SAN FRANCISCO - In a healthcare environment characterized by tight resources -- and, at least until recently, a shift from volume- to value-based care payment models -- who should be responsible for radiology's value chain: the department or the hospital?
At the International Society for Computed Tomography (ISCT) symposium, presenters Dr. Jeffrey Mendel of Tufts University and Dr. Jason Itri, PhD, of the University of Virginia debated the question during a session devoted to understanding and maximizing CT's internal value chain.
Whoever is responsible, it's important to manage the CT value chain well, said session moderator Dr. Geoffrey Rubin. Rubin is the ISCT course director and a professor of radiology and bioengineering at Duke University Medical Center.
"If the value stream is managed well, the net result is margin and value, and product that can be reinvested in further growth for the enterprise -- in this case, the radiology department or practice," he said.
It's up to the department
The Obama administration supported an effort to shift healthcare payment models in the U.S. from volume to value, but the current administration isn't as keen to do this, Mendel said. U.S. Secretary of Health and Human Services Dr. Tom Price has stated that the U.S. Center for Medicare and Medicaid Innovation (CMMI) developed payment and healthcare delivery system models "absent input from impacted stakeholders" and that the models "commandeer clinical decision-making."
In fact, physician knowledge and enthusiasm for a change to value-based care is limited, Mendel said. He cited 2016 research conducted by Deloitte that found that 50% of physicians have never heard of the Medicare Access and CHIP Reauthorization Act (MACRA), 79% don't support tying compensation to quality, and only 27% of healthcare organizations have a value-based care pilot program.
"If [Price's views] reflect the government's philosophy, the government will not be pushing value-based care," Mendel said.
The American College of Radiology's Imaging 3.0 program stresses that radiologists are drivers of value-based care, and, by extension, this means that radiology's value chain should be under the department's purview, Mendel said. Within radiology, the majority of value-based care improvements will be in the department.
"When you look at the radiology department's noninterpretive activities, not many of them are intradepartmental," he said. "Yes, radiologists will need to participate in hospital IPUs [integrated practice units, which provide services based on a patient's medical condition], and administrative support will be needed for value-based care efforts that extend beyond radiology. But as radiology departments create their own initiatives, most will focus on internal radiology workflow -- and are best handled by a department-centered effort."
Radiology departments should lead the way, he concluded.
"As Rear Admiral Dr. Grace Hopper said, 'It's easier to ask forgiveness than to get permission,' " Mendel said. "Radiology needs to push forward with value-based care and get permission later."
Not so fast, Itri told session attendees. In the current financially constricted healthcare environment, hospitals need to manage radiology's value chain.
"In a system where resources are constrained, we need to use an enterprise model and get away from the 'every department is its own silo' mentality," he said.
Itri used the implementation of clinical decision support (CDS) as an example, stressing that the health system has to own the CDS project, not the radiology department. Otherwise, radiology and ordering physicians will get bogged down in ordering providers' concerns, such as whether the CDS is efficient and whether its content addresses their needs, he said.
"The enforcer for something like clinical decision support has to be the hospital's chief medical officer," he said. "Radiologists can be active participants, helping to develop content and customization, but the health system has to take responsibility."
Itri described the University of Virginia's body procedure service, which performs at least 320 CT and ultrasound-guided procedures per month, half of which are same-day requests, he said. Patients come from five to six hours away, and many are cancer patients, for whom beginning therapy is crucial and depends on data from imaging.
The department faces a number of challenges in providing this kind of service, including transport delays and shortages, chronic nurse and technologist shortages, unmanageable volume of procedures, and difficulties in scheduling anesthesia -- which results in procedure delays, he said. All of these challenges compromise radiology's value chain and support the argument that hospitals should be responsible for it, according to Itri.
"We can't fix these problems without the hospital taking responsibility for radiology's value chain," he said. "When each department is its own silo, it may perform its services well, but it also depends on resources outside of the department and needs support from the hospital to provide quality care."