Published on the April 18, 2013, DiagnosticImaging.com website
By Whitney L.J. Howell
As implementation of the Affordable Care Act continues, all sectors of the healthcare industry are being called upon to increasingly rein in costs. For many insurance providers, patient steerage has proven to be an effective strategy. But the impact on radiology has been largely negative, industry experts said.
Patient steerage in radiology occurs when outside forces — usually insurance providers — actively direct patients or physicians to lower-cost radiology practices. And, this strategy is becoming more prevalent nationwide, said Geraldine McGinty, MD, chair of the American College of Radiology’s (ACR) Commission on Economics.
“Our feeling is that as radiology benefit managers have maxed out on the initial imaging volume savings they can offer to clients, so they’ve started participating in programs to drive patients to facilities where the payers have negotiated lower reimbursement rates,” she said. “Recently, it’s been more aggressive due to increasing involvement of patients as they take on more responsibility for their care through higher-deductible plans.”
In fact, according to an informal survey by the Radiology Business Management Association (RBMA) in September 2012, 65 percent of respondents reported experiencing active patient steerage from either radiology business management (RBM) groups, payers, or both. With active steerage, payers give patients incentives, such as gift cards, for choosing lower-cost providers. In addition, 47 percent confirmed the presence of passive steerage — simply making cost differential data available to patients and providers.
However, patients are also driving a certain level of steerage. A recently-published joint ACR-RBMA paper credits high-deductible insurance plans and patient cost awareness with some patient redirection.
What Payers Are Doing
While not all payers have patient steerage programs, many do. For example, in September 2011, Anthem Blue Cross Blue Shield in Ohio implemented a steerage program for imaging services through which company representatives called patients in attempts to redirect them toward lower-cost providers. Within nine months, more than 3,500 patients had been called and steered to different imagers.
In addition, WellPoint launched a passive steerage campaign with OptiNet, an Internet portal through which referring physician were encouraged to schedule patients with lower-cost imagers. When referrers largely ignored this resource, however, WellPoint enlisted RBM company American Imaging Management (AIM) to call patients directly. According to AIM marketing director Ana Perez, nearly 20 percent of patients chose lower-cost imagers in response to the phone calls.
Other payers, such as UnitedHealthcare, also provide radiologist cost information, but they do not actively contact patients. Still other payers successfully steer patients by classifying certain providers as out-of-network in a patient’s insurance plan.
The Impact of Patient Steerage
The increasingly prevalence of patient steerage can potentially impact practices and departments on a variety of levels, McGinty said. According to the ACR-RBMA paper, she said, radiologists should be aware of the three main ways patient steerage can affect everyday practice.
1. Daily operations: When payers redirect patients, providers can lose any time they’ve already spent in the pre-authorization process. They can also experience productivity dips , and if they don’t know patients have been steered elsewhere, they could face vacant or missed appointment slots. Imagers could also be asked to answer patient and provider questions about any steerage and why it occurred. Overall, up to 82 percent of RBMA survey respondents indicated steerage decreased their patient volume. However, some respondents — about 14 percent — actually saw volume increases due to patient steerage.
“The big item will be the loss of business, and virtually every practice is looking at a decrease in volumes,” said David Levin, MD, a radiologist with the Center for Research on Utilization of Imaging Services at Thomas Jefferson University. “It’s not like in the early 2000s when volumes were growing like crazy and it wasn’t a problem if we lost a little business because insurance steered our patients elsewhere. No one feels that way anymore.”
2. Legal issues: When payers actively steer patients to lower-cost imaging centers and away from a referring physician’s initial suggestion, they open themselves up to potential medical liability if findings, such as a lung cancer, are missed. In addition, legal action can also be launched against the chosen imager, the imager’s corporation, and the RBM. It’s also possible, especially with active steerage, that these activities violate the federal anti-kickback law that forbids any payments or solicitations that influence patient health decisions.
According to the ACR-RBMA paper, radiologists could also assert payer-directed steerage impedes their legal right to practice, defames their professional reputations by listing them as lower-tiered providers, or violates any existing contracts they have with facilities to receive a certain amount of referrals.
