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First, a lesson in recent history. MIPPA was passed by the House of Representatives in July 2008, after a presidential veto; the legislation was primarily created to extend expiring Medicare provisions. But, as Lucey points out, the bill also includes the words “for other purposes,” and it turns out one of those other purposes is imaging accreditation. Though the imaging provisions of the bill total only 40 pages out of a whopping 1100, they still pack a considerable punch.

Here’s what you probably already know. Beginning January 1, 2012, all outpatient providers of “advanced diagnostic imaging services” will need accreditation by a CMS-approved body in order to receive Medicare reimbursement. Advanced diagnostic imaging services (henceforth referred to as ADIS) include:

• MR
• CT
• Nuclear medicine
• PET

“Why were these four modalities chosen?” asked Lucey. The answer is simple and predictable: they’re advanced, changing technologies, and they have the largest growth in terms of both number of exams performed and in terms of cost.

CMS must designate its accrediting bodies by January 1, 2010. The ACR looks like a shoo-in. Another organization mentioned in MIPPA is the Joint Commission, a less obvious choice for very obvious reasons: “I did a presentation with the Joint Commission about three years ago where we talked about how our programs were complementary,” Lucey noted. “It’ll be interesting to see what happens if the Joint Commission is selected.”

So what do you need to do to get up to speed? Well, if you’re already accredited by the body CMS designates, nothing for a year. If not, it’s time to get crackin’. For now, CMS says that you will not be reimbursed for any procedures performed until you are accredited, although the ACR is lobbying for a grace period while the accreditation process is underway. Still, Lucey advises:

• Get accredited as soon as you can. Follow all the steps very carefully, and call the accrediting body with any questions.
• Put someone in charge of organizing the accreditation material.
• Make sure the clinical images you send are the best you have and that they’ve been reviewed by a clinician.
• If you get a deficiency, find out what your options are for addressing it.
• Stay current with the accreditation requirements.
• Reapply for accreditation in a timely fashion.

To get in touch with the ACR’s accreditation team, use the contact information below:

Theresa Branham, CT/MR: tbranham@acr-arrs.org

Carolyn MacFarlane, NM/PET: cmacfarlane@acr-arrs.org

Krista Bush: kbush@acr-arrs.org

Leonard Lucey: llucey@acr-arrs.org

And that, ladies and gentleman, concludes our statread coverage of this year’s RBMA fall educational conference. However, we’ll be including much of what we learned at the show in upcoming issues of ImagingBiz.com, so if you’re not already a subscriber, sign up here and stay on top of all the action!

–Cat

“Just to give you an idea of how much this is a reality,” Dennis said, “I heard a news account that the Mayo Clinic in Glendale will stop accepting Medicare in January. This is real. This is happening now, and people aren’t waiting around for health reform to start making changes.”

Regulatory changes for 2010 in the proposed Medicare Fee Schedule include reduced reimbursement for radiology, rad onc, IR, nuc med and most of all, IDTFs. Though there are no changes overall to physician work RVUs, drastic changes have been proposed to practice expense payments, especially the 90% equipment utilization rate for high-tech imaging. High-tech is defined for these purposes as any system costing over $1 million, and includes:

• CT
• MR
• Angiography suites
• Interventional suites
• Radiation treatment delivery systems
• PET

“Irrespective of anything that’s happening on the legislative front, that 90% rate will be put in place January 1, 2010, assuming they don’t go with our comments,” Dennis noted. “I used to be an optimist about that, but I’ve been doing this for quite a while. Now I’m a pessimist.”

Dennis explained that CMS is following MedPAC orders on the equipment utilization front. But that’s not the worst news when it comes to practice expenses. Based on the results of the physician practice information survey — which the ACR views as highly flawed and unfair to specialists — CMS is decreasing PE RVUs on the professional component by 19%, and on the technical component by 33%. “These numbers are not insignificant,” Dennis noted. “In my mind, these are the more devastating hits.”

As to the issue of the national coverage determination on CTC, Dennis told the assembled group that the ACR has formed a coalition to fight for coverage of the technology. “CMS is just not going to pay for new technology anymore,” she said. “It’s an interesting conundrum we find ourselves in, because radiology is a technology-driven specialty.”

