Times have changed in radiology—for the worse, if you gauge solely by reimbursement and regulatory trends without taking into account the burgeoning growth opportunities for diagnostic imaging and the awe-inducing technologic advances undergirding the profession’s many and varied services.

For some time now, the Radiology Business Management Association (RBMA), Fairfax, Va, has fixed its collective gaze on both the good and the bad and come to the conclusion that the biggest challenge faced by its members is lack of information—information robust and timely enough that an administrator of a radiology group or imaging center can leverage it to safely navigate the shoals ahead and secure a brighter future.

To address the problem, the RBMA has embraced a strategy that seeks to morph the association from one primarily oriented around the hosting of conferences and networking activities into a vast repository and clearinghouse for benchmark and best-practices data.

“We’ve begun using our resources and those available to us on the outside to produce survey tools and techniques so that we can gather information from our members about the business of managing radiology services,” said Gregory M. Kusiak, MBA, president of the RBMA Board of Directors. “It will be time-consuming for our members to complete these surveys—and it will be daunting for us to properly sample and validate the data. But we believe this to be entirely worthwhile. The fruits of these efforts will help anyone involved in the management of radiology enterprises reach the top of their game.

“Additionally,” he continued, “it will help regulators and payors—those whose activities affect the business of radiology—better appreciate the impact that their decision-making has on our profession, on consumers of health care services generally, and on the economy as a whole.”

Already, the RBMA has routed among its members a handful of surveys dealing with accounts receivables. Among the first was one intended to establish industry standardized definitions of terms. “This is so that we can all be speaking the same language when we discuss A/R issues,” Kusiak said. “Importantly, we secured the cooperation of radiology billing systems vendors to incorporate our survey-developed standardized definitions in their own products, giving our members the ability to make apples-to-apples comparisons across vendors.”

The few A/R surveys conducted thus far by the RBMA have demonstrated the existence of “a very large, natural variability in performance of the A/R function,” Kusiak added. “Some factors other than competence are affecting this, including variations in laws from state to state governing how billing is to be carried out, variations in the type and quality of the relationships that radiology or-gaizations have with their different payors, and variations in the makeup of the practices themselves.”

Change of Job Description

The RBMA was established in 1968. It initially was constituted as an organization for billing managers.

“Until the Medicare Act of 1965 and for a time afterward, it was customary that hospitals billed for the entire radiology service; radiologists were paid out of the reimbursement collected by the hospital,” Kusiak explained. “Then came the requirement that physicians had to bill Medicare separately for their services. More than anything else, this split-billing gave rise to the need for radiology groups to have billing managers. The RBMA was established to give all those new radiology billing managers a forum to meet and share knowledge.”

The need for billing managers evolved into one for business managers when neurology-oriented, whole-body CT scanning came of age, followed by the development of MR—both of which served to elevate radiology from a service confined to the basements of hospitals and paved the way for the explosive growth of independent, freestanding outpatient imaging centers. In response, the RBMA widened to welcome individuals engaged as administrators of entire radiology enterprises.

According to Kusiak, in the early days of the imaging center phenomenon, a professional could take one of two paths in order to become a business manager of those facilities. The first was to start off as a radiologic technologist; the second was to begin as a billing department employee. In both in-stances, you had to be in the right place at the right time (or in the wrong place at the wrong time, depending on how you looked at things, Kusiak mused), and it helped if you were methodical, analytical, tenacious, and plucky.

Today, the path requires more and better preparation and skills. “In addition to generic knowledge about billing and equipment,” Kusiak enumerated, “you also must have familiarity with finance, facilities management, the regulatory environment, and human relations—the latter especially. Excellent people skills are essential because you will be dealing with diverse personalities and with individuals from diverse income strata who have diverse levels of education. Your constant challenge is to get all of them to work together cohesively.”

Kusiak noted that not only has the manager’s job description changed, but also the spectrum of venues in which that job is conducted has changed. “You find managers just as much in demand for small, single-modality imaging centers that have a mere handful of staff as you do for large radiology groups with well over 500 employees, multiple hospitals under contract, a chain of imaging centers, and mega-millions of dollars in technology investments,” he said.

“Big Tent” Approach

Owing to the broadening of its members’ responsibilities and workplace settings, the RBMA decided several years ago that it needed to become a big tent. “We wanted to create an environment more welcoming to a more diverse set of professionals—everyone from the manager who works for a large-scale, for-profit radiology organization to the one who works for a modestly sized nonprofit hospital, and including the radiologist who owns an imaging center and is himself filling the role of business and billing manager,” Kusiak said.