3. Provider relationships: Any payer-directed steerage can disturb existing healthcare relationships, McGinty said. Referring physicians often have a small cadre of imaging providers, chosen for their levels of quality and service, to whom they send patients. Redirecting patients to different imagers can damage long-term provider partnerships and can impose on referrers the additional cost of transferring all patient records to a new imager. Any instances of incomplete reads prompt the need for a second radiological opinion. And, the radiologists providing the second read do not receive reimbursement.
Impact on Patients
While survey data exists to support the negative effect steerage has on providers, the verdict is out on how much payer redirection influences patient care.
The ACR’s biggest concern, McGinty said, is that steerage can confuse patients.
“Patients build relationships with their physicians over time, and they value their doctor’s advice and guidance,” she said. “We don’t want to see those relationships disrupted or see patients’ confidence shaken when it’s suggested they see an imager their doctor didn’t recommend.”
It’s also paramount, she said, to make it clear to patients that payer recommendations are only cost-based suggestions. Many patients are unaware they have a choice to simply pay a higher fee for seeing the imaging provider chosen by their referring physician.
Payer steerage also increases the risk that patients will be sent to a facility without ACR accreditation. But that risk is small, Levin said, adding that ACR accreditation ensures a certain level of service quality.
“I don’t think steerage will impact patient care that much. People will get scans if they need them even if insurance companies steer patients to places they think are more affordable,” he said. “It’s not as if there’s a huge variation in quality so that if you go to my hospital you’ll get a great scan, but if you go to the hospital down the street, you’ll get a lousy one.”
To read the remainder of the article at its original location: http://www.diagnosticimaging.com/practice-management/patient-steerage-could-harm-radiologists-confuse-patients
Published in the April 15, 2013, Raleigh News & Observer and the April 14, 2013, Charlotte Observer
By Whitney L.J. Howell
Swatting at pesky insects or air-borne particles – it’s a common, everyday activity for nearly all living creatures. It’s a way to keep clean and get rid of anything that might cause future problems.
But what about machines and vehicles that can’t take a swing at annoying parasites, particularly ones submerged in water?
Continual biofouling – the accumulation of microorganisms, plants, algae, or animals on wet surfaces – has been a long-term problem for the global shipping industry. Now researchers at Duke University’s Pratt School of Engineering have developed a strategy that could enable ships to rid themselves of creatures and substances that hitch a ride on their hulls.
Coating ships in a new material that shakes itself on command can eliminate several problems associated with keeping ships clean, said Xuanhe Zhao, a Duke mechanical engineering researcher.
“If you’ve ever seen a horse or cow shake its skin or tail to get rid of flies, that’s analogous to shaking off something that’s bugging the ship,” he said. “We’ve introduced a new mechanism that can deform, and that deformation can literally detach the biofouling materials adhering to the surface.”
Why slough the ships?
Apart from being unsightly, barnacles and other biofouling substances can inhibit a ship’s ability to function. Even a small amount can cause difficulties, said Gabriel López, a Duke biomedical and mechanical engineering professor. He is also the director of Research Triangle Materials Research Science and Engineering Center.
“Even a small layer of slime can significantly increase drag, and
as drag on the ship goes up, the fuel consumption goes up, as well,” he said. “Pollution goes up, and more greenhouse gases are produced.”
Leaving biofouling materials stuck to ships can also have another environmental impact. For ships sailing worldwide, there is a risk invasive species will be transferred from their native habitat to ones where they can be damaging. For example, nutrient-hoarding zebra mussels from Russia were brought via ship hull to the Great Lakes in the late 1990s. Within 10 years, these invaders had wreaked havoc on the region’s fishing industry and levied more than $3 billion in damages.
Ridding ships of biofouling materials is also of military import, López said. The more barnacles and bacteria a ship carries, the noisier the vessel is, making it easier to detect.
How it works
Traditionally, the shipping industry used less-than-optimal means to protect vessels. For more than 40 years, global maritime companies coated their roughly 30,000 ships with paint containing tributyltin, an inexpensive, effective – and poisonous – barnacle- and algae-killer. An international treaty banned its use in 2007.