Where MedPAC is concerned, Dennis noted that the commission is looking at the issue of self-referral, albeit using outdated data. “They’re going to explore the in-office ancillary exception,” she said. “They know self-referral is a problem and that it drives up utilization, but they don’t want to disenfranchise other physicians. They pick and choose their issues, and there’s a lot to lose politically getting involved on this issue.”

Finally, Dennis said that based on a recent GAO report, the possibility still exists of payments being bundled and the multiple procedure reduction being extended to the professional component side of things. ACR and AMA have responded with letters.

“These issues are just not going away,” Dennis concluded. “You have things swirling on the legislative side, but on the regulatory side the train has left the station. We have to keep dealing with these issues as best we can.”

–Cat

Over the years, DIS’ performance plan has evolved from a “capital punishment” model to a “performance improvement” model. In the capital punishment model, qualifying events and behaviors for termination were enumerated, but feedback on performance was absent, and there was no organized mechanism for dealing with issues.

Wanting to deal with these problems, DIS went to a production model of performance, with poor results. “My personal favorite was, ‘I don’t believe in the RVU system,’” Downs recalled. People argued that the problems weren’t on their end, or that they worked hard enough. Over time, there was little change in staff behavior.

The goal evolved. “What if we redefined what performance was?” Downs asked.

DIS set a goal, to have a credible, multi-source evaluation methodology for monitoring and improving physician performance and contribution. “When we began talking about performance versus production, it changed the landscape of how we would evaluate,” Downs said. New goals included:

• Performance had to be defined comprehensively
• The system had to be transparent, and people needed the opportunity to help develop the model
• System had to have different ways to evaluate performance that were data-driven and specific to the practice
• People had to have the opportunity to self-correct
• If self-correction didn’t occur, then there had to be consequences

The new model of performance included factors like practice building, corporate citizenship, production, and clinical. Next, DIS developed a code of conduct “to enumerate those things that physicians value within their practice: anything from sexual harassment philosophy to customer service and quality,” said Downs. The next step was coming up with policies like progressive discipline, which included penalties and the opportunity to do things other than terminate a staff member like restricting vacation time. DIS adopted RADPEER as a clinical measure and self-created a peer evaluation tool.

annual peer review evaluation was adopted, and all findings were correlated. Performance was now continually monitored, and feedback was continually given. The board received all the results in aggregate.

“When physicians receive the peer evaluation, they see their results benchmarked against the results of the entire practice,” Downs said. “RVU information is benchmarked to their subset within the organization – general radiology and so on.” The physicians spent a long time developing the peer evaluation document, which became a 16-point survey ranking physicians on issues like:

• Follows established protocols and standards
• Accurately and thoroughly interprets studies
• Efficiently uses time
• Answers pages/phones and returns calls promptly
• Performs his/her share of the work

In a table of results, two radiologists stood out. One was six RVUs below the mean, the other five; they were both one standard deviation below the mean in terms of production. For both radiologists, these results were confirmed by the peer survey process. The peer survey also illuminated additional issues with the troublesome radiologists.

These staff members were placed on the performance improvement plan, which included RVU information every month and weekly feedback, after which both radiologists began to improve gradually.

From the process, DIS learned a lot. They knew who the troublesome radiologists were before beginning the process, and when the company equally measured and monitored all individuals, they were able to create an atmosphere in which everyone was given fair treatment throughout the process. Downs stressed that good, reliable, accessible data used judiciously is key.

But what he emphasizes most is the “accordion planning” piece of the puzzle. “We ended up spending a lot of time defining the policies, discussing them, voting on them,” Downs said. “Everybody had some ownership. Not everyone thought it was wonderful. But we got all of them involved, and we have begin to correct performance in a constructive way where people have not been terminated or penalized economically. People have chosen to make self-corrections.”

–Cat

Q: What is the role of the breast care specialist/navigator in women’s imaging?

