With payers and policymakers increasingly scrutinizing the value of medical imaging, opportunities abound for radiologists and radiology health services researchers to meaningfully and rigorously demonstrate value. Part one of this two-part series on the value of imaging explores the concept of value in health care from the perspective of multiple stakeholders and discusses the opportunities and challenges for radiologists and health service researchers to demonstrate value. The current absence of meaningful national value metrics also presents an opportunity for radiologists to take the lead on the discussions of these metrics that may serve as the basis for future value-based payments. As both practitioners and investigators, radiologists should consider the perspectives of multiple stakeholders in all they do—interdisciplinary support and cooperation are essential to the success of value-focused imaging research and initiatives that improve patient outcomes. Radiology departments that align their cultures, infrastructures, and incentives to support these initiatives will greatly increase their chances of being successful in these endeavors.
Introduction
With payers and policymakers increasingly scrutinizing the value of medical imaging, opportunities abound for radiologists and radiology health services researchers to meaningfully and rigorously demonstrate value. Value-focused investigation, however, represents a conundrum for many imaging practitioners and researchers, who have traditionally focused on whether services or technologies were effective, rather than being a good value for the money .
In this first of a two-part report from the Radiology Research Alliance Task Force on the value of imaging in health care, we describe various definitions of value and outline challenges in measuring it from both the patient encounter and the larger societal perspective. In the second part, we detail several actionable opportunities for the imaging community to demonstrate its value to patients, payers, ordering providers, health systems, and society at large. Although value-focused research represents a substantive departure from traditional avenues pursued by most investigators, it creates considerable opportunities for those who adapt and innovate, particularly for younger academicians seeking to align their pursuits with long-term societal agendas.
Pressure on Radiology to Demonstrate Value
Claims of overutilization of medical imaging have resulted in substantial scrutiny by the Centers for Medicare and Medicaid Services (CMS), other payers, and a variety of policymakers. In an attempt to both curb that utilization and promote appropriateness and quality, a variety of metrics and mandates have been imposed on radiology providers and facilities. For example, comparisons of hospital advanced imaging utilization, such as the rate of magnetic resonance imaging in patients with low back pain without initial trial of treatment, are publicly available on the Medicare Hospital Compare website . Clinical decision support tools have been introduced in some health systems, and Congress has recently mandated their implementation for advanced imaging ordering beginning in 2017 . Although the growth of medical imaging has slowed in recent years , radiology’s historical disproportionate contribution to rising overall healthcare expenditures has been the focus of many parties .
This increased scrutiny has prompted the imaging community to consider how it can demonstrate the value of imaging to payers and other stakeholders. Research in radiology has traditionally been focused on diagnostic accuracy and efficacy (performance of an intervention under ideal conditions) rather than comparative effectiveness (effect of an intervention in “real-world” conditions compared to other diagnostic tests) and cost-effectiveness. Until recently, comparative evidence for diagnostic imaging uses in oncology, cardiovascular care, and for other conditions has been relatively limited . As discussed in part II of this series, radiologists are also demonstrating value beyond imaging interpretation such as by reducing radiation dose, guiding appropriate ordering of imaging studies, and communicating results directly to patients. The link between imaging and clinical outcome is crucial—the Department of Health and Human Services recently announced that reimbursements will be increasingly tied to quality or value with 30% of Medicare payments tied to alternative payment models by 2016 . Therefore, work that demonstrates the value of imaging to clinical outcomes is urgently needed to justify imaging’s role in these evolving healthcare delivery models.
Defining Value in Health Care and in Radiology
A simple way of defining value is quality divided by cost ( V=Q/C V
=
Q
/
C )—or more colloquially as “bang for the buck” . This permits the value seeker—whether he is a clinician, administrator, or researcher—to focus efforts on either quality or cost and, ideally, towards both. In addition, the definition of each differs depending on the stakeholder of interest. Administrators, for example, may be focused more on the bottom line of their practices, whereas physicians may prioritize clinical outcomes and their own workflow efficiencies.
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Multiple Stakeholders in Health Care
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Table 1
Unique Perspectives of Different Healthcare Stakeholders
Stakeholder Perspective Patients
Providers
Payers
Health systems
Society
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Developing Patient-centered Comparative Effectiveness Evidence
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Value Metrics
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Conclusion
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References
1. Duszak R.: From good to good deal: value-focused research. J Vasc Interv Radiol 2012; 23: pp. 315-316.
2. Iglehart J.K.: Health insurers and medical imaging policy—a work in progress. N Engl J Med 2009; 360: pp. 1030-1037.
3. Welch H.G., Hayes K.G., Frost C.: Repeat testing among Medicare beneficiaries. Arch Intern Med 2012; 17: pp. 1745-1751.
4. Medicare Payment Advisory Commission (MEDPAC) : Available at: http://medpac.gov/documents/data-book/june-2015-databook-health-care-spending-and-the-medicare-program.pdf?sfvrsn=0 Accessed September 25, 2015
5. Centers for Medicare and Medicaid Services : Available at: https://www.medicare.gov/hospitalcompare/search.html Accessed September 25, 2015
6. Allen B.: Five reasons radiologists should embrace clinical decision support for diagnostic imaging. J Am Coll Radiol 2014; 11: pp. 533-534.
7. Lee D.W., Duszak R., Hughes D.R.: Comparative analysis of Medicare spending for medical imaging: sustained dramatic slowdown compared with other services. AJR Am J Roentgenol 2013; 201: pp. 1277-1282.
