only 30 percent of all mammograms are interpreted by breast imaging specialists, signaling a critical need for greater access to these specialists.
But pairing the demand for subspecialty-trained providers with the providers themselves can prove a daunting challenge for many groups across the country. According to a 2013 article published in the Healthcare Financial Management Association’s (HFMA) Strategic Financial Planning, 93 percent of the United States’ 3,000 radiology groups have 10 or fewer providers, significantly limiting their ability to access subspecialists when needed.
An alternative solution
Previously, these groups were faced with few options: try to continue forward despite the industry’s increased competition and regulatory pressures, or be acquired by a national single- or multi-specialty management company, such as Radisphere Radiology or Sheridan Healthcare, to gain the economies of scale and subspecialty access required to survive in an increasingly demanding market.
But emerging technologies and collaboration models are beginning to disrupt the landscape and provide radiology groups an attractive alternative to these options. Rather than sacrificing their clinical autonomy through acquisition, radiologists can facilitate greater subspecialty access through modularized, cloud-based technologies and collaborative business models for noncompetitive groups.
At Integrated Radiology Partners (IRP), our model of collaboration helps foster the growth and success of independent, like-minded radiology groups. By pooling resources, gaining economies of scale and greater access to subspecialists, our group collaborations achieve valuable tools to optimize their clinical operations and outcomes without sacrificing their autonomy.
To learn more about increasing access to radiology subspecialists or IRP’s group collaboration model, please email ContactIRP@IntegratedRP.com.
/wp-content/uploads/2014/05/Logo_header_vs21.jpg00admin724/wp-content/uploads/2014/05/Logo_header_vs21.jpgadmin7242016-10-14 22:18:032017-05-15 21:10:20Subspecialty Access in an Era of Value-Based Payment
As the healthcare industry continues to see widespread consolidation in the forms of mergers, acquisitions, joint ventures and collaborations, it has become imperative for hospital-based radiology groups and outpatient imaging centers to consider their strategy for future growth in their market.
Between 2010 and 2013, the American College of Radiology (ACR) Commission on Human Resources’ annual workforce survey reported a 10 percent decrease in the number of U.S. radiology groups. In an interview with Radiology Today, the commission’s chairman, Edward Bluth, M.D., attributed part of this decrease to consolidation and part to radiologists leaving private practice to join a hospital or health system.
As radiologists combine or become acquired by larger industry players, it is crucial to consider the best path moving forward in this highly competitive landscape. Several business models have emerged over the past decade for practices and imaging centers to choose from, including large group networks, acquisition by management company and regional collaboration among noncompetitive groups.
Below are further details regarding these three models for radiology groups and imaging centers to consider as they plan for future growth and success:
Large group network Large practice consolidation has become increasingly popular in the specialty of radiology. One example of this model is Strategic Radiology, a network of 1,300 radiologists across the United States with shared access to data, clinical information and certain economies of scale.
Although these types of networks aim to connect radiologists to provide high-quality, cost-effective care, they focus on larger groups with a minimum of 50 providers while looking to smaller, regional players only in affiliate status roles. It is a relatively exclusive model built to further bolster large radiology practices, simply selling services to smaller groups with fewer than 50 providers who offer local services on a smaller scale.
Management company acquisition Over the past decade, single- and multi-specialty management companies have steadily acquired more and more physician practices, promising providers fewer administrative headaches and greater economies of scale. A report by consulting firm PricewaterhouseCoopers (PwC) titled “Q1 2015 U.S. health services deals insights” demonstrated how this trend shows no sign of slowing down; in fact, the volume of deals increased from 13 in Q1 2014 to 21 in Q1 2015, with 18 of the 21 deals announced involving physician practice management companies such as MEDNAX and IPC The Hospitalists Company.
While multi-specialty companies begin to add radiology to their service lines, such as MEDNAX’s acquisition of vRad in May 2015, single-specialty management companies such as Radiology Partners (RadPartners) continue to expand their network size through a traditional M&A model. Though RadPartners positions itself as “partnering” with radiology groups, it primarily acquires groups then promises health systems greater stability, while essentially removing or diluting radiology practices of their clinical and operational autonomy.
And while this may appear an attractive option for radiology groups seeking a partner to manage daily operations in an increasingly complex landscape, integrating into the management company often brings a host of challenges regarding workplace culture and the managing of expectations on both sides of the transaction.
Regional collaboration among likeminded groups The emerging alternative to the two aforementioned models is a more collaborative approach, a true partnership between likeminded, noncompetitive radiology groups to pool resources and expand subspecialty access while remaining clinically and operationally autonomous.
Built to support sustained independence and growth in a dynamic market, the collaborative model provides groups the tools they need to survive and thrive in the age of value-based care by transforming practices and centers into more nimble organizations. This model can better help radiology groups prepare for a future of enterprise imaging designed to provide a unified patient view, equip them with economies of scale to offer greater purchasing power, and provide a more advanced analytics platform to collect the necessary metrics to accurately evaluate practice performance. For an overview of the benefits of this emerging model, please click here.
It has become critical for radiology groups and imaging centers to consider these emerging business models and determine which will best prepare them for future growth and long-term success without sacrificing their clinical independence. To learn more about the collaboration model and IRP’s suite of practice solutions, please contact us at ContactIRP@IntegratedRP.com.
/wp-content/uploads/2014/05/Logo_header_vs21.jpg00admin724/wp-content/uploads/2014/05/Logo_header_vs21.jpgadmin7242016-09-19 18:04:272017-05-15 21:11:05The Collaboration Model: An Emerging Solution For Radiology Groups
After decades of fragmentation, financial pressures, heightened competition and regulatory changes are contributing to an increase in mergers and acquisitions across the spectrum of healthcare stakeholders – payers, health systems, physicians groups and more. According to the 2014 Deloitte Center for Health Solutions study “The Great Consolidation,” the average deal size for hospital acquisitions increased from $42 million in 2007 to $224 million in 2013. Using three separate approaches, Deloitte’s research team found that, by all three estimates, only 50 percent of all current U.S. health systems will remain in 10 years.