A: We just started this. We have two certified nurse navigators, and it’s been phenomenal so far. I can’t say enough good things about it. The response from patients is three pages. We’re an outpatient imaging center, and the nurse navigator takes the patient by the hand and explains all the procedures beginning with the biopsy. And they’re just someone to call. They’re the guidance. Especially in this area of women’s health, these physicians aren’t always communicating with each other, so the nurse navigator is the one in the middle tying all the links together. But it has to be someone who can sit with the patient for two hours discussing this with them. It can’t just be anyone.

A: We also have a breast imaging center and we do something very similar, except we do it with our referring physicians and breast surgeons in the area. The report is back to the referring physician within an hour and we coordinate all her care within our facility. Now we’re averaging about a 10% increase per year, mammography-wise.

Moderator: Is anyone here moving in the direction of integrating their practice with an oncologist or radiation therapist?

A: We started an integrated women’s imaging center about two years ago. One of the pushbacks in our community is that the oncologist wanted to be there meeting the newly diagnosed patient instead of the surgeon. Everyone wants to be there when the patient is told bad news. I don’t know if any of you have a suggestion. The oncologists are suddenly realizing that they’re losing out to other oncology groups. As you build your team to work with the newly diagnosed patient, you’re going to see some of those politics. There’s a vast difference between the surgeons and oncologists on who should be first to consult the patients.

Q: What are some creative marketing ideas for patients regarding the importance of the radiologist’s role?

A: What I heard at the last roundtable was that many practices don’t want to get in between the referring physician relationship and the patient. It’s a bit of a controversy to say to the patient via some campaign that the referring physician has no idea what he’s doing and here’s a better option. But some groups have had some success with elevating the idea of the radiologist as an important, fellowship-trained part of the care continuum. But it is somewhat of a controversy if you already have strong referring physician relationships. You’re messing with a delicate balance.

Moderator: I’ve chosen to mess with it. I’m going to present with a partner from the ACR in November on marketing to patients. Some practical aspects related to this concept, I recently hired a facilitator at our imaging center and we conducted focus groups with patients. The first question was, “Define the role of the radiologist,” and the second was “What is your relationship with the radiologist?” And the words they used to the second one made me take notice. They basically said there is no radiologist. It’s anonymous and detached. Two people used the analogy of the Wizard of Oz. They proposed that some level of interaction would really change their view. Bottom line, they said the radiologist is the doctor’s doctor more than my doctor.

A: One of the things we did is any abnormal results, the radiologist delivers the results directly to the patient in their office. It doesn’t take that long, and we saw a great amount of success.

A: Getting the radiologist out of the room is ideal and wonderful, but they picked this role as a physician for a reason. They chose this path.

Moderator: Another approach I’ve mentioned is that most communities have public access networks. We’ve partnered with them and are sponsoring health talks with a celebrity. We pair up a radiologist with a member of the medical community. It’s not formal, it’s not stuffy, it’s very relaxed. I can’t tell you the amount of positive feedback we’ve received. People finally see them as human. And it only costs about $250 per episode. It’s not cost prohibitive.

Q: What are the key differences between an IDTF and an imaging center designated as a physician’s office?

A: The differences are stark. The IDTF has much greater reporting requirements when it comes to Medicare. We have to get inspected. There are limitations, certain things we cannot do, like biopsies. There are things we can’t do from a marketing standpoint. They’re pretty stark. From an IDTF standpoint, we like the concept of everyone else having to play by the IDTF rules. It makes sense to us.

Q: What is being anticipated within ACR and RBMA for imaging centers?

Moderator: Lower reimbursement. More pressure. More challenges. As our opening session speakers on both days have said, we’re also in the position to identify opportunities. We’re going to continue to face challenges, and we’re going to need to make some adjustments. At the last session I asked a gentleman if he thought there’d be a resurgence of IPAs. Anyone think it’s going to happen? He didn’t.

Q: Any known issues to affect the PC billing for imaging centers?

Moderator: With precerts and preauths on the professional side, without the correct number, you’re not going to get paid.

A: We’ve had some success in Washington negotiating with the payors to pay us when the hospital gets denied, because we have no control over that. I would encourage anyone who’s in contract negotiations to pursue that. It can be done.

–Cat

In order, I’ll relate the submitted questions and some of the answers. Preauth, Stark, technical service agreements and much much more, after the jump . . .