Another protection method has been a polymer coating that reduces biofouling substances’ ability to adhere to the boat. It’s a temporary fix, though, because bacteria and barnacles eventually adapt to the polymer and attach themselves anyway, Zhao said.
This new solution, however, starts with an environmentally safe silicon rubber polymer coating on the ship’s hull. Running voltage through the flat polymer turns it into a capacitor – a passive structure that stores energy – and generates an electric field, he said. This cleaning strategy then relies on electrostriction, a property of electrical nonconductors that allows them to change shape when exposed to electricity, to slough away the offending substances.
“There are patterned channels – air channels – beneath the polymer, and if you blow air into the channels, it will increase the hydrostatic pressure and buckle up the polymer surface,” Zhao said. “We basically form a wrinkle on the surface of the polymer, and the biofouling substances simply detach.”
Although this strategy must be tested on the large scale, it does offer two advantages other cleaning solutions have lacked, Zhao said. The silicon rubber polymer could potentially last for years, and this method eliminates the need to dry dock a ship for cleaning. An electric current can be sent to the polymer anytime, anywhere, and the ship will slough off biofouling material.
Challenges, future uses
To date, Zhao and López have only tested this self-sloughing mechanism with areas only a few centimeters wide. But, according to Jan Genzer, a chemical and biomolecular engineer at North Carolina State, larger experiments are needed to prove it’s a valid cleaning solution.
“It’s a very clever, very different way to think about this problem – like trying to stand on a trampoline while it’s being shaken,” said Genzer, who created a different cleaning solution. “The real question is, though, can it be applied to a ship? How will the research translate to application? Will the discovery need to be modified?”
In his discovery, Genzer and his colleagues created a dense layer of molecules capable of repelling biofouling organisms by repeatedly hitting a stretched piece of rubber with reactive oxygen and allowing the rubber to rebound. The result, he said, was a roughness that helped prevent barnacle and algae accumulation.
Even though the self-sloughing mechanism has only been applied to shipping so far, both Zhao and Genzer agree that there are additional uses for this technology. Representatives from the food industry, lubrication companies, and medical device manufacturers have all expressed interest in this development, Zhao said.
“Any time you have synthetic material in contact with some sort of water that might have bacteria or other microorganisms in it, you will form this biofouling layer,” he said. “So, it’s a very pervasive problem.”
Ultimately, Genzer said, concentrating on strategies to remove biofouling materials rather than trying to create ones that prevent accumulation from even beginning will be a productive plan. Organisms adapt to survive when faced with foul-resistant substance, and that can do more harm than good to an ecosystem.
“People are now realizing foul-resistant coatings are more realistic. They allow deposits to settle, but they can be cleaned by shaking or running the ship at particular speeds,” Genzer said. “You can’t outsmart Mother Nature. She’s been around for millions of years, and she’s developed ways for organisms to survive in different conditions. If we can get surfaces clean, we should be happy, and leave it at that.”
Published on the April 8, 2013 DiagnosticImaging.com website
By Whitney L.J. Howell
Zero-footprint viewers. Vendor-neutral archives. Image mobility. Individually, they are helpful tools to radiology and becoming more ubiquitous. But together, they help create a cohesive enterprise imaging strategy.
Enterprise imaging (EI) isn’t a particularly new idea, but to date, it has been largely misunderstood, industry experts say. It’s more than simply implementing new technology. And, achieving the full benefits EI can provide will require both sophisticated software and provider engagement.
“Enterprise imaging is a hot topic, but there’s a big misconception around what we mean by it,” said Paul Chang, MD, University of Chicago School of Medicine’s enterprise imaging medical director. “Enterprise imaging is a much broader, more complex problem when you take the enterprise perspective rather than the silo perspective.”
What is EI?
Put simply, the goal of an EI strategy is to ensure the correct image is delivered to the right place at the appropriate time. It has the potential to fundamentally change how facilities, providers, and patients interact with diagnostic images. Reaching that goal, however, requires a great deal of collaboration, Chang said.