8. Dodoo M.S., Duszak R., Hughes D.R.: Trends in the utilization of medical imaging from 2003 to 2011: clinical encounters offer a complementary patient-centered focus. J Am Coll Radiol 2013; 10: pp. 507-512.
9. Lee D.W., Levy F.: The sharp slowdown in growth of medical imaging: an early analysis suggests combination of policies was the cause. Health Aff (Millwood) 2012; 31: pp. 1876-1884.
10. Levin D.C., Rao V.M., Parker L., et. al.: Bending the curve: the recent marked slowdown in growth of noninvasive diagnostic imaging. AJR Am J Roentgenol 2011; 196: pp. W25-W29.
11. Government Accountability Office : Medicare part B imaging services: rapid spending growth and shift to physician offices indicate need for CMS to consider additional management practices. United States Government Accountability Office Website; Available at: http://www.gao.gov/products/GAO-08-452 Accessed May 29, 2015
12. Pandharipande P.V., Gazelle G.S.: Comparative effectiveness research: what it means for radiology. Radiology 2009; 253: pp. 600-605.
13. Burwell S.M.: Setting value-based payment goals—HHS efforts to improve U.S. health care. N Engl J Med 2015; 372: pp. 897-899.
14. Kaplan G.S.: Seeking perfection in healthcare.Lessons learned in changing healthcare.2010.Longwoods Pub.Toronto:pp. 145-159.
15. Mangano M., Bennett S.E., Gunn A.J., et. al.: Creating a patient-centered radiology practice through the establishment of a diagnostic radiology consultation service. AJR Am J Roentgenol 2015; 205: pp. 95-99.
16. Johnson A.J., Easterling D., Williams L.S., et. al.: Insight from patients for radiologists: improving our reporting systems. J Am Coll Radiol 2009; 6: pp. 786-794.
17. Cabarrus M., Naeger D.M., Rybkin A., et. al.: Patients prefer results from the ordering provider and access to their radiology reports. J Am Coll Radiol 2015; 12: pp. 556-562.
18. Bentley T.G.K., Effros R.M., Palar K., et. al.: Waste in the U.S. Health Care System: a conceptual framework. Milbank Q 2008; 86: pp. 629-659.
19. Kruskal J.B., Reedy A., Pascal L., et. al.: Quality initiatives: lean approach to improving performance and efficiency in a radiology department. Radiographics 2012; 32: pp. 573-587.
20. Porter M.E., Lee T.H.: The strategy that will fix healthcare. Harv Bus Rev 2013; 91: pp. 50-70.
21. Robert Wood Johnson Foundation : Counting change: measuring healthcare prices, costs and spending. Available at: http://www.rwjf.org/content/dam/web-assets/2012/03/counting-change Accessed May 29, 2015
22. Drummond M.F., Sculpher M.J., O’Brien B., et. al.: Methods for the economic evaluation of health care programmes.Third ed.2005.Oxford University PressOxford
23. Gold M.R., Siegel J.E., Russell L.B., et. al.: Cost-effectiveness in health and medicine.1996.Oxford University PressNew York, NY
24. Husereau D., Drummond M., Petrou S., et. al.: Consolidated health economic evaluation reporting standards (CHEERS)—explanation and elaboration: a report of the ISPOR health economic evaluations publication guidelines good reporting practices task force. Value Health 2013; 16: pp. 231-250.
25. Hollingworth W.: Radiology cost and outcomes studies: standard practice and emerging methods. AJR Am J Roentgenol 2005; 185: pp. 833-839.
26. Bessen T., Clark R., Shakib S., et. al.: A multifaceted strategy for implementation of the Ottawa ankle rules in two emergency departments. BMJ 2009; 339: pp. b3056.
27. Gazelle G.S., Kessler L., Lee D.W., et. al.: A framework for assessing the value of diagnostic imaging in the era of comparative effectiveness research. Radiology 2011; 261: pp. 692-698.
28. Smith-Bindman R., Aubin C., Bailitz J., et. al.: Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med 2014; 371: pp. 1100-1110.
29. National Lung Screening Trial Research Team, Aberle D.R., Berg C.D., et. al.: The National Lung Screening Trial: overview and study design. Radiology 2011; 258: pp. 243-253.
30. Jena A.B., Skinner J.S., Chandra A.: The promise and challenge of comparative effectiveness research. June; Available at: http://www.voxeu.org/article/promise-and-challenge-comparative-effectiveness-research Accessed May 29, 2015
31. Black W.C., Gareen I.F., Soneji S.S., et. al.: Cost-effectiveness of CT screening in the National Lung Screening Trial. N Engl J Med 2014; 371: pp. 1793-1802.
32. Allen B.: Are radiologists ready for higher value care?. J Am Coll Radiol 2015; 12: pp. 427-428.
33. Duszak R., Burleson J., Seidenwurm D., et. al.: Medicare’s Physician Quality Reporting System: early national radiologist experience and near-future performance projections. J Am Coll Radiol 2013; 10: pp. 114-121.
34. Duszak R., Saunders W.M.: Medicare’s physician quality reporting initiative: incentives, physician work, and perceived impact on patient care. J Am Coll Radiol 2010; 7: pp. 419-424.
35. Torchiana D.F., Colton D.G., Rao S.K., et. al.: Massachusetts General Physicians Organization’s quality incentive program produces encouraging results. Health Aff (Millwood) 2013; 32: pp. 1748-1756.