Q: How many imaging center providers here today have technical service agreements with referring physician practices? If not, are you being approached to do these?

A: We don’t do these arrangements, but the other group in town does, so it causes a problem. It definitely makes those physicians send their business to the other group. I wish it were illegal

A: Our competitors are running low-quality magnets. We’re being pressured to go there and won’t do it. I agree that it should be deemed illegal.

Moderator: Blue Cross Blue Shield New Jersey is about to disallow orthopedists, urologists, primary care doctors to have in-office imaging. Anyone else? No? I guess New Jersey’s lucky.

Q: Can imaging centers perform pre-auth for referring physicians as part of the referral, or is this a gray area as far as Stark is concerned?

A: In our case, we’re a medical billing company, and we have clients who keep doing this. Their marketing folks think the easier they can make it for the referring physician, the more likely they are to send their business to the center.

Moderator: For those of you doing the preauths, is it authorized by the payor?

A: Yes (echoed around the room).

A: I’m not sure I agree with the position that there’s a Stark issue here. I’m not sure it’s settled. There are people in the industry who continue to do it. It’s clearly a marketing issue and a service to the referring physicians. I’m not convinced it’s a Stark issue, but you do need to pay attention to the payors’ side.

Moderator: This is an issue for all of us. What can we do to better address the situation? Do we need to sit down with the payors as a unified front? It’s a policy they have that is concerning us. We didn’t create this nightmare, but we’re taking the hit. Anyone work out a solution they’re willing to share with the group?

A: I don’t have any great breakthrough, but I think the solution to this lies in a strong statement from the RBMA and the ACR. The foundation on which these RBMs are built is cracked. They’re not after the 2% that are denials. We’ve looked forward to replacing RBMs with guidance from the radiology community. The RBMs aren’t going to go away otherwise, and if we continue to collude with them, I think they will be here to stay. I call on RBMA and ACR to make a strong statement that radiologists should be doing this work with referring physicians.

A: I have a question about that. For those of you, even if you were able to get your referring physicians to get the preauth for you, wouldn’t you verify it anyway, so wouldn’t it wind up being double the work?

A: We do both. It’s a constant eroding of relationships between us and the referrings. That’s what we deal with, trying to keep that relationship good.

A: I think we’re missing the point here. We’re not in the middle of this, the patient is in the middle of this, and I think we’re losing sight of that.

Moderator: Is anyone else building appropriateness criteria as part of their education for referring doctors?

A: We have checked, triple-checked, overviewed. Our goal is to take care of the patient. Period. All those things we’re doing are to benefit the patient. There’s no difference to some of these people between a hip and an elbow, so we’re going back and doing the work anyway, contacting that provider when the patient’s sitting in our lobby waiting. The patient is the one caught in the middle. We’re doing everything on our end to help that patient get the test the doctor’s requested. As someone who’s been dealing with this issue in Arizona for close to ten years now, I bet no one could tell you with a straight face that they don’t have a staff member who is strictly obtaining authorizations on a daily basis. We’re here for the patient. We’re just trying to facilitate the order that came to our office. And it’s not strictly monetary. It’s quality of care. These are the issues we deal with every day. Until we formally address this issue, all we’re doing is rallying around the fact that yes, it’s happening, it’s a gray area. Unless everyone rallies together and puts out a formal document on what should be done, this will continue to be a problem.

Moderator: By the way, CareCore says the ACR appropriateness criteria is not strict enough, so I don’t see that necessarily as the answer to replace RBMs.

A: The problem we’ve had is that our employees are asked, are you an employee of the referring physician? When they say no we’re not, the RBM says we can’t talk to you. What can we do?

A: I know a provider that says no, we’re not, but we’re calling on behalf of . . .

A: If we get those, we call the referring doctor back and say you’re going to have to get this yourself.

A: Working in this business before and now, half of your claims would be denied and you wouldn’t know until three months later. We now get auth, we get the right tests, we get the patient done the right time. I don’t have those same customer complaints anymore. Our customer satisfaction has gone through the roof, so if you look at it that way, we’re doing the right thing for the patient. We’re talking with the business office now where we never used to. Whether we like it or not, doing the auth is patient-centric, so I can’t blame them for making us do it.

