Triple Aim

Clinicians and administrators from CMS Pioneer ACOs discuss radiology?s role in achieving goals set for accountable care organizations.

While administrator of the Centers for Medicare and Medicaid Services (CMS), Donald Berwick, MD, identified a triple aim for health care reform achievable through the Affordable Care Act: better health, better health care, and better value. These objectives, if achieved, will translate to a healthier population, an improved patient care experience, and greater value for the dollars spent—lofty, but popular, goals.

In the effort to achieve these aims, accountable care organizations (ACOs) are taking a big picture view, focusing on outcomes and cost. “The model that Dartmouth-Hitchcock and others espouse [targets] the total cost of care for our patient population and the clinical quality outcomes of that same total population,” said Barbara Walters, DO, MBA, senior medical director of Dartmouth-Hitchcock Regional Practices in Concord, NH.

While administrators focus on the big picture, disciplines have to focus on the details, discovering where and how they can best achieve the triple aim. No one particular department has been singled out; everyone can improve. “Imaging is right in there with absolutely every other clinical service that we provide and is not segregated in any way, shape, or form. But it is key and should be coordinated,” Walters said.

Radiology’s role is important, particularly since it crosses so many other disciplines. “Imaging is critical for making sure patients stay out of the hospital, or that once they’re in the hospital, they move through the system quickly. That doesn’t change in an ACO model,” said Clifford Belden, MD, interim chair of radiology at the Dartmouth-Hitchcock Medical Center in Lebanon, NH.

Right Tests, Right Time

One of the major radiology concerns for health care organizations is the need to ensure they are delivering the right imaging tests at the right time to help move a patient’s care forward. Although sometimes patients may be denied an exam, more often they are prescribed one that may not be necessary. “The feeling is pretty widely shared that there’s more imaging done than is needed to accomplish good medical care,” said Frank Bragg, MD, of Eastern Maine Healthcare System, Brewer, Me.

Overutilization is therefore a target for many departments looking to increase efficiency. “We can improve health by determining whether any test is warranted at all. If so, which one would provide the most conclusive evidence? And how often does the test really need to be repeated? Superfluous testing exposes patients unnecessarily, and layers on cost, without adding value to their care,” said Tricia H. Nguyen, MD, MBA, chief medical officer of the Banner Health Network, Phoenix, Ariz.

A large portion of radiology tests are ordered by primary care physicians, who may request an advanced imaging test that is not necessarily immediately indicated. Often, this is a response to the pressure of time, patients, and/or quality concerns. “So, it’s probably out in the primary care community where this goal can be accomplished,” Bragg said.

Radiologists may be reluctant to reach out to ordering physicians to correct their requests, in part because of the etiquette of the situation and in part because of the business aspect. Bragg has had radiologists call him to suggest another test that may be a more appropriate choice, “but it’s very infrequent that they’ll call back and say a test isn’t indicated. And it’s understandable because I should know what I’m doing, and they are just responding to my request,” Bragg said.

But that cultural paradigm is shifting. “The time has really come for radiologists to stop turning a blind eye to the overuse of imaging tests that don’t add a lot of value,” Belden said.

Technology Tools, Paradigm Shifts

An excellent way to achieve the aim of education, without excessive radiologist involvement, is through technology. Clinical decision support tools are poised to become integral to the process of health care. “Inappropriate ordering can be reduced with rules,” said Bragg.

Using the classic example of back pain, he notes that 90% of such complaints tend to disappear without any intervention, but that few primary care physicians will wait the standard length of time. “The patient may pressure the provider, or the provider may think it’s necessary,” Bragg said.

A decision tree can indicate when and what test to order in response to the factors plugged into the system, providing the physician with knowledge and confidence. “So a screen would pop up and ask how long the pain has been present, where it is located, whether there is any indication of a herniated disk or pressure on a nerve, etc,” Bragg said. It would then provide the value of a selected test and possibly suggest an alternative. In this way, the primary care physician receives immediate guidance without radiologist intervention.

However, it’s important to include radiologists in the decision behind the acquisition of any such system so that they are in accordance with the system. Generally, Bragg notes, clinical decision support tools for radiology use the criteria published by the American College of Radiology (ACR). Even so, there can be disagreement, and if the radiologists continually override the “decision” of such a tool, its efficiency and usefulness are negatively impacted. Their buy-in is, therefore, key.

Similarly, primary care physicians must buy in as well, and this could require another paradigm shift. “Doctors are used to acting independently, making the decisions, and being in control. These tools require they give up some of the autonomy they are used to having, and that takes a culture shift. It is occurring—in some places, it’s going rapidly and in some places not so rapidly,” Bragg said.

