CXOFiles No.7 Saunders and Mid-South Imaging Bet on Quality
Worth M. Saunders, MHA, has served as chief administrator for the 32-radiologist Mid-South Imaging and Therapeutics, PA, Memphis, Tenn, since 2003. The position was a change of pace for the outpatient-imaging veteran, who worked for Radiologix for six years prior. Primarily a hospital-based practice, Mid-South serves six of the 14 hospitals operated by Baptist Memorial Healthcare Corporation, and also provides reads for numerous imaging operations located in physician offices, primarily multi-specialty clinics, billing for more than half a million CPT codes annually. The group made an early decision to participate in the Centers for Medicare & Medicaid’s Physician Quality Reporting Initiative (PQRI). Saunders talked to about the practice’s decision to participate in PQRI and quality initiatives in general in an evolving marketplace. What can you tell us about the governance/decision-making process there at Mid-South Imaging and Therapeutics? Worth: Everybody who is a partner is a shareholder, so we have 30 shareholders at this point. The shareholders elect a nine-member physician board of directors every year. They serve two-year terms. The board is primarily charged with overall governance and broad decision-making powers for the group. I serve, as the chief administrator, as an ex-officio member of the board, but I am not an official member of the board. I attend all of the board meetings and help facilitate a lot of the overall decisions. I am responsible for the operations, the business operations of the practice including billing, compliance, operations with regard to our outside read business as well interfacing with the hospital administrators and managers that interact with our group on a regular basis from the hospital-based operations. With regard to PQRI, the decision to participate mainly was driven by our management team, our non-physician team, in concert with our billing company. We brought it to our board as a recommendation that we participate, and they approved it. There has not been a lot of interest in participating in PQRI thus far. Why did the practice decide to participate? Worth: When we got into looking at the specific measures, we discovered there was only some basic communications we had to do. There weren’t any big changes we had to make to the structure of the reports. So we wrote some reminders to the physicians, cheat sheets if you will, just to remind them to mention the key findings that are in the measures. Take, for example, the stroke measure. You have to mention whether there is a hemorrhage, mass, lesion or other pathology. They were doing that anyway, so it was fairly easy for the physicians, at least for those measures, to implement. The main work was on the billing and the coding side, the programming that our vendor had to do to ferret out the services that applied to the PQRI measures. They had to program their system to catch any of the CPT and ICD-9 combinations that would potentially apply to the PQRI measures. So they did that on the front end for the July 1 start of the program. Once they designed the programming of that, they had to set up a process for the coders to go through the reports that were caught to make sure it was coded properly relative to the PQRI algorithms that were set up. We outsource our billing to McKesson. Per Se was acquired by McKesson a year or so ago, and the practice has a long-standing relationship with that company that goes back 25 years. They did most of the heavy lifting. We ultimately made the decision to participate, but they did the implementation, because they were responsible for billing, collections, and coding. The coders we use are McKesson employees. It was part of our overall arrangement, and they didn’t charge us extra for it. It was a standard percentage-based arrangement with them. So they did a lot of work that did not really have a return on investment, at least initially, but hopefully it will down the road, in setting up the processes and knowing how to implement it. I think there will be a long-term pay-off for them, but not a short-term pay off for the billing company, or for us. We may get a bit extra money next year for our participation, but it certainly wasn’t based on return on investment from a financial standpoint. It was more of a strategic decision, wanting to be on the front end of this pay-for-performance wave that seems to be happening in the industry right now. It’s just for Medicare and that is about 40% of our charges, and a lesser percent of our collections. So it is 1.5% potentially of 0.5% of our overall collections. So it is not going to be a material amount at the end of the year when they look at their compensation that is purely related to PQRI. Assuming that P4P is a reward for quality, how is the practice approaching the subject of quality in imaging from the technical, professional, and service perspectives? Worth: Overall, in the quality arena, we are doing the standard things a lot of radiology groups are doing. For instance, over reads. We pull out a sample every month for the hospital interpretations that we perform, and in the interventional area, we look at complication rates and track that. From a service point of view, we look at the standard indicators: report turnaround time, occasionally our hospital does surveys of the medical staff to look at perceptions of the medical staff of our service and other hospital-based services. It’s not directly related to pay for performance, but we try to do some education on radiation dosage to both our medical staff physicians as well as our outside read contracts, and physicians related to that. And we try to structure our imaging scanning protocols to give us the best exams with the least amount of radiation dose. I