Clinical Integration: Deeper Accountability Without Radiologist Employment
As accountability in health care becomes an increasingly critical priority, many anticipate a future in which radiologists are employed by hospitals attempting to share risk and align incentives. Accountability can be achieved without employment, however, according to Carl Black, MD, of Utah Radiology Associates (URA), Orem/Provo, a 24-physician practice covering five hospital systems, including the oft-lauded Intermountain Healthcare (Orem). The practice’s relationship with Intermountain Healthcare was the subject of a presentation made by Black on July 28, 2013, in Minneapolis, Minnesota, at the annual meeting of the AHRA. “What keep us up at night are the same issues our hospitals are thinking about—decreased payment, financial uncertainties, the consolidation in the market, and restrictions on what procedures we can do,” Black says. “As radiologists, we always have to remember that our relevance and survival depend on how well we are clinically integrated. Some people think of integration as assimilation or control; I think it’s something very different. It’s really an alignment of incentives.” The Visible Radiologist Black’s presentation, “Physician Integration with Technical Operations,” begins with an examination of where hospitals’ and radiology groups’ priorities overlap. “We’ve heard many people saying that employment is the only way to align incentives,” he notes. “That’s a lack of creativity and trust. We had a discussion group on this at Intermountain Healthcare, and we made it clear that we have a firm commitment to sharing its core values. We all want great care, excellent service, and evidence-based medicine. Radiologists tend to be naïve about managing costs, and it’s healthy to have a closer interaction with administrators—to understand their concerns and the pressures they feel.” Black observes that radiologists have sacrificed their visibility to increased efficiency, over the years. “Invisibility has its benefits, but one of the benefits is not survival,” he says. “We have to make ourselves more visible and more involved. Our customers, payors, employers, consumers, and policymakers all want high-value care. If we can be proactive, we can define a lot of what that value will mean.” To achieve this visibility, URA works closely with Intermountain Healthcare’s administrators to align priorities. “We make it clear to them that we want to perform best-practice radiology,” Black says. “We try to exceed any benchmark put in our contract. We work to establish subspecialty standards of reading, we commit to fast turnaround times, we have a peer-review program, and we want to be more involved in education and guidelines for utilization. Wherever there is a system service standard, we want to do everything we can to help our hospitals exceed their benchmarks.” Steps to Clinical Integration This degree of clinical integration doesn’t happen overnight, of course. Black details the many steps that URA has taken to stay clinically engaged and aligned with Intermountain Healthcare, beginning with participation in health-system strategic planning. “We have an imaging guidance council at Intermountain Healthcare, where we meet with the systemwide medical director and collaborate with IT and operations,” he says. “It’s an excellent opportunity to plan strategically, together, over a large system.” Clinical collaboration is another key initiatives. “Every month, we’re participating in conferences—including those covering stroke, trauma, oncology, sports medicine, musculoskeletal cases, urology, ICU patients, and more—and radiologists are either directing or codirecting them,” Black notes. “It’s a big source of loyalty and satisfaction. You can pick any clinical area, and it will be almost unheard of for a clinician to collaborate with a radiologist to develop a best-practice model, but we do it at Intermountain Healthcare, and it’s a big opportunity to improve care. This is a model I would encourage every radiologist to apply in his or her practice: Find a way to work with a clinician to improve care.” The leadership team at URA routinely solicits feedback from its health-system partners and addresses any issues that might arise. “Transparency and feedback are very important,” Black says. “We can’t improve on what we don’t know. As soon as a problem arises—be it patient relationships, relationships with our technologists, or a conflict of interest with one of our outpatient centers—we want to hear about it and act on it. We take it very seriously.” This approach has enabled URA to assist Intermountain Healthcare in improving quality and lowering costs—all without radiologist employment. “Reform doesn’t necessitate employment,” Black concludes. “What we need to do is align ourselves to meet the needs of the patients and clinicians we work with; we need to respond in a measured way to the challenges at hand. Patient care should always come first, and leadership from radiologists is critical. Going forward, radiologists and hospitals will have to look for creative ways to share risk and to be mutually accountable.” Cat Vasko is editor of Medical Imaging Review and associate editor of Radiology Business Journal.