According to a 2012 KLAS report, many facilities are already moving in that direction. Of the 134 providers surveyed, most reported being in early EI stages. To create a fully integrated EI system, Chang said, these facilities and others must address five factors that affect how the healthcare system currently views and uses diagnostic images.
1. Archive architecture. For many providers, EI simply means implementing a vendor neutral archive (VNA), an archive-neutral vendor, or using a zero-footprint viewer, all methods for easily sharing images within the facility and off-site. However, the archive is only one part of a successful EI strategy, albeit an important component. It’s important, Chang said, to free radiology departments and practices from being tethered to one PACS, but identifying and employing an effective VNA is largely an IT responsibility.
“VNAs and zero-footprint viewers are just the middle wear that links commodity storage to the application layer,” he said. “We’ll do it, and we’ll go to the cloud. But it’s all buzzwords and plumbing. That’s designing the car. Now radiologists have to learn how to drive it.”
2. Multiple creators and consumers. Radiologists are no longer the only specialty that produces and uses diagnostic images. Today, cardiology, gastroenterology, pathology, and several other departments rely on imaging to provide proper patient care, so facilities must have a streamlined way to distribute scans throughout the health system.
“To do this right, you do need the architecture of a VNA or archive-neutral vendor, but there’s a bigger concept behind enterprise imaging,” Chang said. “This view is the realization of the modern enterprise that it must deal with both consumers and producers of images simultaneously throughout the hospital — not just radiology.”
3. Ubiquitous electronic health records (EHR). The concept of an EHR isn’t new to radiology, an industry that has used PACS and RIS for many years. But now, meaningful use requirements are calling upon the specialty to interface seamlessly with patients’ records through an entire health system. Consequently, according to KLAS imaging research director Ben Brown, all new systems must be interoperable. It will be up to a facility’s IT department, Brown said, to create an infrastructure that manages and stores PACS, maintain a patient index to ensure proper patient identification, and determine how long images are stored.
4. The enterprise concept. Years ago, when radiologists discussed “the enterprise,” the term referred to anyone outside the department who still worked within the hospital’s firewall. But as health systems have expanded and more specialties have become image producers and consumers, the definition of “enterprise” has expanded, Chang said. Radiology groups have consolidated, many facilities within the same system are separated by hundreds of miles, and providers are now required to read scans for multiple hospitals.
The logistics of moving images from one facility to another aren’t difficult — the real challenge comes in coordinating the workflow needed to properly use transferred scans. According to Rasu Shrestha, MD, MBA, a University of Pittsburg Medical Center radiologist, however, the potential exists, for EI to have a significant positive impact on work flow management.
“[EI] allows for a patient-centric approach to care versus an image- or application-centric approach,” he wrote in a 2012 Applied Radiology article. “It allows for the possibility of true collaboration among care teams, which would bring the value of imagers back into the spotlight.”
5. Tying it all together. The real challenge behind effective EI, Chang said, is to fuse the needed technology with the proper workflow perspectives. But it can be helpful, he said, to consider that EI is less about imaging and more about radiology’s need to re-invent itself as healthcare enters a new chapter of value-based purchasing.
“The concept of enterprise imaging is a proxy or code word for having to re-engineer a more useful, comprehensive workflow solution for a more complex enterprise,” he said. “It’s better not to talk about enterprise imaging but talk about re-engineering ourselves so we can continue to add value.”
How can you plan?
It’s no longer a question of whether EI is right for your practice or department. Radiology’s move toward EI is clear, and it’s up to you to determine how you will navigate these new waters. There are many moving parts with this imaging strategy, Chang said, but you can outline your course of action by remembering one question: “What is the role of radiology or the radiologist in this decision?”
For example, as the end-user, you can — and should —tell your IT department what you need out of a VNA, but don’t expect to be included in any purchasing decisions. The facility’s chief financial officer and chief information officer will make that determination, he said.
You will, however, have a greater role — alongside cardiologists and other providers — in determining how the VNA architecture will support your needs and workflow. In addition, you must make it clear to your hospital administrators and IT department that any EI system must offer interoperability for the strategy to succeed, said Robert Barr, MD, president of Mecklenburg Radiology Associates in Charlotte, N.C.
