“St. Paul Radiology: A Leader in Implementing the Triple Aim Health Care Initiative” by MD News

Health care spending is the biggest financial issue facing our nation. According to the Health Care Cost Institute, health care costs have risen more than three times faster than wages during the past decade. Some contributing factors are inevitable; an aging population, increased longevity and chronic health problems don’t easily lend themselves to corrective initiatives. Other factors, such as the overutilization of health care services — including the unnecessary use of imaging tests — offer significant opportunity for improvement.

Historically, physicians have been trained to focus on patient outcomes and have not been privy to the array of costs incurred along the path of care. A treating physician might respond to a patient complaint by ordering an X-ray. If the X-ray doesn’t provide an answer, the physician may order an ultrasound, a computed tomography (CT) scan and magnetic resonance imaging (MRI) before an ultimate diagnosis is made. Although an experienced subspecialty radiologist might have identified the MR as the correct study from the outset, saving significant imaging costs, the historical health care model did not encourage collaboration between a diagnostic physician and a radiologist at the time a study was ordered.

But economic realities have been pressuring practitioners to change this model. Today’s patients have insurance plans with higher deductibles and copays, and patients are much more focused on cost and value. They understand that unnecessary studies cost them money. To bring down imaging costs, health care leaders have realized the benefit of proactively encouraging consultation between radiologists and referring clinicians to order the right test the first time.

The 71 subspecialty radiologists at St. Paul Radiology have been at the forefront of health care imaging reform initiatives. When the Triple Aim health care initiative was introduced to address unnecessary imaging by encouraging cooperative partnerships between radiologists and the hospitals and private practices they serve, St. Paul Radiology took a leadership role in implementing Triple Aim. The initiative has three objectives: good patient outcomes, high patient satisfaction and lower costs.

“It’s not widely known, but Minnesota radiologists lead the nation in proactively addressing imaging issues,” explains St. Paul Radiology President Michael Madison, M.D. “In 2004, the national use of CT and MR studies was increasing at double-digit rates, prompting insurers to require unwieldy preauthorization of all studies. The Institute for Clinical Systems Improvement [ICSI] responded by organizing to limit the growth of inappropriate high-tech imaging. In exchange for removing preauthorization requirements, the Minnesota radiology community committed to meet imaging-appropriateness criteria established by the ICSI. These standards were adopted, despite their negative impact on the bottom line of radiology practices. Minnesota radiologists took the lead in this effort. Since 2004, our state’s high-tech imaging growth has been among the lowest in the country.”

Controlling Health Care Costs Starts at the Source

“When it comes to controlling health care costs, we can most effectively impact the health care system by understanding imaging utilization, deploying decision-support metrics at the point of scheduling and trying to reduce that utilization while getting to a patient outcome faster,” says St. Paul Radiology Chief Operating Officer Mark Martin. “The conundrum we are addressing is the fact that, historically, physicians and hospitals have been paid based on the number of procedures they do. The more you do, the more revenue you make. We’ve embraced the fact that this is going to change, and we want to be on the forefront of that change. As imaging specialists, we can help determine which imaging study or procedure is most appropriate from the outset. A great way to accomplish this is with subspecialty radiologists working with other specialists as part of multidisciplinary teams.”

The collaborative approach to imaging improves the quality and value of care because imaging options are evaluated from multidisciplinary perspectives, which can save time and money. Experienced subspecialty radiologists are key, and this puts St. Paul Radiology at a unique advantage.

“Our degree of subspecialization is what differentiates our group from most groups around the country,” explains Martin. “Dr. Madison is the president of our group, but he is also one of four neurointerventional radiologists in our practice serving multiple hospitals in the metro area and Duluth. More than 95% of our physicians are fellowship-trained. We offer 37 body fellowship-trained radiologists focused on the chest, abdomen and pelvis. We have 10 neuroradiologists, six musculoskeletal radiologists, four neurointerventional radiologists, nine body interventional radiologists, three pediatric radiologists and two nuclear medicine specialists. The patient studies referred to us are assigned to the appropriate subspecialty radiologists, and this translates to high-quality care for our patients.”

SPR is the Only Group in the East Metro and western Wisconsin Marketplace that Provides Services in All Sites of Care

St. Paul Radiology is the only group in the East Metro and western Wisconsin marketplace that provides services in all sites of care, including outpatient imaging and inpatient hospital emergency departments. Wherever a St. Paul Radiology patient presents for an imaging study, St. Paul Radiology physicians will have access to the patient’s entire history of studies. Additionally, St. Paul Radiology actively participates in weekly educational conferences, collaborating directly with clinicians and providers on site at numerous hospitals.