A: What is the ACR and RBMA’s position on this? Do they have one? If the ACR isn’t taking a position, this will continue to be a problem.

Moderator: I’ll attempt to answer that question. I believe the position of RBMA is that we support a decision support system for physicians. We’d rather not see the RBMs interfere. We want the decision made at the physician level, not by some company that’s taking twenty cents per member per month. A lot of work and effort has gone into this, and we’re going to continue to push for the decision support system. RBMA has a white paper and you can access that on our website.

–

To be continued in part 2!

–Cat

Jakielo began by asking how many people in the audience had done wage freezes. A few hands went up. He asked how many radiologists had taken a pay cut for the first time, and a few more hands went up. “If your hand isn’t up, folks, odds are it will be by this time next year,” he said. “That means we have to change and adapt. If you’re not paying close attention to what’s going on in health care today, you may find yourself . . .” He drew laughs from the crowd as he displayed a picture of a shack with a sign reading, “Sh** Creek Paddle Store.”

The issues outlined by Jakielo are, by now, familiar to us all: a shifting payor landscape, the possibility of universal health care looming, the nascence of ICD-10, the return of capitation, practice consolidations and breakups, hospital closings, and much more.

[Sidebar: another challenge mentioned by Jakielo was the notorious millennial, the lazy and spoiled 20-something with no work ethic who needs constant positive reinforcement to do the most basic tasks, but, on the brighter side, is good with computers. As a millennial myself, I bristled a bit. But I suppose I see his point. Some millennials -- some -- can indeed be like that.]

So how can a good leader prepare him- or herself to lead the team into the fray? There were two works Jakielo used again and again: PAY ATTENTION. Pay attention to the changes happening to health care. Oh, and two more: STAY POSITIVE. Adapt to change instead of living in the past.

Jakielo pointed out that “to earn more you must learn more,” and urged the crowd to become continuous learners, attending training programs and researching the health care environment to stay ahead of the curve. He reminded attendees that their cars can serve as “rolling universities,” with books on tape and other audio programs providing ongoing education.

Jakielo also reminded leaders to praise or compliment a minimum of three staff members a day, maintaining the positive environment. (There were a few more groans at the expense of millennials when he mentioned that we need much more praise than older workers and should be evaluated EVERY THIRTY DAYS because we need constant feedback to succeed. Are there any other millennials in this room? Am I the only one feeling unfairly singled out here?)

To further improve your effectiveness as a leader, Jakielo recommends:

• Blocking out an hour on your calendar for “thinking time”
• Avoiding the notorious plague of the smartphone, otherwise known as “Crackberry disease”
• Keep a to-do list
• Keep a stop-doing list. “Because, as a leader, you can give someone else about 80% of what’s on your list,” Jakielo explained. “Do the important stuff yourself. The rest is filler.”

–Cat

Depending on which side of the political divide you stand on, his remarks have an equal chance of inspiring you or enraging you. Either way, though, they represent a valuable inside look at the number-one policy issue facing America today. I also took notes on a few attendees’ questions, as well as Shadegg’s answers, all after the jump.

“Why health care?” Shadegg asked. “Health care has been an interest of mine since I got into congress. Health care is where our nation is closest to embracing socialism, and I don’t want that to happen. I first said that ten years ago, and here we are, very close to the first step in that direction.

“I know HR 3200 pretty darn well. I’ve read it multiple times flying back and forth to DC, and if you need to drift off to sleep after a long week, just pick up HR 3200. I think we have the best health care in the world. I think the problems with the delivery of health care are all created by government. If you look at what’s screwed up with health care in America, you’ll find that the government did it. If you don’t like your employer’s plan, buying your own plan is at least 30% more expensive. Making Americans buy health plans with after-tax dollars is outrageous. It just frustrates me. I personally believe the current structure goes a long way toward building barriers between patients and physicians. I think it’s not good to put employers and plans between patients and doctors. I don’t think it’s good that your industry has to come hat in hand to Washington year after year to try to influence a bunch of congressmen who don’t know squat about health care.