While this may be an alarming statistic for radiology practices and imaging centers to digest, a solution has emerged in recent years to combat this trend and keep medicine local. Collaboration among likeminded, noncompetitive physician groups has provided an attractive alternative to the recent increase in M&A activity. The collaborative model provides radiology groups the opportunity to work together to achieve some of the benefits of larger industry players, while keeping medicine local and maintaining a strong connection with the community in which they serve.
The following are five key benefits of this emerging model:
Increased subspecialty access Increased access to subspecialists has become a critical factor in the survival of radiology groups and the quality of care they provide. According to the American College of Radiology (ACR), radiologists have an average error rate of nearly 30 percent, with 70 percent of the errors due to an unperceived, or “missed,” abnormality in the reading.
By joining a collaborative, radiology groups can expand their capability to serve their patient population by becoming interconnected remotely with subspecialists throughout their community, state or even region. This can produce better clinical decisions, increased patient safety and improved patient care through improved contribution by radiology to patient care diagnostics.
Medical malpractice cost-savings While an increased number of providers tends to lower medical malpractice costs, there is a ceiling associated with how large a practice can become, preventing future cost-savings. By combining a larger provider pool with a powerful analytics platform, collaboratives can build a customized medical malpractice program based on the group’s documented, detailed performance. By tracking key metrics like the number of incidents and the number of misdiagnoses, radiology groups can begin to better understand their risk profile and create a custom risk management program designed to lower costs and improve the quality of care they provide.
Advanced analytics capabilities The healthcare industry is gradually understanding the potential power of analytics to improve results and enhance operational and clinical efficiencies. According to a 2015 survey from the Deloitte Center for Health Solutions, more than half of the health systems surveyed identified population health analytics as the top investment focus moving into 2016, and more than three in five reported they will invest in advanced analytics capabilities for clinical and population health functions.
By collaborating with likeminded groups, radiologists can adopt an advanced analytics platform that can leverage structured and unstructured data to track key metrics and improve practice performance. To learn more about the capabilities of analytics, please download our white paper here.
Enterprise imaging technology For the past three decades, healthcare has been increasingly focused on interoperability and the pursuit of a comprehensive, unified patient view. Radiology has been at the forefront of this movement, beginning with the development of Digital Imaging and Communications in Medicine (DICOM) in the early 1990s.
As patient coverage expands and the quality of care improves, the full transition toward interoperability in healthcare hinges in part on the success of enterprise-wide imaging, a movement to eliminate inefficient silos in radiology and, ultimately, develop a unified patient view that gives the clinician access to everything he/she needs to provide high quality care in a timely fashion. Through a collaborative model, groups can begin to adopt cloud-based technologies that bridge these silos of data, increase efficiency and improve patient care and regulatory compliance.
Economies of scale As reimbursements continue to decline and the industry continues its shift from fee-for-service to payment-for-value models, it is increasingly important for radiology practices and imaging centers to reduce costs and improve productivity to create a leaner organization.
Membership in a group collaborative provides radiologists the opportunity to achieve economies of scale for their practice while maintaining clinical autonomy. By improving purchasing power and pooling resources, radiology groups can better prepare for the future of healthcare and secure their independence despite increased competition.
Collaboration among likeminded radiology groups has emerged as an attractive alternative for radiology groups seeking to remain independent in an increasingly consolidated market. To learn more about this business model and its varied benefits, please contact us at ContactIRP@IntegratedRP.com
The era of value-based healthcare is (almost) here.
The Centers for Medicare and Medicaid Services (CMS) recently proposed a new program that would further shift the nation’s healthcare system away from the fee-for-service payment model, and more towards value-based care. The proposed Quality Payment Program (QPP) is part of the agency’s implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the bipartisan “doc fix” and children’s healthcare extension that became law in 2015.
QPP would create a “unified framework” for transitioning the national insurance program for seniors towards outcomes-based payments, according to CMS. The proposed payment program will include two payment pathways: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). These would replace “a patchwork of programs, including the Physician Quality Reporting System, the Value Modifier Program, and the Medicare Electronic Health Record (EHR) Incentive Program.”
Under the proposal, a provider’s MIPS score initially will be comprised of four parts: cost (10 percent), quality (50 percent), clinical practice improvement activities (15 percent) and advancing care information (25 percent). The MIPS score will then be used to determine if a provider is reimbursed more than, less than or at the standard Medicare rate. In addition, certain providers will be eligible for an exemption from the MIPS system by participating in APMs—specialty incentive payment models proposed under QPP.
The public comment period for QPP ended June 27, 2016.
Of course, performance-based reimbursement is not an entirely new concept in healthcare. Today, most groups’ reimbursement is based on its Clinical Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey score. Conducted annually, this survey attempts to measure patient satisfaction based on a variety of healthcare experiences, such as communication with medical providers or pain management after a procedure is complete.
As a result, successful practices are taking their own snapshots of patient satisfaction and other operational and clinical factors. Proactively measuring ongoing performance allows physician leaders to make the necessary adjustments before reimbursements are affected and a group’s bottom line suffers—an activity that inevitably will become more important in the coming era of value-based care.
Conduct internal surveys Sensing a growing need for more accurate and efficient practice information regarding patient satisfaction, valuable tools like Survey Vitals help physician groups better assess their performance. Conducting internal surveys independent of those required by the federal government provides practices with the opportunity to better understand the intricacies of the satisfaction metric.
For example, the CG-CAHPS survey delivers information based on the last three to six months; as a result, practices may not know about an internal issue or weakness until it has been happening for 180 days. Tools like Survey Vitals have 24-hour turnaround times, providing real-time data to practices at an affordable cost. In addition, these tools can be catered to specific medical specialties, offering relevant feedback that providers can immediately act upon to reduce errors and operational inefficiencies while improving patient satisfaction.
Generate actionable reports In an era of increased pressure to lower costs and expand productivity, physician groups that show a proactive interest in adding value to the organization are especially attractive to hospitals and health systems.
While CG-CAHPS and Hospital Consumer Assessment of Healthcare Providers and Systems (H-CAHPS) surveys may provide skewed, old or irrelevant information, physician groups can use specially designed electronic surveys to generate actionable reports that detail strengths and weaknesses. And presenting these reports to hospital leaders and tracking progress over time shows initiative in an increasingly competitive healthcare landscape.
