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Why better radiology management can lift revenue, cut unnecessary utilization

The real dollars that are at stake are based on the radiology report, and what clinicians do with that information.

Jeff Lagasse, Associate Editor

The field of radiology is highly fragmented. Sequestered in their own geographic areas, radiologists struggle to adhere to a universal set of best practices, and that has made it difficult for those in the field to decrease unnecessary utilization and reduce costs. But that's changing.

Groups like Radiology Partners have sprung up to bring radiologists together, and according to Radiology Partners CEO Richard Whitney, that scale is absolutely key to making the kind of transformative changes that are needed in diagnostic imaging.

"It's really incredibly fragmented," said Whitney. "I believe it is the most fragmented healthcare services segment in the U.S. That really represents the opportunity for physician groups to scale up and recognize the value they can add to the healthcare system."

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One of the driving forces behind Radiology Partners and like-minded groups is reducing the geographic disparities that exist in healthcare, and in driving down unnecessary utilization. Bob Sheehy, CEO of Bright Health, said his interest was piqued by a fundamental concept: utilizing radiologists' training and expertise to recommend what follow-up care should be provided to the patient based on the interpretation of the image, rather than just providing the diagnosis.

"Providing a recommendation for follow-up care, sometimes that care can result in a required intervention, so sometimes there is no follow-up," said Sheehy. "So I think there's a real opportunity there. From an insurance perspective, the more you look the more you find. So really, I think a great resource to help make sense of the complicated health system is the knowledge and expertise of a radiology practice -- sharing their expertise with each other so there's a more consistent output."

In radiology, the focus in terms of cost and utilization has typically boiled down to: "We're doing too much radiology." That's been the case historically. As technology has gotten better, however, that's no longer the issue; while there are likely still pockets in which physicians are ordering images they shouldn't be ordering, it's no longer the main event.

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The real dollars that are at stake are based on what happens in the radiology report, and what happens next. Imaging is powerful, but if clinicians aren't doing the right things with that information, the value that radiology has to offer isn't being captured.

To illustrate that, Whitney used the example of AAAs, or abdominal aortic aneurysms. An aneurysm is a bulging of a blood vessel in the body; the aorta is the biggest blood vessel.

If you have AAA, you have a ticking time bomb in your body," said Whitney. "It may not grow, and if it doesn't grow, it may not rupture. If it grows, your chances of rupturing get higher ad higher, and if it ruptures, you die. The mortality rate is over 90 percent. You need to monitor it. If it starts to grow to a particular size and at a certain pace, you've got to intervene.

"These are extremely expensive events if someone comes into the ER with a ruptured AAA," he said. Depending on the size, sex of the patient, a number of different things, you can calculate the likelihood of risk and schedule a follow-up. In our crazy healthcare system, two things are happening. Oftentimes, no recommendation is made for a follow-up; the radiologists need to know what the guidelines are, and they need to write a report that says, 'No follow-up necessary.' Or, you immediately intervene, right now.

"That's the best practice piece of it. When you have an aneurysm, you don't always know it. The system is relying on the radiologist putting in the report and making it clear they need to follow up. Did they make an impression on the patient as to how serious this is? And who's reminding the patient to follow up? Usually, it's no one."

This gap can be avoided with an appropriate IT infrastructure. In a well-functioning system, a list is created so that every month physicians know which patients are due, and which ones need follow-up imaging for their AAA. That closes the loop, so to speak, and the critical follow-up can take place. 

That's the advantage of scale. Without it, the system reverts back to geography-based clinical variation. In one market there might be a patient with a certain follow-up path, like an angiogram or other imaging, at which point they may have additional surgical interventions. In other markets, the approach may be more conservative. To determine what actually works best there needs to be a certain level of scale and unification, with the ability to share information and expertise and spread best practices across these disparate geographies.

"When that appropriate care requires follow-up and intervention, both the diagnostic imaging itself and the follow-up care provides opportunities for revenue growth within the facilities," said Sheehy. "As hospitals compete for patients, focusing on quality and outcomes, more of a clinical evidence-based system, people are going to be choosing the physicians that have the better outcomes and better quality."

It's a trend that's happening more and more across the country. Hospitals and health systems are increasingly focused on population health and differentiating for the populations they serve. The idea is to give consumers more information so they can choose which physicians and clinicians drive the best quality and outcomes; that, ultimately, is what will drive an increase in patient revenues.

Sheehy sees the future heralding more of this consolidated approach. Physicians are aligning in different ways than they have in the past, and part of it is due to the economy. By working together and sharing administrative costs, billing and back office functions, they're able to get better economy of scale. But it's also about the ability to work together professionally; clinical best practices can be more widely adopted. Those are issues physicians are looking at, and many want to know how they can become a part of a larger organization.

"With some investment, with some innovation and accountability and taking charge … there really is a tremendous amount of value to be added to the healthcare system," said Whitney. "And this isn't like a little sideline field. Virtually everyone getting admitted to the hospital gets some kind of imaging done on them. This is a field where you can make a big impact. Having payers recognize them and pay for them, you can have a transformational change in healthcare overall."

Twitter: @JELagasse
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