“The good news is that there is substantial agreement in this nation on two of the three issues in health care. Republicans and Democrats both agree that you shouldn’t be denied coverage or told you can’t get coverage if you have a preexisting condition. Whether it’s through high risk pools, risk readjustment or other issues, I think America is ready to resolve this, and we shouldn’t be fighting about it.

“The second issue is universal coverage. I argue a lot with my Republican friends that we are already supplying universal coverage because those without health insurance just go to the emergency room.

“The third issue is how do we control costs. With the Baucus plan, the other side has given up on controlling costs altogether. The Republican school is we need to connect patients with their primary care physicians again, enable them to pick their plans and that will control costs. They won’t buy a plan they can’t afford. The Democrats’ answer is, if we put the government in charge, they’ll control costs. I don’t mean to be partisan, but that’s putting the same group responsible for Hurricane Katrina in charge of health care costs. That’s the way I see it.

“Now let’s talk about the outrage. For those of you who spend a good part of your time interfacing with the government or supervising someone who does, the good news is, if this bill passes, there’s lots and lots and lots more of that to come. Mr. Baucus was extremely thrilled because the CBO [Congressional Budget Office] scored their bill and said only $829 billion, and it will cover more people. How many of you could make the financial side of whatever you do look really good to the people in charge by including ten years of revenue, but only seven years of expenditures? The taxes begin in 2010, but the expenditures begin in 2013. CBO scored from 2010 to 2030. I think it’s an outrage, and only in Washington would you get this kind of accounting.

“That’s what the bill does. It says we’re going to save a whole bunch of money on Medicare by doing away with Medicare Advantage. Well, it might, but you’re going to have a lot of people angry. The rest of the money comes from them saying the SGR will never happen, and you’re all going to live without a cost of living adjustment for the next 10 years. The last one is kind of, I’ll try to talk about it as though it’s funny, but it’s not. It’s corruption, Washington-style. If you want Soviet-style, gulag politics running health care in America, then you’ll love this bill. It turns out that Senator Harry Reid is up for reelection this year. It turns out that they want to expand Medicaid to cover more people. It turns out states would have to match that. So guess what’s in the bill? Mr. Reid wrote an addition saying that in four states, including Nevada, the government will pick up all of the Medicaid costs. If you want your health care to be determined by how powerful your US senator is, then this bill is great.

“In the Baucus bill, they’ve decided that we ought to tax gold-plated health care plans to pay for care for everyone else. I’m perfectly happy to pay for health care for those in our society who don’t have it, but I think it ought to be fair and equal. In this bill, here’s what they did. They wrote the bill to say that all gold-plated health plans in America will be taxed at the level of $2,200. But then Schindler worked with the senators to get that portion rewritten. So if you live in Kentucky, the tax kicks in at $2200, but if you live in New York, it’s $2500; in Connecticut, it’s $2600. So if you’re lucky enough to live in a state with a powerful senator, you pay less. Sounds like gulag-style politics running our government. The senator from Michigan Debbie Stabenow said, ‘I’ve got to keep my union workers happy,’ but she got an addition to subsidize only union plans in Michigan and New York.

“Now you know how I feel about this bill, and I’ll be happy to answer your questions.

An attendee asked, “Why are we throwing the baby out with the bathwater? Why are we taking a hatchet to a lot of good things that are working well? And the second thing is, why is Congress trying to cram something down America’s throat that it doesn’t want?”

Shadegg answered, “In Washington, anyone who bases their life on the numbers CBO comes up with, you might as well read tea leaves. When Medicare was first created they allocated a budget for it. It turned out to be enough money to cover two states. On the uninsured, the number they cited kept creeping up over the years until it was eventually 50 million. But when you take out illegal immigrants, it’s closer to 30 million. Most people hear that number and they think there are 30 million Americans who’ve had no insurance for years. That’s absolutely wrong. The number is based on the number of people who were uninsured at any point in time in a 12-month span. The chronically uninsured? Who knows how many there are.

“Covering everyone is a societal value. I think we’ve made our minds up about that. But I think it’s crazy to be throwing the baby out with the bathwater.  One of the things I like to remind audiences of, you want to talk about health care, the one thing that scares most Americans is the big C. We beat the socks off the rest of the world on cancer. Our five-year survival rates are better than Canada, better than England, better than all of Europe.”