Leverage data Equipped with detailed patient satisfaction data, physician leaders must use this information to move their practices in the right direction. Identifying areas for improvement and appropriately addressing deficiencies to increase satisfaction survey scores is the critical final step in improving patient outcomes and overall satisfaction. As survey scores continue to further affect reimbursement, groups must leverage their data to make better-informed decisions regarding clinical care, operational efficiencies and practice performance.
According to CMS, hospitals could stand to lose or gain 2 percent of reimbursement dollars by 2017, depending on their H-CAHPS scores. For a typical hospital, that could put as much as $850,000 at risk annually. There is an upside. Under proposed changes, a hospital with $120 million in annual revenues could also receive as much as $5.4 million in additional incentive payments, according to a report by Press Ganey.
In healthcare, measuring performance is no longer optional. It is vital for success in today’s competitive market. As a result, patient satisfaction surveys provide physician leaders with a real-time snapshot of a practice’s performance, allowing the necessary adjustments to be made to ensure optimized cash flow.
Interoperability has been at the center of many of healthcare’s biggest advances in the past three decades. Radiology, in particular, has been at the forefront of the profession’s pursuit of a unified patient view, beginning with the development of Digital Imaging and Communications in Medicine (DICOM) in the early 1990s.
Looking ahead, as patient coverage expands and the quality of care improves, the full transition toward interoperability in healthcare hinges in part on the success of enterprise-wide imaging, a movement to eliminate inefficient silos in radiology – and, ultimately, develop a unified patient view that gives the clinician access to everything he/she needs to provide high quality care in a timely fashion.
The following are three key benefits of enterprise imaging technology within the healthcare profession:
Improved Patient Care
The ultimate goal of enterprise imaging is to provide the clinician a complete view of the patient across the continuum of care. Whether the provider is a specialist, a primary care provider, or even a physical therapist or psychiatrist, a comprehensive view of the patient’s health and history is key to improving the quality of care.
By adopting and using a forward-leaning, cloud-based technology, radiology groups can eliminate the geographical and time-based challenges that previously prevented them from providing the highest quality of care at the right time in an efficient manner.
Providing physicians a complete view of the patient can lead to enhanced operational and clinical efficiencies. The use of a cloud-based system can not only improve patient care, but can eliminate redundant procedures and the need for patients to explain their condition or symptoms multiple times, thereby reducing visit times and administrative costs.
As technology progresses in healthcare, the ultimate goal is to generate interoperability between different silos of data information. In addition to eliminating those silos, we can work to bridge them and improve patient outcomes while enhancing practice and hospital efficiency.
In recent years, the federal government has released specific mandates regarding meaningful use—rewarding groups who have implemented various programs with payments and assigning fairly heavy fines to groups who did not.
The Protecting Access to Medicare Act (PAMA) of 2014 required all ordering professionals in the Medicare program to order advanced imaging studies utilizing clinical decision support (CDS) software based on appropriate use criteria (AUC) by January 1, 2017. This deadline has since been pushed to summer 2017, but essentially allows the federal government to ensure the right procedure is being done at the right time by the right physician.
While this initiative aims to reduce overutilization and costs while improving patient outcomes, it will be critical for physicians to prepare and comply with this legislation to avoid significant fines. Should the Centers for Medicaid and Medicare (CMS) find inappropriate use when collecting and tracking the CDS data, the offending physician will not be reimbursed. Groups utilizing a cloud-based Best in Class technology platform will be able to add this module much faster than those relying on single-vendor systems.
Enterprise imaging is the future of a truly interoperable healthcare system that connects providers, patients and payors across the continuum of care to ensure optimal results. Many of the changes within healthcare, from the new CMS legislation to the development of population health databases, are moving toward an outcomes-based reimbursement model that will require greater connectivity among key players within the profession.
Moving forward, radiology groups will have three options:
1. Be unable to comply with new legislation and risk substantial fines from CMS and other federal agencies;
2. Invest massive amounts of time, energy and capital to build their own system to comply; or
3. Adopt a cloud-based suite of Best in Class technologies that can not only be implemented quickly and cost-effectively, but is primed for the future
of enterprise imaging by being highly adaptable for future changes in technology.
This can be a daunting challenge for even the largest of organizations. A December 2015 study by the Constellation Group concluded the following regarding how organizations should acquire these emerging technologies: “Organizations must determine if they should buy a suite of products from a single vendor or piece together tools from multiple vendors in a ‘best-of-breed’ approach. While there are benefits and challenges to both options, Constellation believes that overall a suite approach, from a proven integrator, remains the correct decision for most organizations.”
Federal and state regulators are aggressively taking action to rein in costs and investigate fraud in the healthcare industry. Initiatives to identify non-compliance are more intense than ever, and officials are increasingly focusing on the specialty of radiology.
Imaging has consistently been one of the fastest growing Medicare costs, rising from $6.5 billion in 2000 to $11.7 billion in 2009. According to a 2010 study published in the Journal of the American College of Radiology, 26 percent of the 459 CT and MRI exams studied were deemed inappropriate. As policymakers and payors strive to contain costs and reduce waste, radiology groups will increasingly need to prove medical necessity and demonstrate their value to the health systems and communities they serve.
In 2010, the Centers for Medicare and Medicaid (CMS) developed an advanced analytics system called the Fraud Prevention System (FPS). In its first three years of use, the agency identified and/or prevented $820 million in inappropriate payments, according to a statement released by CMS.
The passage of the Affordable Care Act of 2010 required a broad range of providers, suppliers and physicians to adopt a compliance and ethics program. This legislation no doubt impacted smaller physician groups and suppliers most significantly, given that many larger health care providers already had some form of compliance program in place.
A corporate compliance program is a “code of conduct” consisting of written guidelines, policies and procedures for acceptable business practices designed to prevent and detect violation of laws. A failure to implement certain compliance program elements will invite regulatory and law enforcement scrutiny, as well as potential False Claims Act liability for failure to prevent or identify improper federal healthcare program claims and payments. When paired with the stronger sanctions and expanded application of the federal False Claims Act, Civil Monetary Penalties Law and Anti-Kickback Law, the existence, or lack of, robust provider compliance program controls will dictate to what degree enhanced focus in fraud and abuse inquiries and prosecutions by the Office of Inspector General are likely.
