Appropriateness and the ACO: How Radiology Can Position Itself to Lead

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Edward RittwegerRadiology groups’ conversations with their hospital partners are undergoing an evolution, in the experience of Edward Rittweger, MD, president of Navesink Radiology (Red Bank, New Jersey). “In the past, most of the hospital discussions involving imaging have been about decreasing turnaround times and increasing efficiency in response to decreased reimbursements,” he says. “As we move forward, however, it will be more important for the radiology group to assist the hospital in developing metrics to evaluate how imaging adheres to decision-support mechanisms and evidence-based care protocols.”

Navesink serves Riverview Medical Center in Red Bank and Bayshore Community Hospital (Holmdel, New Jersey); both are part of the Meridian Health System, which is in the process of developing an accountable-care organization (ACO). “The hospital system is very supportive of us in our efforts to develop initiatives to improve patient satisfaction and reduce costs,” Rittweger says. “The system’s main focus is on quality and patient care, and there are several committees, even at the corporate level, that are focused on quality. The system has gain sharing for primary care, and although it has yet to be established for radiology, we expect things to start changing as the ACO reaches maturity.”

The Radiologist As Consultant

Rittweger sees limitations in commercially developed decision-support systems in that they have the potential to usurp the radiologist’s potential role as an appropriateness consultant. “For clinical decision support to work, it’s important that the partners involved—the medical groups and the hospital—be able to share equally in the profits, while still maintaining high patient-care quality,” he says. “Radiologists need to be involved on a leadership level. It’s important to hospitals that they foster the implementation of these algorithms among the medical staff and throughout the hospital system.”

Turnkey clinical decision-support software sidesteps the radiology group, putting it at risk for commoditization. Instead, Rittweger advocates an approach in which radiology groups develop (with the participation of hospital committees) evidence-based criteria that they then help disseminate to the medical staff. This should be a key initiative even for groups that do not see ACO participation on the horizon, he stresses.

“These initiatives improve quality because everyone is using algorithms that have been proven,” Rittweger says. “They decrease cumulative radiation dose, and they improve turnaround time by limiting shotgun medicine: Clinicians are focusing on a single test that has been shown to be beneficial, instead of ordering several. There are a lot of compelling reasons for this; it’s not only the ACOs that are driving it.”

The Plan in Action

At Navesink Radiology’s hospitals, radiologists help co-develop and disseminate appropriateness criteria using a top-down approach, participating in committees at every level. “I’m president of the hospital medical staff, and we have people sitting on several key committees in the corporate system, as well as in quality committees higher up in the system,” Rittweger says. “We place people at high levels to guide protocols and processes and to be on the cutting edge of what’s happening in the health system.”

Further, Navesink spearheaded the development of a radiology steering committee that unites all four radiology groups serving the health system. “We discuss things together and ensure that any changes are implemented across the board,” Rittweger says. “It’s a cooperative effort between multiple groups.” The next step will be to aid in the integration of IT platforms across the system’s five hospitals. “It’s the job of the radiology groups to help them with the implementation and to guide them as to what might be the best way to go,” Rittweger says.

While Rittweger anticipates that the enforcement of some appropriateness measures—for instance, the use of ultrasound or MRI instead of CT, where appropriate, to reduce cumulative radiation dose—will initially affect the group’s income level, he expects to see the consultative model yield dividends down the line. “We’ve positioned ourselves in a consultative and helpful role. We want to do the best we can, and the system has been very helpful in supporting us,” he says. “If everyone only looks at what’s in it for him or her, the future can be very bleak, but if the focus is continually on quality improvement