Another attendee asked, “What’s being done on the insurers’ side of things?”

“I’ll tell you what I think about insurers,” Shadegg answered. “I think the health insurance industry in America has got a fat hog, and we’re the victims. If you flick on the TV tonight, in the span of an hour and a half you’ll see five commercials for auto insurance saying they can make you a better deal, but you won’t see a single health care commercial make the same argument. They don’t have to sell to you and me. The health insurance industry does not have to sell to individuals by and large, and they like that. They like it so much that the big guys are onboard with this bill. They want the government to put a gun to the head of every single American saying now you’ve gotta buy their product. If we rewrote the law to say you could take your employer’s plan tax free or go buy your own plan tax free, and that will keep the competition going.”

Finally, another attendee asked, “My question has to do with what is helpful for members of Congress to make decisions. Are surveys that organizations like the ACR do helpful to members of Congress?”

“Obviously,” Shadegg said. “What influences an individual member of Congress on any important vote ranges from soup to nuts. There was an amendment in front of my committee on the issue of imaging utilization. The current team in Washington thinks imaging is overutilized. Some of us don’t agree with that. My answer to your question is facts are stubborn things. When you bring the facts to people like me or any other member of Congress, that makes a difference, but so do other factors. I guess my answer is facts help, but to the extent that medicine has become phenomenally intertwined with government, which to an extent it has. You can’t open your eyes in the medical field without asking the government for permission, and it’s going to get worse. Studies with hard facts make it more difficult to ignore the merits of your position. And therefore all the other things come into play. The other thing I would suggest is that personal contact really does matter. Do the string theory. Find somebody in your community who knows somebody who knows somebody who knows your congressman, and work that string. Find a way to have a personal conversation. Then you’re in their head, and they’re doing it with someone they know and respect.”

Bauer dropped more than a couple of jaws in this morning’s general session when he forecasted a slim 30% chance that some form of health care reform legislation will pass. Those jaws were dragging on the floor when he suggested that radiology, already a beleaguered sector of medicine by anyone’s standards, needs to take the initiative in enacting measures that will improve efficiency and quality of care.

So: how does he imagine the grassroots revolution playing out? What can we do?

Health care, Bauer pointed out this afternoon, has become highly inefficient. According to a meta-analysis of several studies, in health care, which currently represents 17% of the GDP, anywhere from a fifth to a third of costs are attributable to waste of one form or another:

• Additional services necessitated by incorrect or unsafe practices
• Widespread use of unproductive or counterproductive clinical interventions
• Failure to use the least expensive resources to achieve desired outputs
• Poor utilization of personnel and facilities
• Redundant reimbursement procedures with “perverse” economic incentives
• Imbalance between acute care, disease management and prevention

Bauer says the mission statement of every health care organization should be “doing it right all the time, as inexpensively as possible” — i.e. making quality the number-one priority, with cost-effectiveness playing second fiddle but still very important. “It’s imperative that we do new things, not the old things in new ways,” he noted. “We have to recognize the rising cost of human error, both clinical and operational.” According to what Bauer has observed in other industries, the way to solve this puzzle is a continued commitment to both performance improvement and embracing the power of new IT.

So what are some common characteristics of successful health care provider organizations — those that have trimmed waste, reduced costs and maintained or even improved quality? According to Bauer, they are standardization, flexibility, integration, alignment of strategic goals, leadership (in all but two of the successful health care systems he’s studied, the leadership consisted of physicians), accountability, and creativity.

Bauer concluded that health care will continue to develop unevenly over the next few years. “There will be winners, there will be losers,” he said. Reform will continue to evolve, and if anything does make it through, it’ll cause new problems. Consumerism will shift the focus even further onto affordability. Reimbursement’s deficiencies will get increasing attention. Policy focus will shift from cutting costs to maximizing use of existing resources.

But Bauer also believes that private-sector developments will achieve desired systemic improvements. “The really neat changes will occur because of you all,” he said. “We need to be proactive and bring a sense of urgency to this, but at the same time, you have the opportunity to do something with other stakeholders.”

–Cat

http://rbma.org/conferences/fall_educational_conference/sessions.php

–Cat