Accountable Radiology: Eliminating Sleepless Nights
James ReinertsenFor 2012, James Reinertsen, MD, CEO of the Reinertsen Group, was invited by the ACR® to deliver the Moreton Lecture at the college’s Annual Meeting and Chapter Leadership Conference in Washington, DC. Reinertsen, a former hospital executive who now educates hospitals and health systems on issues of quality and safety, presented “Possible or Passable? Setting Aims for Accountable Health Care” on April 23. He issues a clarion call for radiologists to raise the bar on quality, cost, and outcomes. “The word accountable doesn’t do a very good job of describing what we are facing with accountable-care organizations (ACOs),” Reinertsen says. “Physicians have always been accountable for quality—there’s no lack of accountability in our current system. What the term captures is a shift from a model in which we are responsible for the quality of our services to a system where we are accountable for both quality and cost.” Overuse and Income Reinertsen notes that the ACR itself has suggested that as much as 30% of imaging done today constitutes overuse, and thus could be eliminated through the implementation of appropriateness criteria and other measures. “Imagine the ripple effect if, overnight, all overused services went away. What would your practice—your revenue—look like?” Reinertsen asks. “Accountable care will force the individual radiologist to ask this question: Of the services that I am now performing, what proportion is, in fact, overuse?” The question is of no small consequence for radiologists and the patients they serve. As Reinertsen highlights, the accountability in accountable care is to the patient population—and that population is ill served by escalating costs. “A worst-case scenario is that a patient really needs a procedure and can’t afford it, and that results in a diagnostic delay that makes the patient’s care situation worse,” he says. “That’s the potential outcome of the growing copayments and deductibles we are seeing right now.” Further, Reinertsen says, anecdotal evidence shows that when radiologists and other physicians make a fixed amount of money, irrespective of whether services are performed, they are more inclined to initiate conversations with referrers about overuse. “Radiologists should function as consultants, and that happens when they make the same amount of money whether they do the procedure or not,” he says. Much of the concern surrounding the ACO model has focused on the sharp decrease in income that radiologists are likely to face. Reinertsen does not mince words when he addresses this subject, noting that the median income for a US radiologist hovers around $470,000 per year. “Here’s the problem: If your income is $470,000 and it goes down by 30%, no one is going to march on Washington on your behalf,” he says. “Nobody feels sorry for you because you could live very well on 20% to 30% less income.” He takes his message a step further: Not only should radiologists reconcile themselves to making less money, but they should also double down on the quality side of the equation, with more focus on patient satisfaction. “Let’s get on with making radiology more efficient and more accurate,” he says. “Let’s just get better.” Fewer Sleepless Nights Reinertsen issues a challenge: Eliminate sleepless nights. As providers of diagnostic information, radiologists are uniquely qualified to address this aspect of the patient experience by ensuring that patients receive imaging results as quickly as possible. “Let’s make things work so efficiently and quickly in diagnosis that we can give a worried patient an answer within a day,” he says. “This is exactly the kind of thing that radiologists need to focus on if they want to be valued players in the ACO world.” Reinertsen notes that imaging technology and IT are usually advanced enough to provide same-day answers. It is the personnel involved who need to improve their coordination and efficiency. He recalls an example from his experience as a health-system executive in the 1980s, when one of the system’s hospitals had the second stereotactic breast-biopsy system in the United States installed. Initially, results took three weeks, but within the system’s pilot period, a team was able to reduce that time to three hours. “At that point, everyone realized this was a better process—the quality was better, the cost was lower, and we had eliminated sleepless nights,” Reinertsen recalls. The process hit a snag, however, when the health system’s surgeons came to Reinertsen with a problem: Breast biopsies had constituted a significant portion of their annual income, but these biopsies were now being performed by radiologists. In the end, the surgeons agreed to a fixed annual salary to address the issue; the radiologists were salaried as well. “The salary system was so that no one got hurt as a result of making care better,” he says. “It was an example of the effectiveness of cooperation and partnership across multiple specialties.” To prepare for an accountable future, Reinertsen urges radiologists to reconcile themselves to lower incomes quickly—and to turn their focus to collaboration that improves care. “My call is for radiologists to work together with other specialties to improve the quality, accuracy, and speed of diagnosis,” he says. “Eliminating sleepless nights should be the specialty’s ultimate goal.” Cat Vasko is editor of Medical Imaging Review and associate editor of Radiology Business Journal.