Through interoperability, he said, his practice — which has been using EI for several years — is able to quickly migrate images between all subspecialties, streamlining patient care and facilitating greater access to patient records.
Your biggest role, however, will be in providing evidence that supports the true value you bring to your facility. Your worth is no longer tied solely to the number of interpretations you produce daily, Chang said. You must now demonstrate your impact on patient outcomes, population management, and down-stream resource utilization and cost control.
“In the fee-for-service environment, we could be selfish and insular in our thinking. We floated everyone else’s boat,” he said. “But now we’re a cost center, and every CT you order better be worth it. Justify it, and demonstrate its positive impact.”
To read the remainder of the article at its original location: http://www.diagnosticimaging.com/enterprise-imaging-beyond-cloud-based-image-sharing/page/0/1
Published on the Feb. 26, 2013 DiagnosticImaging.com website
By Whitney L.J. Howell
Communication. It’s been a big topic of conversation in the radiology industry, both at national meetings and inside individual practices. There’s a distinct need to improve the way radiologists and referring physicians talk to each other. The sticking point, however, has been how to do it.
There’s no question, though, the specialty needs to implement effective strategies to make communication faster, easier, and more effective. With more than 70 percent of referring physicians sending their patients to multiple facilities for imaging studies, according to one national study, it’s incumbent upon radiologists to make these working relationships as worry-free and attractive as possible, industry experts said.
“The overall effectiveness of an organization is highly dependent upon the radiology department’s ability to provide top-notch service to referring physicians, and streamlined communication is a very important piece of that puzzle,” said Mats Björnemo, director of radiology IT product marketing at Sectra, a Sweden-based radiology consulting firm. “Radiology lies at the very center of the healthcare chain. Most patients pass through an imaging department at one point or another in their treatment.”
Not only does this fluid information transfer allow for immediate input from radiologists, potentially staving off any inappropriate or repeat testing, but it also ensures patients experience fewer — if any — delays in care. In addition, these processes help radiologists quickly share any critical findings, as well as play an active role in multi-disciplinary discussions, Björnemo said.
Why Improve Communication?
While many industry leaders promote better communication as a way to raise your department’s profile within a health system or demonstrate the impact you make as radiologists, there are other reasons behind fine-tuning the way you connect with referring physicians.
According to an October 2012 Sectra report, doctors have a great interest in being able to access your schedule and book appointments for their patients online. But only 7 percent of surveyed physicians indicate the radiologists to whom they refer have web scheduling as an option. Many physicians included in the report consider offering this capability is vital to completing time-sensitive scans.
That doesn’t mean referring physicians want to eliminate all face-to-face or phone contact with you, Björnemo said. This is where the pendulum that has lurched toward teleradiology in recent years is beginning to swing back toward having in-house radiology staff. When reviewing results, physicians want — and appreciate — being able to ask questions and talk with you directly.
Steps to Take
To effectively improve communication, however, you will need the right tools. In today’s mobile world, you will likely get the most use out of zero-footprint viewers that require no software installation or extra equipment, Björnemo said. It’s also important to consider communication products that are vendor-neutral.
For example, Carestream’s Vue Motion offers zero-footprint, vendor-neutral access to diagnostic images through any web browser or electronic health record. Without installing or downloading software, providers can use sticky-note communication, order information entry, side-by-side image display for comparisons, and synchronize images.
This type of universal product is particularly efficient in transferring critical findings in a timely manner, Björnemo said.
Clear communication can also be difficult because radiologists dictate reports in their own style and lexicon, and these differences can sometimes confuse referring physicians. And, communications products that standardize report narratives have eliminated this problem, said Aaron Brauser, Catalyst solutions manager at M*Modal. The M*Modal Catalyst for Radiology™ product uses the RadLex® Term Browser to create uniform reports.
“The biggest challenge to communication lies with the various inconsistencies of systems used in complex healthcare environments, and we’re starting to see people move toward uniformity,” Brauser said. “It’s important that no matter how the radiologists might dictate the report, or who the report is from, that the referring physician be able to readily see what’s indicated.”
