Improving Imaging Quality: The Macroeconomic View

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Stephen PomeranzIn April, Medscape released results from its annual physician survey¹ on salary, job satisfaction, and more; among the most controversial of these results was the revelation that only 54% of those surveyed said that they would choose medicine again as a career. Stephen Pomeranz, MD, founder and CEO of ProScan Imaging (Cincinnati, Ohio), connects this sentiment with the struggle physicians have to improve quality: both, he says, are cultural issues that health-care organizations need to address. “When you hear people talk about being unhappy with medicine, that’s very distressing,” he notes. “You’re getting asked to heal another human being. He or she is trusting and depending on you, and it’s lifelong learning.” Pomeranz notes that quality is a multifaceted issue in imaging and is growing more difficult to achieve, with macroeconomic pressures such as commoditization. Increasingly, radiology groups must do more with less; he cites culture and technology as the keys to surviving in health care’s seemingly paradoxical future. “Physicians aren’t selling commodities,” he observes. “They’re selling the human condition, and that should always be in the backs of their minds. It’s the way medicine was meant to be practiced.” Consultancy Versus Practice ProScan Imaging owns 24 freestanding imaging centers around the United States, in addition to providing teleradiology services internationally; its radiologists are all fellowship and subspecialty trained, and their work is double read every day during their first two years of practice for the company. “Our young attending physicians are really well trained, but physicians don’t hit their stride until they’ve been practicing for two or three years,” Pomeranz explains. “We double read as many as 250 to 350 cases a day and give feedback and notes.” Pomeranz sometimes refers to the group as a consultancy, and he notes that this philosophy underscores the rigorous training that its radiologists undergo. “Quality and appropriateness require education and intimate communication with referring physicians,” he says. “If you don’t have the kind of physician relationship where you can recommend a better exam for his or her patient, you’re not really a consultant.” The philosophy of consultancy also extends to reports—which, Pomeranz notes, are often misconceived by both radiologists and referrers. “You’re not there to report findings,” he says. “On an MRI, there may be 50 findings, and 49 of them may be incidental, or wear and tear. Radiologists are there to report findings and ascribe their significance in a specific, nondictatorial way that relates to the patient’s clinical syndrome. The ability to communicate and tell a story is really what the report should be about, and it should be generated so that the recipient can quickly assimilate the information.” Taking the extra step to contextualize clinical information is critical to building consultant-like relationships with referrers, Pomeranz says. “You have to establish a relationship based on trust, and trust is earned,” he says. “If you earn it by delivering consistently high customer service, quality, and education, referrers will want to work with you.” Proving Quality Much has been written about commoditization of imaging and how to fight it, but Pomeranz observes that in some cases, commoditization might be inevitable. “Unfortunately, there are some modalities where experience required to generate correct information doesn’t require as much training,” he says. As an example, he cites certain types of bone radiographs: “There, the person who provides the lowest price is going to get the business,” he says. Instead of focusing on these areas of imaging, Pomeranz believes, radiology groups should specialize as much as possible, making them the go-to consultants for particularly complex or difficult clinical scenarios. “When you have a service that’s unique and has a definite, major impact on the patient—and you can do it accurately 99% of the time—that is no longer a commodity,” he notes. “People are willing to pay a premium for that, and it’s well worth it.” Of course, quality is complicated to prove, even as it is becoming more critical to hospitals and referrers. To prove its quality in MR and CT to the large hospitals for which it reads, ProScan takes a multifaceted approach, including facility inspections and over-reading reports; everything from patient wait times to image quality is assessed. ProScan also participates in the ACR’s RADPEER program, which conducts peer review reports for each interpretation submitted by a ProScan radiologist and measures its accuracy. “Quality has always been something very challenging for people to measure,” Pomeranz says. “We offer these measurements as part of our services. We’re able to get our arms around quality because we have the talent, systems, and procedures in place to do it in an ethical fashion. Most of it is automated and computerized.” Payors are another story. He says, “Insurers, at this time, don’t really pay based on quality—they pay based on leverage. Right now, there’s a huge discrepancy between what they’ll pay a hospital and an outpatient imaging center. Where they might pay a hospital $1,000 or more for a knee MRI, we’ll get paid $420.” As a result, ProScan is able to provide medical imaging services at a fraction of the cost compared to local hospitals, Pomeranz notes, saving patients up to 80 percent per exam. Looking Ahead A high level of automation is critical to providing—and proving—quality, while remaining competitive on price, Pomeranz says. “You have to use technology wisely; you can’t be pushing paper around anymore,” he notes. “You have to be able to collect information comprehensively and assess it quickly and expediently, and you need highly intelligent, dedicated people who really understand that they are serving other human beings—that they are, in some way, responsible for the care of another person.” This brings Pomeranz to the cultural aspect of quality. He argues that in addition to doing more with less, radiology groups will need to create and enforce cultures in which quality and service are highly valued, in spite of their growing geographical scope. “Culture starts at the top,” he notes. “The first lecture our employees get is about service, giving, and philanthropy. You have to want to do this.” The good news, he says, is that the discrepancy between what payors give hospitals for imaging and what they give imaging centers creates opportunity for those who can manage to offer high quality at low prices. “Insurers are aware of that discrepancy and are steering to outpatient imaging centers for that reason,” he says. “With the new health-care system, high-quality, low-cost providers will be positioned well.” Cat Vasko is editor of and associate editor of Radiology Business Journal.