Bridging the Gap and Meeting Demands:
Healthcare Excellence Despite Lower Reimbursements
Healthcare reform ups the ante in terms of expectations, attempting to measure (and pay) in a world of quality, where patients are “cured” the first time around and the effectiveness of their physicians determined by whether they accomplish that goal. Value-based compensation models, while still functionally vague, are the intended mandate and represent a quantum change from current fee-for-service models.
The “new” model of healthcare comes on the heels of recent reimbursement cuts, the implementation of “5010” (the new format for standard electronic Health Insurance Portability and Accountability Act transactions), the threat of penalty for failure to submit quality data codes compliant with Physician Quality Reporting System (PQRS) measures to the Centers for Medicare and Medicaid (CMS), confusion regarding changing Meaningful Use requirements, an often hostile environment of Recovery Audit Contractor (RAC) audits and even more confusion over how to function with future payment systems. In our new world, the quality of healthcare will improve based on objective measurement and the “value” of the patient experience, all at lower cost for those paying the bill.
Better healthcare for less cost? The demand for more service, higher standards of accountability (while at the same time simplifying administration), and increased levels of compliance reporting usually go hand in hand with higher costs. Practices are rapidly facing the need to upgrade technology and personnel skills, with perhaps a greater reliance on support from consultants and professional organizations to help them navigate the waters.
This type of contradictory, disruptive messaging tips the balance of certainty and stability, puts us on high alert, and allows for fear, uncertainty, and doubt to set in. Some of the credible surveys conducted in 2011/2012 show physician morale at an all-time low, with many providers considering the safety of employment over practice ownership and others even considering a change in career.While this should come as no surprise given an increasingly hostile business environment, it would be unfortunate and further add to the predicted physician shortage in the future. In fact, solutions to this crisis are actually within reach.
Radiology is usually viewed as a “behind the scenes” specialty, where contribution to the patient’s circle of care is consultative and supports those physicians with direct patient contact. While radiologists could in theory support the concept of “value” in medicine, they in fact have little control over how their interpretations are used to drive improved outcomes. At the same time, as quality becomes the watchword, insurance companies in some parts of the country are attempting to steer patients to lower cost providers without consideration of quality. How does radiology move then from the perception of being a “passive” specialty in regard to patients, potentially treated as a low-cost commodity and therefore, able to maintain some level of control over its destiny?
Alan C.Kay stated, “The best way to predict the future is to create it.” What can this look like for radiology?
A View of the Future
We know future reimbursement will likely consist of value-based pricing or pay for performance instead of the current fee for service reimbursements, although it is likely that for some transitional period of time, practices will face the challenge of functioning under both payment models. Living in both worlds at the same time requires a transformational approach, but the need to think differently doesn’t necessarily demand major changes to how a practice operates. In fact, the very definition of transformation is “change for the better” which suggests opportunity.
This new healthcare world equates to a new way of thinking. It is “patient facing” and requires a dynamic architecture to support new lines of communication. In the new world of healthcare, radiology groups will no longer be confined to the traditional dynamics of working behind the scenes, but rather can implement a four dimensional model with patient and referring physicians in the center of its gravity (see illustration). Direct contact lines then reach to each of the four stakeholder dimensions, which include not only traditional marketing/education for referring physicians, but direct contact and education for patients (an underutilized resource) as well. Cutting edge practice technology delivers patient centric, self-service technology, and of course, directs patient and referral contact.
It is unlikely medical specialties like radiology, which have traditionally been behind the scenes as the “doctor’s doctor,” are going to storm to the forefront and change their personalities to incorporate salesmanship. The good news is that this level of change isn’t necessary either. Technology will bridge the gap. If implemented and maintained properly, technology can be the answer to more income and better lifestyle while answering all of the reporting demands imposed on physicians now and in the future.
Since future reimbursement systems provide an opportunity to focus on the entire patient wellness lifecycle,instead of single episodes of care and sickness, this will facilitate the hybridization of supporting technology systems, optimizing efficiency while potentially driving market share.
So what does the future look like? What we are really talking about is an in-house health information exchange platform (IXP).This system will be provider controlled, infinitely adaptable, and “interfaceable,” using artificial intelligence to automatically manage, configure, and allow any inbound and outbound feed to all four stakeholder dimensions from any number of systems. The IXP workhorse information platform will be based on the principles and the complexity of an electronic medical record (EMR) system that allows physicians access to complete patient information obtained at the primary-care point of service. Naturally, the exchange will feed all internal functions and accept information from financial systems, picture archiving and communications systems (PACS), hospital information systems (HIS), radiology information systems (RIS), credentialing, and peer review systems on a real time basis. In other words, we will consolidate data elements already available through disparate technology to build a single value-added resource base for our varied stakeholders.
Since compliance and security cannot be compromised, these systems must exist on private networks with only select information exposed to public Web-facing portals (the Cloud). Pertinent information can then securely be pushed to referring physicians, along with expert blogs or articles educating physicians on new procedures, appropriateness criteria, best practices, or simply, the proper patient history and ordering procedures—or any other relevant information that nurtures the relationship between the radiologist and the referring physician. Similar information can be pushed to the patient exchange for financial (billing) information and patient education. The patient-facing exchange will, of course, include self-service options from scheduling to records access to payment options. Needless to say these external systems will meet market expectations by running on smartphones and although only non-mission critical systems are exposed, security still plays a critical role.
In this information-rich environment, non-specific patient education and redacted expert opinions will be also posted directly to relevant healthcare blogs and social media, facilitating both inbound and outbound marketing extensions. Practices will nurture patient loyalty through digital marketing as well as directly through patient relationship management systems working with relevant information fed by the IXP.
Radiology’s New Value-Based Role
Rather than passively being buffeted by the storms of change, radiology can begin planning for an expanded role and an enhanced relationship with referring physicians, patients and even payors. We have always represented the source of authoritative information as consultants to the referring physician base and can expand that value throughout the circle of care for our patients. Those physician and administrative leaders with vision will quickly be planning for and/or incorporating the technology infrastructure to maximize the use of available data elements, as well as adding new reporting requirements—while minimizing the need to add staff members in order to keep pace with information demands.
This moves radiology from behind the scenes to a position more reflective of its true value in the process of patient diagnosis and treatment. In addition, we can maintain technology-based flexibility allowing the ability to pivot as new demands surface. The future belongs to the bold — and the visionary.
By SAM F. KHASHMAN for the November-December 2012 RBMA BULLETIN published by Radiology Business Management Association www.rbma.org