A well-crafted, consistently administered and comprehensive compliance program is not an option to consider – it is mandatory. In some states, enrollment and participation in Medicaid programs requires attestation of having a compliance officer and compliance program in place as a condition of participation and payment for services.
The following is a list of five essential elements to be included in most radiology groups’ compliance program:
1. Compliance Manual: A copy of the organization’s compliance manual should be found at each of its locations, and should consist of the following components:
Overview of the compliance program – Fraud and Abuse, Anti-Trust, Anti-Kickback
Introduction to the compliance officer and compliance committee
Employee training and education policies
Policies regarding auditing, disclosure/reporting, record retention, discipline and enforcement/prevention
Employee performance evaluations
Goals of the program
Hotline Reporting contact information (federal and state)
Areas of potential risk for healthcare entities
Procedures in the event of an investigation/search by a federal or state government agency
2. Compliance Officer’s Manual: The compliance officer’s manual should aggregate a variety of forms, policies and reports regarding ongoing compliance initiatives and goals, including:
Signature list of compliance program review
Training/education documentation of individual employees
Zero tolerance policy
Simple error log form
Employee auditing form
Confidential incident report form
Quarterly/annual report to board of directors
3. Code of Conduct: The code of conduct should be adopted by the owners and management team and must be signed by each radiologist and staff member to be filed and maintained by the compliance officer.
4. Compliance Training Program: The training program should consist of an initial course for new hires as well as ongoing training modules for employees and radiologists to review new policies and identify risk areas within the organization.
5. Continuous Monitoring and Compliance Audits: Audits should be performed on a regular basis to ensure strict adherence to compliance regulation and to identify any risk areas or issues within the group. Remember, the government does not prosecute people for simple mistakes – it does go after negligent entities and “bad actors.”
Keep this in mind — a well-crafted and administered compliance program should not only minimize errors and enable the practice to compliantly navigate regulatory requirements and laws applicable to the profession; it has the potential to enhance revenue through improved billing and documentation processes. It also facilitates the best response to possible regulatory investigations, audits or inquiries in the future.
By placing compliance initiatives at the core of their organization, radiology providers can create an environment that encourages accountability, open lines of communication and transparent activity among employees, radiologists and billing providers while protecting the assets of the owners.
To learn more about how to easily develop a comprehensive compliance program for your radiology group, please contact us at ContactIRP@IntegratedRP.com.
As the healthcare industry continues to evolve, radiology groups face mounting pressures to simultaneously improve clinical care, increase their bottom line and enhance productivity. Add to the mix changing reimbursement models, better informed healthcare consumers, and rising costs, and it is easy to see why some radiology leaders are scrambling to innovate and generate new solutions in this highly dynamic marketplace.
As the industry transitions to a value-based care model, analytics platforms have emerged as a way to integrate, organize and analyze data to better understand how organizations are performing, what clinical results need improvement, and whether patient needs are being met. In addition, if radiology leaders leverage the right data points, they can generate significant cost savings for their practice.
According to a 2015 survey from the Deloitte Center for Health Solutions, however, fewer than half of the health systems surveyed have a clear analytics strategy, and one in four do not have a data governance model in place. And yet, health systems seem to recognize the importance of analytics capabilities. More than half of the systems surveyed identified population health analytics as the top investment focus moving into 2016, and more than three in five reported they will invest in advanced analytics capabilities for clinical and population health functions.
The application of analytics will allow for the identification and management of specific procedural protocols and their underlying risk profiles. This provides radiologists access to leading insurance underwriters offering premium coverage, long-term rate stability and the ability to create a custom risk management program.
A key player at the forefront of medical malpractice innovation is Chicago-based Arthur J. Gallagher & Co., a risk management firm developing these programs and identifying new ways physicians can save on malpractice insurance costs. According to Lee Newmark, area senior vice president at AJ Gallagher, physician groups need to combine a collaborative model with advanced analytics capabilities to achieve full cost-savings when it comes to insurance.
“At a certain size threshold, pricing for a radiology group will shift toward being based on their overall claims performance vs. the more traditional crediting methods,” Newmark said. “When the group hits that threshold, comprehensive analytics can help to identify key areas for a practice to focus on in terms of their risk management. Doing so should ultimately lead to a reduction in risk and therefore more competitive pricing.”
By tracking key metrics, radiologists can work with insurance carriers to build a superior medical malpractice program based on documented, detailed proof of the group’s performance. Two key metrics to track are the number of incidents and number of misdiagnoses; these can significantly impact the program’s price, and low or declining numbers over time can reduce costs for radiology groups.
“If analytics are proven and they trend in the right direction, the radiology group makes the case that they are a better risk and deserve to have their pricing evaluated in a more competitive manner,” Newmark explained. “These analytics can also give radiologists information and feedback regarding ways they can alter or modify their behavior to mitigate risk.”
In the event of a claim, groups can collect data regarding the suit, such as who is being sued and why. This can then encourage and inform risk management discussions among providers to drive better outcomes, cost savings and fewer claims in the future.
It has never been more critical for radiologists across the country to leverage the power of analytics to achieve greater efficiencies and lower costs. The utilization of clinical information to drive business and clinical decisions is essential to thrive in the highly dynamic and competitive healthcare landscape. By leveraging an advanced analytics platform, radiology leaders can experience significant cost savings and improve the quality of care they provide their health system and patient community.
/wp-content/uploads/2014/05/Logo_header_vs21.jpg00admin724/wp-content/uploads/2014/05/Logo_header_vs21.jpgadmin7242016-04-26 15:28:052017-05-15 21:13:15Leveraging Analytics to Lower Medical Malpractice Costs
By Doug Smith, Managing Partner of Strategic Positioning & Consulting Services
Since the Affordable Care Act’s adoption in 2008, the healthcare industry has been inundated with waves of change, ranging from the utilization of electronic health records to ICD-10 implementation to greater patient choice regarding medical decisions.
Shifts in industry payment methodologies have been on the horizon for several years, but are just now entering the landscape’s forefront as the next major change within U.S. healthcare delivery. In 2013, the Bipartisan Policy Center issued a report calling for major reform in payment models to “promote better care coordination, improve quality of care, and slow cost growth.”