In early 2006, the RBMA undertook a formal assessment of its members’ interests and needs. Out of this process came a decision to develop closer ties with several outside organizations, such as the Medical Group Management Association and a number of those catering to professionals involved in the oversight of billing operations. RBMA also used the feedback from its members to create an independent entity—the Radiology Coding Certification Board—that sets standards for coding of radiology procedures. Moreover, the RBMA set up a peer group for members who manage small practices and want to be able to get together in an atmosphere of confidentiality and freely advise one another. (The key to the success of this group is that the participants’ practices are not in competition with one another.)

According to Kusiak, RBMA membership is more valuable than ever not only because of these new features, but also because the association is helping administrators acquire the knowledge necessary to produce cogent responses to the federal Deficit Reduction Act of 2005 (DRA).

“We want our members educated enough to be able to minimize the financial losses that the law promises to inflict,” Kusiak said. “But our message is that the effects of the DRA are not going to be temporary and so should not be dealt with on that basis. In fact, I’m fully convinced that the DRA is only the beginning of the intensification of economic and regulatory pressures against health care in general and radiology in particular. We need to get used to the idea that the primary cost-control technique of private payors and the federal and state governments alike is to ratchet down reimbursements.”

The question then becomes, what will a sage, protracted DRA-counteroffensive look like? Kusiak isn’t sure. “There’s not a good answer other than to go back to the basics,” he suggested. “Review your portfolio of services and, using all the traditional and nontraditional methods of analysis at your disposal, try to identify which are the winners and losers. Consider your operation’s cost structure, capital outlays, alternative methods of financing, and personnel practices—all the fundamentals of how you run your business and what those elements contribute to or take away from the bottom line.”

Back in the Day

Of course, the economic realities of today are a world removed from those that existed when Kusiak entered the field of radiology management in 1985. Actually, his involvement with health care dates back even further, by 15 years to be exact. “My first job was administering a program under the auspices of the federal Office of Economic Opportunity, which was a ‘Great Society’ War on Poverty initiative,” he said.

That was followed by a succession of posts in which Kusiak managed rural hospitals and physician practices before moving on to become the director of planning and marketing for a large regional medical center. Later, he was vice president of development for Council Shared Services Inc, a for-profit subsidiary of the Hospital Council of Southern California (now the Hospital Association of Southern California).

His move into radiology came when he was hired to administer an ailing imaging center in Santa Monica, Calif. “They recruited me to turn the place around, restore it to economic health,” he said. “Eventually, it made a modest profit, but nowhere near what the partners imagined they might make before they built the center.”

It was remarkable that the imaging center ran into difficulties at all, given that restraints on such facilities were virtually nonexistent. “This was pre-Stark,” Kusiak noted. “It was an era when imaging centers were being formed by referring physicians as limited partners with a developer as a general partner. There were no prohibitions about self-referring, and any revenues from cases sent by a physician–owner to that imaging center went right back into the practice’s pocket. Still, it was possible for centers in those days to flounder. You could go wrong by making bad business decisions—for example, undercapitalization, overestimation of referral volume, poor choices of equipment, and improper staffing.”

At about the same time that he went to work for the Santa Monica imaging center, Kusiak joined forces with a handful of partners and launched a billing and management company. He sold his interest in it to them when he moved north to Sacramento, to serve as chief operating officer of a radiology group there. While in Sacramento, he started another billing and management venture; this, too, he eventually sold to his partners. In 1998, he returned to Southern California to become president of California Medical Business Services, a then 2-decades-old billing and management company located in the city of Arcadia and now responsible for the operation of five outpatient radiology centers. Concurrently, he serves as practice manager of The Hill Medical Corp, a radiology group covering Huntington Memorial Hospital, Pasadena, Calif.

Kusiak joined the RBMA in 1991 and quickly emerged as one of its more active members. “I spoke at several conferences, wrote for the RBMA Bulletin, created the first RBMA online bulletin board forum, and had a hand in developing our first RBMA Web site,” he recounted. “From the get-go, I thought the RBMA was a terrific association. It offered me access to a large cadre of talented people from whom I have learned a great deal—and whom I have been able to help by sharing knowledge of my own in return.”

Ambitious Goals

Kusiak assumed the RBMA board presidency last September after then-president Shannon J. Doyle stepped down 4 months into his term. Because Kusiak was president-elect at the time of the move into the vacated post, he will continue as the board’s highest officeholder until May 2008. “I will always consider it one of the greatest honors to have held the gavel in my hand on the RBMA’s 40th birthday,” he enthused.

