Embracing value-based care: Radiologists are more than read, rinse, repeat

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James Whitfill, MD

The shift to value-based care is looking like less of a transition and more of a reality for imaging departments.

2017 marks the first year where practices are incentivized to use alternative payment models (APMs) and required to report data under the Merit-Based Incentive Payment System (MIPS). While CMS is allowing providers to ease into Medicare Access CHIP Reauthorization Act (MACRA) reforms, imaging practices should be prepared for an evolution in the overall role of radiology in a health system.

“The value radiology brings is more than just churning out as many diagnostic reports as fast as possible,” says James Whitfill, MD, chief medical oficer for Scottsdale Health Partners and professor of internal medicine and bioinformatics at the University of Arizona College of Medicine in Phoenix. “Focusing too much on that might bring short-term economic gain in a fee-for-service world, but long-term, it will lead to a negative outcome for imaging.”

Yes, the days of an MRI scanner doubling as a money-printing machine may be over. For imaging departments, cost control is now a primary focus, something we’ve already seen with CMS requiring clinical decision support for Medicare procedures beginning in 2018.

Other value-based initiatives also have a gloomy outlook for imaging, according to Whitfill.

“If you look at the spectrum of APMs coming out of CMS, they all have one principle: begin to put a brake on total medical spending for each Medicare patient,” he says. “The challenge radiology has under this model is there are no good examples of where a specific imaging intervention is shown to reduce total cost of care for a patient or population.”

However, APMs are still in their infancy, giving academic radiology a chance to head off cost-cutting by showing where imaging interventions can reduce spending. “There will be a huge explosion in the use of whatever method that’s shown to be beneficial,” Whitfill says. “In contrast to that, if radiology is unable to show it can be beneficial in that way, there will be continued downward pressure on reimbursement.”

At a crossroads

This brings us to a crossroads for radiology, one that will define the future of the specialty. In one direction: commodification. Whitfill can foresee a world where imaging centers operate with a “lowest cost at good enough quality” mindset, resulting in an environment where the only differentiator is cost and productivity is strictly measured by RVUs. That’s less than ideal, but some industry leaders have seen the danger of commodification and are instead embracing value-based care.

“Something that takes time away from reading exams is seen by some radiologists as taking away income, but the right leaders understand how their product is helping or hurting the overall health system.” Whitfill says. “Forward-thinking leaders in radiology are focusing on value metrics like readability of reports, following up on incidental findings and engaging on quality metrics.”

Radiologists in leadership positions will be a key factor in avoiding commodification, hopefully facilitating trustworthy and mutually beneficial relationships with health systems. Whitfill recommends the American College of Radiology’s Imaging 3.0 initiative for radiologists who have yet to take the first steps towards value-based care, calling it a great place to start.

Whitfill explains that radiologists should also do everything they can to own the transition to enterprise imaging. Radiologists have an abundance of subspecialty and health IT knowledge by virtue of their centralized position in the health system workflow. Providing value to the health system in ways other than directly reading images helps avoid the commodification of the profession, but radiologists need to ensure they aren’t glossing over the nuances of other departments.

“Drawing on radiologist expertise is helpful, but radiologists need to be sensitive to the fact that a wound care nurse has a very different workflow,” Whitfill says. “Radiologists need to work with other specialties.”

Enterprise imaging can also provide economy of scale efficiency by uniting the hospital’s imaging data under one roof. Data is typically siloed by department or specialty, creating costly redundancies or security flaws, according to Whitfill.

“In each case you have uncoordinated spending for storage and security—if there’s any at all,” Whitfill says. “In organizations that don’t have an enterprise imaging strategy, it’s not uncommon to find unsecured data sitting on USB drives or people’s smartphones. So one of the powerful value propositions of enterprise imaging is a unified security and storage approach, which is beneficial from both a compliance and cost perspective.”

Participating in the shift

Image annotation is yet another way for radiologists to own the transition to enterprise imaging, according to George Shih, MD, professor and vice-chair for informatics at Weill Cornell Medicine in New York.

While the oft-discussed specter of artificial intelligence (AI) and deep learning appears to threaten radiologists everywhere, a collaborative approach is much more likely than a takeover of the profession. Current AI approaches to radiology work by feeding a system thousands of images of normal and diseased cases, letting the system develop algorithms for classifying images on its own.

However, these images must be annotated for enterprise imaging and radiologists are part of the small pool of experts qualified to convert pixel data to medical information, according to Shih. There’s nearly an exabyte (one billion gigabytes) of medical images in the U.S and over 99% of it is not yet annotated—giving radiologists yet another opportunity to provide added value to a health system.

It may be tempting for radiologists to think wistfully on the days of fee-for-service, where advanced imaging was seen as a revenue stream for the entire health system rather than a cost center. But that would be counter-productive—instead, radiologists can add value by guiding appropriate imaging and providing input into IT and informatics systems, effectively participating in the industry’s shift to value-based care.