And it is easy to see why policy leaders are calling for cost containment when it comes to healthcare. According to a study published in Health Affairs, in 2012, U.S. healthcare spending increased by 3.7 percent to $2.8 trillion, or $8,915 per person. This composed 17.2 percent of the nation’s Gross Domestic Product (GDP). And it doesn’t stop there; The Centers for Medicare and Medicaid Services (CMS) projects that by 2022, U.S. healthcare spending will reach approximately $5 trillion, amounting to 19.9 percent of GDP.
A recent white paper developed by the CMS Health Care Payment Learning & Action Network (LAN) describes an update to the alternative payment model (APM) “framework” they are developing. This update reflects the result of a prior period of public comment and input from various constituents including hospital providers, physician providers, insurance companies and CMS policy makers. The good news: LAN recognizes that fee-for-service must be the anchor for all future payment methodologies.
Below are some key points from LAN’s recent white paper which provide a “pathway” to its shift toward APMs in the health care industry.
Population-Based Payment Methodologies
The plan ultimately culminates in population-based payment methodologies and, in the long term, is designed to move from what is known as “Category One” (Fee-For-Service) to “Category Two” (Fee-For-Service linked to Quality and Value Metrics). This includes Foundational Payments for Infrastructure and Operations, Pay for Reporting, Rewards for Performance, and Rewards and Penalties for Performance.
Then comes “Category Three” (Alternative Payment Models Build upon Fee-For-Service Architecture) with APMs with Upside Gain Sharing, APMs with Upside Gainsharing and Downside Risk. And finally, we have “Category Four” (Population-Based Payment), including Condition-Specific Population-Based Payment and Comprehensive Population-Based Payment.
Also mentioned in the report was an evolution of “Bundled Payments” for certain episodes of care provided by multiple providers. CMS defines an episode of care as the set of services provided to treat a clinical condition or procedure, such as a heart bypass surgery or a hip replacement. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care.
This payment methodology demands we get a seat at the table when “who gets what” is being determined. It also necessitates we are at the table with supporting evidence of our position with respect to what we should be compensated before we are told what we are going to be paid.
Equally as important as understanding the implications of the LAN report is our understanding that our customers (hospitals) are reading the same report with optics focused on what this may mean for their future. We are already seeing many hospitals wanting or even requiring data and information on clinical, quality and utilization management as well as operations and financial cost to the patient. These are all essentially measures of a practice’s value.
At IMP, we believe strongly in the power of predictive and prescriptive analytics to improve practice performance and future outcomes. We equip our clients with the data they need and the knowledge to transform that data into meaningful and credible information in order to “win” at the previously mentioned negotiations. In addition, it is critical to regularly report practice metrics and initiatives physician leaders have implemented to clearly demonstrate the value provided to both hospital and patient customers.
By Bill Pickart, CEO, Integrated Radiology Partners
Healthcare has become one of the most dynamic and competitive industries in the past few years, with M&A activity increasing as physician practices struggle to survive in a rapidly evolving market.
According to a recent Business Insider article, the 2015 worldwide M&A volume stands at an all-time high of $4.86 trillion. The largest volume and activity has come from the healthcare sector, reports Dealogic, reaching $39.4 billion (304 deals), up from $28 billion (262 deals) in 2014.
As we say goodbye to 2015, it is important to note the factors that have contributed to this heightened activity in the healthcare services provider sector, which include technology demands and declining reimbursements. As publicly traded and private equity-backed consolidators continue to expand throughout the industry, promising health systems economies of scale, increased service offerings and greater operational efficiencies, it is important to review health systems’ and radiology groups’ options to remain competitive and successful in the new year.
National, Multi-Specialty Company
National healthcare management companies such as TeamHealth, AmSurg/Sheridan and Mednax are all highly focused on expansion into new markets and acquisition of new hospital contracts. These companies prove a highly competitive player in the market; because of their size, they can easily offer the economies of scale and service offerings hospitals are seeking to thrive in a highly competitive market.
While M&A activity has been prevalent in the specialty of anesthesia, these groups have increasingly edged their way into the field of radiology. In 2015 alone, Sheridan acquired Radisphere and Mednax acquired vRad, two major players in the radiology market.
This has radically altered the playing field for radiology groups, who now must compete with not only other local practices, but also the national management company down the hall who has the hospital’s anesthesia or emergency medicine contract. This concept of the “fin in the water” proves a direct threat to radiology groups who are trying to stay independent and competitive.
Of course, other local radiology groups are still competitors for the health system contract. If a radiology group is chronically underperforming, clinically inefficient, or is unable to integrate the latest technologies and best practices into its daily operations, it is at risk of being ousted by another, more attractive group across town. Likewise, if a radiology group does not have the necessary subspecialty access critical for accurate and efficient image reads, a hospital may turn to other options.
Technology and Collaboration
In response to these two threats to radiology groups’ independence and survival, there is an emerging practice within the industry that involves the creation of noncompetitive group networks that provide the economies of scale, subspecialty access and service offerings hospitals seek. Leveraging distributed imaging workflow technology as provided by Plexus Teleradiology, radiology practices can collaborate with other like-minded groups to gain the access and services they need at an affordable price.
Because these collaborations are not mergers but rather joint ventures, radiology practices across the country can maintain their independence while remaining an effective and competitive partner for the hospital they serve.
For more information about the Plexus Teleradiology platform and its capabilities, please contact ContactPlexus@plexustelerad.com.
/wp-content/uploads/2014/05/Logo_header_vs21.jpg00admin724/wp-content/uploads/2014/05/Logo_header_vs21.jpgadmin7242015-12-29 22:13:392016-07-19 18:59:05The Subspecialty Quandary: Avoiding the “Fin in the Water”
By Bill Pickart, CEO, Integrated Radiology Partners
The application of Quality data has become one of the most critical ways radiology groups can improve accuracy and ensure success in a rapidly changing market.
In 2012, the Centers for Disease Control administered a national survey to understand the effectiveness of electronic health record (EHR) systems within medical practices. The results were published in a report titled “National Perceptions of EHR Policies,” and stated that of the surveyed physician leaders who had already adopted an EHR system, 75 percent reported a subsequent improvement in patient care, and 67 percent reported their practice benefitted financially due to the switch to an electronic records platform.
EHR systems have the ability to collect massive amounts of data that can be used to fuel superior practice performance while reducing costs—and that is important, given the rate at which diagnostic imaging spend is increasing.