Reduce Redundancy, Reduce Waste

Another area where tools will be key to success is that of redundant ordering, a second key target for improvement in the radiology departments of accountable care organizations. “About 20% of imaging studies are somewhat redundant,” said Belden.

Redundant imaging is an obvious waste of health care resources and, if the modality uses radiation, an unnecessary risk for the patient. But there have been few tools to help physicians avoid this inefficiency. “In medicine, we still don’t talk to each other very well,” Bragg said.

He notes that it is very easy for a physician to order a repeat imaging test simply because they did not know it would be a repeat. If the patient didn’t provide the information, there has been no way of checking to see if an exam has been performed elsewhere. This is changing as health information exchanges (HIEs) begin to fill in this gap. “They are not robust and not yet active enough to be reliable ways of exchanging information, but there are some interesting companies coming on the scene,” Belden said.

Solutions will have to incorporate ways to ensure that all regulations regarding patient privacy and health care information are met. “We don’t yet have a mechanism in place, aside from the traditional fax machine or CD, to make sure the permissions are in place,” Belden said.

Once the details are worked out, however, most think HIEs will provide an excellent solution to this long-term problem. The majority of states have at least one “cloud” forming above their networks, and people are beginning to use them, although, again, adoption rates differ.

In Maine, Bragg notes the HIE is operational, and many—though not yet everybody—are adding their data. “I can already dial into the Maine HealthInfoNet and see what studies have been done anywhere in the state,” Bragg said. The system makes it fairly easy to search, find, and obtain data.

Faster Care Cycles, Balanced Costs

The bonus to targeting these areas and implementing these tools is the impact they are expected to have on the entire health care cycle. Ideally, they can help to shorten it. “I think the cycle time of care has to increase in intensity,” Belden said, noting radiology is key to this effort.

Rather than allowing radiology equipment to sit idle after 9 pm, hospitals should begin to develop solutions for 24-hour coverage. “Imaging sometimes plays a role in key decisions on whether you’re going to discharge a patient, keep them an inpatient, or take them to the OR, and so we can help improve the cycle time,” Belden said.

Cycle time is just one performance measurement. Other measures focus on quality and cost. All involve multiple factors that must be considered to develop an accurate assessment. Each institution tends to customize calculations to match their resources and objectives, but some standards do exist. And as comparison becomes more important to consumers, the benchmarks will become even more solidified.

“All of the accountable care approaches, contracts, and engagements that Dartmouth-Hitchcock is involved in have a quality gauge. So the clinical outcome is measured by evidence-based metrics that are nationally recognized,” Walters said, citing the National Quality Forum and the Agency for Healthcare Research and Quality (AHRQ) as examples.

But, of course, cost is also an important measure, particularly as cost control is one of the triple aims. “As you’re moving from a fee-for-service to an ACO model, at first, they seem diametrically opposed. One is do more and get paid more; the other is do less. But in reality, if you focus on the cost per unit of service, then you will benefit under both models,” Belden said.

This figure will have a significant impact on the overall total cost of care, another important measurement, particularly in terms of imaging. By focusing on the end point, there may be a path that is seemingly more expensive in the near term but is ultimately cheaper over the life cycle of the health care episode. “Imaging represents about 4% of the Medicare dollars that are spent. So if you forego an imaging test for other types of care, such as specialist consultations, you can actually end up spending more,” Belden said.

Even with standardization, there will continue to be multiple paths possible to get a patient with condition x to outcome y, and some will use more imaging than others. The most cost-efficient pathway of care is likely to vary with each organization, pending the resources it has available.

“Is a neurology appointment cheaper than a CT scan for a patient with headaches? Can we keep the headache patient in the medical home of the primary care physician office and use imaging to give them more confidence to manage that patient rather than send them to a neurologist? These are questions that are going to vary from one institution or accountable care organization to another but that need to be looked at,” Belden said.

The results can make a difference. At a former institution, Belden notes the addition of a CT angiogram to the head CT for patients admitted for stroke helped to reduce the overall length of stay and cost of care. “It was an extra test, but it improved the protocol of care,” Belden said.

Again, these types of decisions will vary with each institution. Some organizations may focus more on utilization, others on redundancy, others on new protocols. In all of them, radiologists should be significant participants in the discussions. “Clearly, our imaging specialists are best positioned to lead the rest of us down this road to more responsible and cost-effective utilization of imaging studies for our patients,” Nguyen said. Their role is key: better health, better health care, and better value.

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Renee Diiulio is a contributing writer for Axis Imaging News.