A common misperception is that radiologists have minimal impact in providing value-based care. The reality is that radiologists are taking an active and leading role in the development of value-based, pay-for-performance initiatives. As medical imaging touches nearly every patient, any plan to improve overall performance must include radiology.
The transition from fee-for-service to value-based payment is very much upon us, yet there is a lack of standardization across the industry. For example, government and private payers have not agreed on a uniform set of measures across the care spectrum. And while metrics are a necessary part of a pay-for-performance system, today we often find these metrics to be inconsistent and arbitrary. The risk, of course, is that using the wrong metrics wastes valuable resources, both time and money, and can, at their worst, negatively impact patient care as they drive attention away from activities that do genuinely benefit the patient.
As we transition to value-based care, identifying the correct metrics that align with quality and value has become the Holy Grail. But how do we make this transition successful, what metrics do we need and how do we measure them? Below are three criteria to take into consideration when defining metrics for performance-based reimbursement. While developed with radiology in mind, they can be applied across the provider spectrum. Specifically, an ideal pay-for-performance metric should:
• Be something that meaningfully impacts patient outcome or cost. The value equation is generally accepted as "outcomes relative to costs."1 Through my work as a radiologist, I created a framework to understand the idea of "value creation" in radiology. This framework is based on the two types of diagnostic radiologist activities. One part is interpretive value, evaluating how well imaging exams are performed and interpreted. The second part is non-interpretive value, such as quantifying the role of value-added activities like speaking to a patient or family, conducting clinical consultations, and performing research. When you combine the interpretive value and the non-interpretive value you get the total value of a radiology practice or department. By analyzing both types of value, we gain greater insights into areas where we can improve patient outcomes and lower costs.
• Be something you can realistically and reliably measure. While it sounds straightforward enough to include something you can realistically and reliably measure, many desired outcomes are abstract in nature making them hard to quantify. For example, how do you quantify the value created by discussing patient care with a clinician? Is the value of time a good measure of worth? Is a radiologist who spends 18 minutes speaking with a clinician inherently doing better than one that spends only 12 minutes? Time can be a sometimes useful metric, but certainly a limited one. The ideal metric is something that can reasonably be quantified. It is also important to establish benchmarks, and measure improvements over time.
• Be under a group's control. If payment is going to be based on performance, it seems only logical that the group being evaluated has reasonable control over the outcome. By analogy, a suboptimal metric of baseball pitcher performance is team win/loss record. A pitcher could throw a great game, allowing only one run, but still lose if the team scores no runs. There are better, pitcher-specific measures of pitcher performance, just as there are measures specific to other positions on the field that don't apply to the pitcher. Similarly, a patient's outcome is influenced by many factors beyond the control of the radiologist. Therefore, simply measuring patient outcomes is not an ideal measure of radiology's performance. Instead, we should focus on those activities that impact either the numerator or denominator of the value equation and are under our control as radiologists.
To provide an example for these criteria, our own practice is implementing a program to objectively evaluate and grade our radiology reports. We believe that better and more complete reports, utilizing best-practice recommendation standards, will positively impact care, aid hospital economics and improve clinician satisfaction. We have a way to quantify this process and measure it across the full practice. And of course, how well we meet the reporting standard is completely under our control. Thus, this program meets all of the criteria described above.
As the healthcare industry pushes forward with value-based care, all of us have a role to play in the transition. Radiology is helping lead the way, evaluating novel ways to aid patients and maximize value. It will take a collective team effort to drive meaningful change across the system. For this to work, we must identify those metrics that best define success. While this won't be an easy process, use of the three criteria outlined above can serve as a useful reference point.
1 Porter, M. E. (2010, December 23). What Is Value in Health Care? The New England Journal of Medicine, 2477-2481. doi:10.1056/NEJMp1011024
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