According to the American Academy of Orthopedic Surgeons (AAOS), the annual spend on diagnostic imaging is $100 billion, making it the second-largest—and fastest growing—item for healthcare payors. AAOS also estimates that $30 billion of this spend is unnecessary, due to inappropriate utilization of imaging or duplication of studies.
Inappropriate utilization of imaging and study duplication are not only financially costly, but they cost radiology groups and imaging centers time and effort, and can significantly slow a practice’s productivity.
In response, many groups have turned to the trend of consolidation to not only generate the economies of scale needed to survive in the rapidly evolving healthcare marketplace, but to consolidate clinical data to support the decision-making process. This aggregation of both physicians and data can highly benefit groups from a clinical and business perspective.
One recent application of using analytics to lower costs is the reduction of medical malpractice insurance rates, an often lofty expense for practices.
Within IRP’s group collaboratives, radiology leaders are able to apply analytics to generate a 20 percent discount on malpractice insurance premiums within the first year, with additional discounts expected in the future. Further premium cost reduction will come through the application of analytics allowing for the identification and management of specific procedural protocols and their underlying risk profiles. This provides radiologists access to leading insurance underwriters offering premium coverage, long-term rate stability, and the ability to create a custom risk management program.
By utilizing practice information to drive decisions, radiology leaders can experience significant cost savings. Remember, power in numbers is good, but coupled with the power of information it gets even better.
By Keith Chew, MHA, CMPE, Managing Director of Strategic Positioning and Consulting Services
In last month’s installment of the Collaboration Series, we discussed the evolving, varied business models of radiology group collaborations, partnerships, affiliations and acquisitions. This month, we will be focusing on using the collaborative model to improve the quality of care radiology groups provide.
In the pursuit of cost-effective, high-quality services, the healthcare industry today is experiencing tremendous change. Consolidation, in particular, has been particularly brisk in recent months, as firms look to build scale, cut costs, expand service lines and gain market share.
So it’s easy to see why hospital leaders now are paying particularly close attention to radiology. According to the American Academy of Orthopedic Surgeons (AAOS), “the annual spending on diagnostic imaging in the United States is $100 billion, making imaging the second-largest and the fastest-growing item for healthcare payors.” The medical organization estimates that $30 billion of this total outlay is spent unnecessarily, due to the inappropriate utilization of imaging or duplication of studies.
With so much opportunity for increased efficiency in radiology departments, what can radiologists do to ensure they remain a valuable partner to hospitals, payers and patients? They can come together. Radiology group collaboration is a proven strategy for improving quality, lowering costs and increasing efficiency. Here are three reasons why:
Access to the appropriate subspecialists is a key component of improving quality within radiology practices. It is critical to have access to the most qualified specialist with the greatest knowledge and experience in the specific area of diagnostic imaging being utilized. This will decrease the likelihood of additional diagnostics being ordered, which can put strain on a facility’s time and resources.
Subspecialty access can also help to reduce clinical errors in radiology readings. According to the American College of Radiology (ACR), the average error rate of radiologists is nearly 30 percent, with 70 percent of the errors due to an unperceived, or “missed,” abnormality in the reading. If radiology groups form a collaborative and become interconnected remotely with subspecialists throughout their community, state or even region, they immediately become empowered to work toward meeting the goals of the Image Wisely campaign of supplying the right diagnostic test to the right patient at the right time. This can be brought about through better clinical decisions that will ultimately improve the quality of care and patient safety.
By combining resources, collaborative radiology groups can utilize key imaging workflow technologies that address operational inefficiencies, limited capacities and workflow integration. This technology can provide radiologists comprehensive, detailed patient clinical history to use when interpreting studies. The more specific the clinical information at hand, the more actionable that diagnostic interpretation can be. This provides added value for the referring provider to develop an effective treatment plan for the patient.
At IRP, we make available to our Regional Radiology Group Networks (RRGNs) a customized imaging workflow management software that features a unified work list, enhanced voice recognition capabilities, advanced performance reporting, automated peer review and critical results notification. All of these elements are specifically designed to enable greater operational and clinical efficiency in an era of value-based care. Practices can optimize their performance and better position themselves for success in the market by pooling resources and investing in sophisticated technology solutions.
Radiology groups that collaborate with other like-minded practices reap the reward of cost-savings in a variety of areas. One example includes medical malpractice insurance; groups involved in IRP’s collaborative model can save an average of 15 to 20 percent on their annual malpractice insurance costs initially. That savings can also increase as analytics are applied to the risk management functions of the practice or network. By focusing on cutting unnecessary costs, radiology groups can target their resources on quality improvement initiatives.
As the industry continues to move toward a value-based care model, radiology practices and imaging centers will increasingly need to demonstrate and deliver their value proposition. Advanced data and analytics capabilities will play a key role in proving a practice’s value.
Stay tuned for the final installment of the Collaboration Series, when we will discuss the different ways data analytics and quality metrics can be built into collaborative practice models in order to demonstrate, prove and even improve their value proposition.
/wp-content/uploads/2014/05/Logo_header_vs21.jpg00admin724/wp-content/uploads/2014/05/Logo_header_vs21.jpgadmin7242015-10-26 19:33:002016-07-19 18:59:05Collaboration Series Part II: Improvement in Quality
Within the past ten years, physician leaders and hospital executives have seen more consolidation in the healthcare industry than ever before. As the industry transitions to a value-based care model, efforts are underway by leaders across the board to reduce costs, improve results and increase hospital-physician alignment. A recent report by Deloitte, “2015 Health Care Providers Outlook United States,” states:
As patient rolls lengthen and networks narrow, providers may need to adapt to this realignment of market forces. Smaller players (e.g., single hospitals, independent physician groups) may be in danger of exclusion from more narrow networks. In contrast, market-dominant players are likely to be immune from exclusion and can negotiate from a position of strength. Dominance comes partly from being big, and the need to be big is driving sector consolidation. (3)
Changes in regulation, technological innovation and financial pressures are all contributing to this push toward market consolidation—toward “being big” in order to survive.