With a year left to go in the Kusiak presidency, opportunities are aplenty for him to accomplish much. Topping his to-do list is the task of further expanding the ranks. “We were at 2,000 members last year,” he said. “I’d like to see our numbers grow significantly beyond that. We have in place the marketing professionals and tools to help us more successfully generate interest in joining.”

In January, the RBMA relocated to Virginia from its longtime home in Irvine, Calif, to be near policy chieftains and, in turn, be better able to influence their decisions affecting radiology. “Our primary role is not lobbying, but we still felt we needed to have face-to-face contact with lawmakers and regulatory agencies in order to provide them with good information,” he said. “And the only way to be effective at that is to be in the Washington, DC, area.”

Kusiak’s hope is that the association can develop a truly interactive relationship with policymakers. “We want to get to know them at a level that allows us to understand what their concerns are, what they’re trying to accomplish, and

how they’re trying to accomplish it,” he said. “Then, we also can gain a clearer sense of how little or much they understand the way things work in radiology and the impact their proposed changes will have on things. Armed with those insights, we then can supply the information necessary to fully enlighten them.”

In short, the RBMA is seeking a seat at the table. Given that radiology exists in a context of an industry that represents one sixth of the gross domestic product, policymakers would do well to hear from and take heed of as many voices as possible, he contended.

To be sure, Kusiak said that keeping in mind the big picture is important whoever you are—but no more so than when you are managing a radiology enterprise. “If you understand where your organization fits into this 15% of the nation’s economy, you’re going to be in a stronger position to make reasonable decisions about how to survive and thrive in the current and future radiology environment,” he said. “The RBMA is committed to helping our members do just that. The RBMA stands for excellence in the management of diagnostic imaging services, first and last.”

Rich Smith is a contributing writer for Axis Imaging News. For more information, contact .

Surviving the DRA: Kusiak’s Counsel

Gregory M. Kusiak, MBA, recommended that survival-minded imaging centers shed any modality or service that appears unviable in the era of the Deficit Reduction Act of 2005 (DRA). Admittedly, though, this course carries the risk of alienating longtime customers, who, if alienated enough, might cancel their contracts and take their business elsewhere.

“That certainly could happen,” said Kusiak, board president of the Radiology Business Management Association. “You may find that eliminating one modality eliminates an entire set of customers. That might not in and of itself be significant, unless it turns out that those customers brought you lucrative collateral business in some other area. This is why you must very carefully analyze your service lines before divesting. Still, keep in mind that, in this environment, you might not necessarily be able to satisfy every need of every customer. You might have to make some very hard and difficult choices in order to cope with the DRA.”

A challenge for radiology managers is the question of how to devise an effective DRA survival strategy for practices and facilities that have physician-owner employees. “In this particular situation, straight economics have not necessarily governed all of your past decision-making,” Kusiak said. “Lifestyle choices and other issues related to owner-operators have governed part of that decision-making, which will have had an effect on equipment selection, on how many hours a day the center will be open, on the center’s style of operation, and on how many and what kinds of staffers are present during business hours.

“When you analyze your operations as part of the revising of strategies in response to changing economic and regulatory pressures,” he continued, “you find that some of the items you’re looking at turn out to be very important to the owner and, thus, difficult to address from a strictly what’s-best-for-the-bottom-line perspective.”

Another challenge is competition from former big customers—chiefly orthopedic practices, cardiology groups, and neurologists that have bought their own imaging equipment. Kusiak’s thought? The threat may be overblown, and to fret about it would be unhealthy. “Some specialized services will make a lot more sense provided on some kind of shared or integrated basis,” he said. “For example, large orthopedic groups in some cases can offer much better patient service and higher quality of care if imaging is integrated into their practice. But it doesn’t necessarily follow that the radiologist or the radiology organization is going to be shoved aside because of this. It always will be the case that, with some specialized services, only the radiologist or the radiology organization will be skilled enough to provide them. What we really must do is identify all these new methods of working together, which ultimately allows clinical quality to increase and causes underlying costs to decline.

“I believe that future growth for radiology has to do with understanding the integrated nature of diagnostic imaging within the practice of medicine in general,” Kusiak continued. “From there, we must identify the areas of excellence that radiologists and radiology organizations bring to the table, then build on those, and play to the strengths embodied by them.”

—R. Smith