don’t think we are doing that much more than any other radiology group, but we are doing a good job of it, and I think in the future there could be more done. We will be looking at what the ACR comes out with in terms of quality guidance and recommendations in that regard, and try to implement more of those in the future. Have you look at what the ACR has proposed as a quality measure to the CMS for radiation dose? Worth: Briefly. I don’t have any in-depth knowledge of that, so I can’t say that I’ve looked at it from the point of view of how easy or how hard it is to implement. I think it’s a good topic to be talking about, and I think it’s an important issue for all of us with the increase in, particularly, CT imaging in the ER and the outpatient imaging setting that’s being done. We need to be more cognizant of radiation dosage, the Europeans are definitely ahead of us here in the states in that regard. So we are definitely going to have to do a better job educating and communicating on that in the future. What kinds of administrative burden does P4P present in general and how is your practice ramping up to meet those demands? Worth: We are just in the beginning stages. Medicare PQRI is really the first pay for performance practice that our group has been involved in. The commercial payors in our area are just starting to ramp up and we do very little business with the ones leading it in our area. ,So we haven’t been forced, for lack of a better term, to get into P4P yet, but I definitely see it coming. It will continue to be a burden on our billing and collections process, our coders, and management, from the point of view of tracking it and contract negotiations. The other thing you might consider in the P4P arena from a broad perspective is the idea of price transparency. A lot of our payers are talking about price transparency and publishing ranges of fee schedules so that the consumer will know where hospital X or physician group X falls from the cost perspective, So if they have an HAS (health savings account) or have to pay a large out-of-pocket expense as a lot more people are doing these days, they will have at least a general guideline. A lot of payers are talking about that, including our Blue Cross plan. They haven’t implemented it yet, but I see that coming as well. Doesn’t that mainly affect those with technical holdings? Worth: They are talking about implementing it for all services, so it is yet to be determined whether they will do that for hospital-based physicians like our group. But they are talking about it, and I think they might. Certainly, patients who seek out services from a hospital-based facility—which we provide a lot of—and to whom the radiology interpretation will be billed, would want to know where that falls within the cost ranges. How do you see meeting those demands? Worth: Working with the payors to see that it is accurately represented and that it is a fair process for publishing that data. I don’t see that we will be able to stop that from happening, with the consumer-based health care movement. And I can see some need for it out there, for consumers to know more about what they are paying for in health care. So I don’t think we should be obstinate about it, but I think we need to be sure it is accurately portrayed to the members out there. I think it will be driven by the payors, I don’t think the providers will be the ones driving this. There have been anti-trust considerations in the past around sharing negotiated fee schedule information with other providers in the area, and there are typically confidentiality provisions in most contracts that physician groups have with insurance companies. So, there are major reasons why we haven’t discussed it. I know when I talk with other radiology groups, we are always careful not to mention any specific fee schedule. Recognizing that P4P will play a more important role in the future, how will this impact the future practice of radiology? Worth: My projection is that more reimbursement dollars will be at risk based on P4P indicators, rather than just structured as a small bonus like it is structured now. So we are going to have to participate in these programs to continue to participate with most of the payors out there, including government and private payors. I know the ACR is taking an active role in trying to develop good measures, and we are going to have to work with them and provide good input on what measures can be real indicators, rather than just pay for compliance. It’s not just setting up measures that are hoops you have to jump through or buzzwords you have to put into your report, but really don’t make any difference from a quality standpoint. That’s going to be the challenge, to come up with indicators that make a real difference in patient care from a radiologist standpoint. It’s going to be a real challenge for the specialty to come up with consistent measures that are real indicators. Is this subject discussed within your practice? Worth: We discuss it more from a scanning protocol point of view, looking at the latest articles out there on how different studies should be scanned. We certainly monitor what the ACR is doing. We look to the ACR to take the lead on that. We are actively looking at RadPeer and considering that for the future, we have a quality assurance process already in our hospital that uses a similar type of system, but we are talking with groups that are using it to get their feedback and it seems to be a good system from what I have learned so far about that. I’ve heard positive things. Once you get past the learning curve, it is not too burdensome. I think you have to pick 50 cases a month. It is Internet based, so you can jump onto the Internet to do the review of of the case. I’ve talked with four or five so far that have used it.