But it is important to examine physician practices’ options in today’s rapidly changing environment. The multitude of possible models that lie on the spectrum of consolidation prove that there is no one way to align with hospitals and become a stronger market player. On one end of the spectrum lies traditional merger and acquisition (M&A) activity, while beyond that exist joint venture models, clinical integration networks (CINs), affiliations and collaborations as potential solutions to avoid sacrificing practices’ independence.
Below are three examples of the different options available to radiology groups in the current landscape:
Collaboration of Large Groups
Collaborations of large practices are becoming more popular in the specialty of radiology. An example is
Strategic Radiology, which strives to provide its network of 1,300 radiologists shared access to data, clinical information and certain consolidated expenses in a collaboration-based model. Although its goal is to deliver higher quality, cost-effective care, Strategic Radiology focuses on practices with fifty or more providers, essentially ignoring smaller regional players. Though collaboration provides the tools necessary to succeed in such a model, it is an exclusive model which has not focused on the independence and survival of smaller groups across the U.S.
Acquisition by Management Company
Single-specialty and multi-specialty national management companies are also on the move within the radiology market (see MEDNAX’s acquisition of vRad spring of 2015). One example is Radiology Partners (RadPartners). The group’s approach resembles the traditional M&A model of acquiring practices to join its expansive network of over 100 locations. Though it positions its services as “partnering” with radiology practices, RadPartners primarily acquires local groups and promises health systems greater stability. This corporate-sponsored management company has over 200 radiologists who share technology, quality data metrics and economies of scale in order to hope to succeed in the era of consolidation, yet simultaneously cede to this trend as they lose their independence.
IRP’s Model of Small Group Collaboration
At IRP, our collaborative model is built to support regional radiology practices’ sustained independence. We provide radiology groups of all sizes the resources they need to survive in the age of value-based care. IRP’s model helps transform practices into more nimble organizations that allow for faster, more efficient decision-making in a rapidly moving market. We prepare our collaborations for the future of healthcare; for example, as CMS moves its 2018 Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) initiative forward, we equip our groups with the data submission capability and metrics necessary to evaluate the assumption of greater risk as these models come to fruition.
It is critical for radiology leaders to examine the emerging and evolving practice models and make an informed decision regarding their practice’s future. As the current regulatory environment fuels increased demands and pressure on physician practices around the country, what is your plan to solidify your independence and ensure your success?
–By Keith Chew, MHA, CMPE, Managing Director of Strategic Positioning and Consulting Services
Stay tuned for part two of the collaboration series next month, where we will discuss the various benefits a collaborative model brings to radiology practices nationwide.
/wp-content/uploads/2014/05/Logo_header_vs21.jpg00admin724/wp-content/uploads/2014/05/Logo_header_vs21.jpgadmin7242015-09-28 14:21:202016-07-19 18:59:05Collaboration Series Part I: Evolving Business Models
Oct. 1 is rapidly approaching, and no medical specialty, including radiology, will be exempt from ICD-10’s industry-wide overhaul.
A recent article in the Radiology Business Journal warns physicians to “brace themselves,” citing a Journal of American College of Radiology study which predicts a 6-fold increase in the number of codes used by radiologists.
“As the conversion from ICD-9 to ICD-10 will require acquiring and documenting even more detailed clinical information than is currently required for billing purposes—information that remains difficult for many radiology practices to adequately capture—that transition is perceived as a particularly daunting task for facilities, physicians, administrators, and coders alike,” Dr. Margaret Fleming from the department of radiology and imaging sciences at the Emory University School of Medicine reported.
Although the conversion to ICD-10 is a daunting task, there are many things radiologists can do to “brace themselves” for Oct 1st. Let’s examine what radiology leaders should do to prepare for this challenging transition and avoid any cash flow or productivity-related disruptions:
Confirm Medical Necessity
Confirming and documenting medical necessity for encounters is problematic in today’s reimbursement environment, but this process will become even more of a nuisance come Oct. 1. Add to that, over 40% of radiology studies result in no finding. In these cases, radiology groups are completely dependent on the referring doctor to provide detailed presenting conditions in order to get paid. Put another way, it is not how prepared your group is but how prepared each and every referring practice is for ICD-10. We recommend practices start tracking referring doctor and practices’ poor documentation of patients’ symptoms and condition. In addition, groups should contact their primary referring practices and confirm their ICD-10 readiness.
Findings from the reading must be dictated with a greater level of specificity than ever before required. For example, in scoliosis cases, radiologists must now be able to answer when exactly it began, is it acquired or congenital, along with the specific area of the spine affected. Without these key pieces of information, radiologists may face a significant increase in claim denials and a host of other reimbursement and compliance issues.
Medical Economicscites: “Of the ICD-10 codes that do not have ICD-9 counterparts, about half are related to laterality (left, right and bilateral indications), AHIMA says. Another big chunk of ICD-10 codes consists of ‘external cause reporting’ codes, such as what caused a particular injury.” The article continues to describe additional codes radiologists must support with documentation, including those related to linked conditions such as hypertension and heart disease as well as musculoskeletal conditions such as bone fractures. Familiarizing yourself with the codes most relevant to your practice as well as the required information associated with those conditions will ensure appropriate reimbursement and an uninterrupted workflow.
The top five areas radiologists will need to provide additional documentation in their reports are:
1) Fractures: Radiologists will need to expand their documentation; laterality, type of fracture as well as encounter, is the fracture open or closed, is the fracture pathological or traumatic and in what stage of healing is the fracture.
2) Limb pain: Radiologists will need to document the specific limb and laterality.
3) Abdomen pain: Radiologists will need to document the specific location of the pain in the abdomen.
4) Congestive heart failure: Radiologists will need to document the type of heart failure, and if it is acute, chronic, or acute on chronic.
5) Osteoarthritis: Radiologists will need to document the specific location and laterality.
Learn the Most Relevant Codes
ICD-10’s addition of 56,000 codes and change in code structure is overwhelming for any physician to absorb. Although all practices will have to do some preparation for and education around these new codes, it is important to narrow in on which codes are most relevant to the practice’s patient population.