In addition to implementing a product that is compatible with almost any system and standardizing your reports, 60 percent of referring physician’s surveyed in Sectra’s report indicated 3D visualization would improve communication. Presenting findings this way would be one strategy for enhancing their ability to present and explain results to patients, they said.
To read the remainder of the story at its original location: http://www.diagnosticimaging.com/practice-management/how-radiologists-can-improve-communication-referrers
Published on the March 7, 2013 DiagnosticImaging.com website
By Whitney L.J. Howell
The tides are turning for breast imagers nationwide. After struggling through several years of declining demand and facility closures, the market is rebounding and more growth is expected.
The number of breast imaging facilities dropped by nearly 7 percent from 2002 to 2011, according to a recent report from global growth consulting company Frost & Sullivan. Roberto Aranibar, a Frost & Sullivan advanced medical technologies industry analyst, said several factors — the rise in breast cancer incidents, an increase in breast cancer surgical procedures, and an uptick in supplemental screening exams — are converging to prompt expansion in this area.
In fact, Aranibar said he anticipates breast imaging market revenues to climb from $1 billion in 2011 to $1.4 billion by 2016, crediting the rise in the number of exams performed. Diagnostic Imaging talked with Aranibar about this report, why the market has changed, and what the industry can expect.
What are the main factors behind the decrease in breast imaging facilities nationwide?
It’s part of a larger trend. There’s consolidation going on among healthcare providers, and individual facilities are reducing their own costs through staff reduction. Using their equipment more efficiently also helps them be more productive. We’re also seeing a lot of mergers between large facilities of chains of facilities. The decrease in the number of these imaging centers is just part of a broader trend.
What caused the drop in facilities to stabilize?
From a broad perspective, there’s a little more certainty in the healthcare industry after the Supreme Court upheld the healthcare reform bill last summer. Some of the major questions and unknowns have been answered. Consequently, it’s helped people better plan their next steps to maintain the stability of their facilities.
What do you expect will happen with breast imaging over the next five years?
There are many different trends going on right now. There’s a lot of controversy around X-ray mammography and its risks and benefits. Based on that, it’s probably the most highly-regulated imaging field. There’s a lot of technological innovation in this area — a lot of new imaging systems with different modalities, including MRI, ultrasound, molecular breast imaging, and tomosynthesis.
I think one of the biggest trends we see is there’s a lot of talk about breast density notification legislation. That’s a major factor when considering what will happen in the market over the next few years. By law, physicians must include in a woman’s mammography results letter if she has been identified as having dense breast tissue, explain the implications, and discuss whether they could benefit from supplemental exams. We saw a major increase in breast ultrasound procedures after the law went into effect in Connecticut. X-ray mammography is a great tool — it’s very efficient, fast, and cost effective, but it’s being questioned more than ever right now for its reliability. That leaves the door open for a lot of supplemental exams to come into the picture, and that’s where more of the growth in this field will be concentrated.
Breast ultrasound is also an area that is expected to grow. In addition, there’s a major study out that could help move tomosynthesis, which is currently really costly and not something that CMS reimburses for, into something that could get the agency’s approval for reimbursement. As soon as something like that happens, and the cost comes down, we’ll start to see it used more. It’s really proven itself to be a reliable and effective tool, and I think you’ll see a lot more of this as facilities try to stay at the forefront of technology. Rather than referring their patients out for supplemental exams, facilities are going to try to keep everything in-house.
Molecular breast imaging is a modality like PET and nuclear medicine. It involves an injection of radioactive tracers, and radiologists look at where those tracers are concentrated. It’s a more tedious process, and there’s as learning curve involved. Facilities must be licensed to handle radioactive material, and the procedure takes longer, is more costly, and it isn’t reimbursable by CMS. There’s work ongoing now to try to prove that molecular breast imaging is more diagnostically reliable in identifying cancers. But there are issues with it currently, such as managing the radiation dose. So, I don’t think it will be affected much as the market starts to grow again.
To read the remainder of the Q&A at its original location: http://www.diagnosticimaging.com/breast-imaging/breast-imaging-market-picking-after-slow-period