“This type of connectivity is very unusual anywhere in the country,” explains Martin. “We have a full-time staff of quality assurance individuals working 24/7/365 to queue all of our studies and scan the network for other images related to the patient’s diagnosis. Having access to a patient’s entire imaging history is a significant diagnostic advantage.”

St. Paul Radiology is also the only group in the Twin Cities offering 24-hour, in-hospital subspecialty reads by body and neuroradiologists to its three strategic partner organizations in the East Metro area: Allina, HealthEast and HealthPartners. When a patient is rushed to Regions Hospital’s emergency department following a motor vehicle trauma at 3 a.m., a St. Paul Radiology fellowship-trained emergency radiologist is on site to interpret the studies and confer with the trauma surgeons. This is an example of how subspecialty radiologists interact with other specialists as part of a multidisciplinary team to provide high-quality, high-value care.

“We’ve made a big investment in our own people to cover our community with 24/7 subspecialty care,” explains Dr. Madison. “Fewer than 5% of national radiology groups provide this level of accessibility and 24-hour care. We have a tight alliance of diagnostic radiologists and interventional radiologists working with stroke neurologists, emergency physicians and neurosurgeons to manage stroke and brain trauma patients in the after-hours time frame. Our stroke code process enables us to get information to the treating emergency physician and stroke neurologist in a very timely fashion so they can make treatment decisions. These partnerships allow us to act as true consultants. We aren’t just giving our referring clinicians a report; we are part of the team working through the next steps for patient treatment.”

The cost of imaging reflects both the technical component of doing the study with imaging equipment and scanners at a hospital or outpatient center, and the study interpretation component handled by the radiologist. St. Paul Radiology can provide both components via its outpatient imaging centers. However, in a hospital or clinic, that facility provides the equipment and the technologist to perform the scan, and St. Paul Radiology handles the imaging interpretation. In all cases, a referring clinician, primary care physician or specialist is writing the order for the study. In the old model, radiologists fulfilled the order. Under the Triple Aim model, the radiologist is involved as a consultant from the outset to ensure the correct scan is being ordered for the patient.

One of the pressures in the Triple Aim model is delivery of a cost-effective product that patients find acceptable. Whereas once, an MRI was ordered as soon as a patient complained of pain, today’s approach may be one of watchful waiting and rehabilitation before an MRI is considered. Patients used to instant gratification may struggle with this, but most patients are highly motivated to spend less on health care.

“Health care reform is a process that will require the reorganization of physicians, hospitals, health care systems and payors,” Dr. Madison observes. “Until now, there has been remarkably little communication about costs in the interplay among physicians, hospitals and payors. Now we are 100% engaged in working collaboratively to deliver a high-quality product at a lower cost. Our goal is to reduce costs while maintaining excellent patient outcomes and high patient satisfaction.”

In the past, most physicians did not know which hospital supplies cost more; they simply used the resources with which they were most comfortable. Guided by Triple Aim’s collaborative model, the health systems working with St. Paul Radiology are sharing the financial aspects of treatment so radiologists can understand and help direct use of resources.

“If two device options perform equally well,” explains Dr. Madison, “we should be choosing the less expensive option.”

St. Paul Radiology has applied the Triple Aim initiatives to foster partnership collaborations that not only reduce unneces- sary imaging but also review other critical components, such as hospital discharge protocols, affecting the cost of care. The radiology practice has been conducting cost discussions with each of its hospital partners during the past six to 12 months and using what it learns to create best practices across all hospitals.

The Advantages of This Collaboration Are Contagious

“Historically,” Dr. Madison says, “when we treated a patient with a brain aneurysm, we sent him or her to the ICU for recovery. Now, as we’ve worked with the hospitals, we understand the 1:1 nurse-to-patient ICU ratio costs $4,500 per night. In a step-down unit, where the ratio is one nurse for every three patients, the cost is $1,900 per night — and there’s no adverse impact on patient outcome. Now, we are transition- ing appropriate patients from the ICU to the step-down unit. That type of connectivity between our practice and the health care systems we serve is helping us find opportunities to make health care more cost effective without sacrificing quality. When we find opportunities in one hospital, they almost invariably translate into the other hospitals we serve.

Guided by the Triple Aim objectives, St. Paul Radiology is forging a new collaborative model for health care delivery.

“At the end of the day,” says Martin, “our goal is cost transparency while focusing on quality care for our patients. This goal reflects our culture — a practice built on a rich history of well-trained, caring medical leadership.”