According to an RBMA ICD-10 resource, this new system affects diagnosis codes in different ways. For example, the ICD-9 code for headache, 784.0, is only broken into two ICD-10 codes (G44.1 Vascular headache, not elsewhere classified, and R51 Headache). Other diagnoses, however, present a more alarming picture; ICD-10 breaks down ICD-9’s 786.09 Respiratory abnormal NEC into five different diagnosis codes, and ICD-9’s 729.5 Pain in Limb code into no fewer than 30! Many billing groups are looking for simple translations from ICD-9 to ICD-10; although there are many codes for which this will be possible, to address the vast majority of codes in this manner would lead to improper coding and negatively impact both compliance and reimbursement.
It is critical to understand which of these conditions occur most frequently in the radiology practice or imaging center to appropriately allocate ICD-10 preparation time and funds. Radiologists do not need to learn all 68,000 codes, but they will certainly have to familiarize themselves with the additional codes that will affect them the most. Our findings indicate that less than 4 percent of the ICD-10 codes will be used in radiology. In addition, the top 62 ICD-10 codes will cover as much as 65 percent of a radiologist’s primary findings. Physicians need to know not only these top codes, but also what to document in order to provide the specificity required to properly assign these codes. Talk to your coders and find your top ICD-10 codes.
If there is a “silver lining” to ICD-10 for radiologists, it is that the required additional information from the referring doctors for ICD-10 should provide a much clearer picture of what’s actually going on with the patient. Thus, radiologists can more accurately address the presenting conditions of the patient.
Please click here for additional, radiology-specific ICD-10 resources.
In April’s first installment of the Patient Empowerment series, we discussed how increased patient responsibility and widespread use of technology has led to the creation of the new patient-consumer. Part II of this series asks the question: So what?
The rise of patient empowerment has given way to a startling amount of autonomy when it comes to healthcare information and decisions; the Pew Internet and American Life Project found that 83% of Americans look online to research health and medical information as well as physician providers.
The patient-consumer’s ability and tendency to research both medical information and providers has dramatically altered the traditional pattern of physician referral. Although physician referrals previously accounted for over 51% of patients’ providers source, this number has fallen to about 30% in recent years. Instead, patients choosing a provider on their own has risen from 24% to 60%, with 80% of high margin procedures such as orthopedic surgery sourcing back to patient choice, rather than physician referral.
The following are two primary ways this change in referral pattern has impacted radiologists and the imaging centers and hospitals they serve:
Hospital Marketing Spend
As a result of this interrupted referral pattern, hospitals have had to become proactive in both attracting and engaging patient-consumers. According to an article by National Public Radio, hospitals’ spend on marketing and communications doubled between 2000 and 2009. A 2012 study by UBM Medica cites that a bulk of the hospitals’ digital marketing budget is used to improve the hospital’s and its physicians’ rankings on digital search engines.
And this is not surprising, considering, as HP Social Media Solutions’ whitepaper “Social Media in Healthcare” states, “whole sites—RateMDs.com, Healthgrades.com, Vitals.com, and others—are dedicated to patient reviews of physicians and hospitals.”
This is crucial as hospitals are becoming increasingly focused on gaining market share and increasing their value. Providing high quality readings and offering subspecialty access such as interventional radiology have become some of the most significant ways radiologists can serve their hospitals and imaging centers. Maintaining a progressive online presence through communication of expanded service offerings and positive patient experience is now a primary way health systems and associated radiologists attract patients and provide added value to their community. A negative presence has the ability to seriously affect a radiologist’s encounter numbers and thus productivity, decreasing his or her value in the eyes of the hospital and/or imaging center.
Widespread use of technology to not only research imaging centers and hospitals but also to check symptoms and seek medical advice has fundamentally changed the way patients interact with their radiologists. In its report titled “Doctor Innovation,” The Economist states: “Many initially saw the spread of medical information on the Internet as a nuisance or even a risk, although most have since come to see it as a way of enriching doctor-patient conversations.” Patient-consumers are no longer receivers of information from physicians, but rather collectors of information from friends, family, websites and social media channels. This therefore grants them a larger, more proactive role in their healthcare decisions.
An article featured in the NY Times last year, “Radiologists Reducing the Pain of Uncertainty,” touches on how this development impacts radiology: “…Patients are more and more insistent on knowing how and why doctors make decisions about their care. And more and more medical centers and doctors’ offices are allowing patients to log on and see their medical records, which can include reports on scans.” The article continues to explain initiatives taken by both the Radiological Society of North America and the American College of Radiology to demonstrate “how some radiologists have successfully managed to communicate with patients and by letting radiologists know this is something patients want.”
With the patient-consumer becoming increasingly accustomed to direct access to medical information and records online, radiologists are finding a greater need to adapt to this trend, developing positive relationships with patients built on trust and open communication.
In the third and final installment of the Patient Empowerment series next month, we will outline what steps radiology groups and imaging centers can take to proactively engage these patient-consumers and capitalize upon this new industry trend.
/wp-content/uploads/2014/05/Logo_header_vs21.jpg00admin724/wp-content/uploads/2014/05/Logo_header_vs21.jpgadmin7242015-06-16 15:41:532016-07-19 18:59:06 Patient Empowerment Part II: The Rise of Patient Choice
The entry of corporate management companies into radiology
May 19, 2015
On May 12, 2015, MEDNAX announced its official agreement to acquire Virtual Radiologic, commonly known as vRad, for $500 million. vRad is a leading outsourced radiology physician services company comprised of over 350 U.S. board-certified radiologists. It is also the largest corporate provider of national teleradiology services. Read more
/wp-content/uploads/2014/05/Logo_header_vs21.jpg00admin724/wp-content/uploads/2014/05/Logo_header_vs21.jpgadmin7242015-05-19 18:27:412016-07-19 18:59:06What the Acquisition of vRad Means for the Practice of Radiology
The changing healthcare landscape has directly affected providers, hospitals and medical staff, but it also has had a profound effect on patients. The increase in patient responsibility for healthcare costs paired with the ease of sharing information via technology has created a patient population that is more aware, knowledgeable and concerned regarding the healthcare industry and their interaction with it. Read more
The needs of the hospital have dramatically changed as the healthcare industry transitions to a value-based model. These changes have required a greater level of hospital physician alignment than ever before. Read more
/wp-content/uploads/2014/05/Logo_header_vs21.jpg00admin724/wp-content/uploads/2014/05/Logo_header_vs21.jpgadmin7242015-03-12 15:53:142016-07-19 18:59:06Radiology Leadership: Fulfilling the Hospitals’ New Needs