In 2012, Ron Vianu grew intellectually curious about something. He was working at a fast-growing referral management platform in New York at the time and began to uncover what he describes as a major disconnect between payers and providers over radiology.
When presented with a referral platform in radiology that would assess providers based on quality and price, he says most payers declined and noted they had bigger problems to tackle, such as unnecessary surgeries or extended narcotic use, which they did not feel were impacted by radiology. "And the feedback we received from the provider community could not have been any more different," Mr. Vianu says.
In talks with hospitals, health systems and medical groups about radiology, Mr. Vianu heard anecdotal evidence illustrating the risks of variation in diagnostic imaging. People shared stories of loved ones who were misdiagnosed, recommended unnecessary surgeries or not recommended necessary surgeries because of the varying quality of an MRI or other diagnostic image.
Years later, Mr. Vianu would eventually go on to co-found a company to solve this problem. But well before then, he set out to gauge how many different diagnostic reads the same person could receive in the same market. In 2013 he took to the streets of New York with his mother, who experienced lower back problems and agreed to undergo three MRIs at three providers to compare results. The images came back with different results that could have supported three different recommended treatments.
Mr. Vianu's informal experiment findings was reinforced by a 2017 study in The Spine Journal, which found "marked variability in the reported interpretive findings and a high prevalence of interpretive errors in radiologists' reports of an MRI examination of the lumbar spine performed on the same patient at 10 different MRI centers over a short time period." The authors concluded that a patient's radiological diagnosis, choice of treatment and clinical outcome may be directly impacted by where he or she receives an MRI and the radiologist who interprets it.
The same year the study was published, Mr. Vianu partnered with orthopedic surgeon Raz Winiarsky, MD, to found Covera Health, a New York City-based company that offers a radiology centers of excellence program for health plans and self-insured employers.
Their broader undertaking is to ensure radiology is not taken for granted.
"The presumption has been that radiology is an objective test that is telling you what your anatomy looks like," says Mr. Vianu, CEO of Covera Health. "Then you take the image to the doctor, and they'll decide what treatment you should have. But if that test isn't completely accurate or adequately descriptive, then everyone from that point in time is going to have some limitation with respect for what to recommend for you."
Enter Walmart
Around the same time Mr. Vianu was realizing the severity of variation and errors in diagnostic imaging among healthcare providers in New York City, the same finding was growing apparent roughly 1,300 miles away for employee benefits managers at Walmart's headquarters in Bentonville, Ark.
They noticed associates throughout 49 states and Washington, D.C., were experiencing stark variation in their diagnoses, treatment recommendations and outcomes. The retail giant set out to solve this problem in 2013 with the creation of its Centers of Excellence Program, wherein Walmart covers the full cost of travel and treatment for associates' defined medical episodes — including certain cancer evaluations, transplants and common surgeries — if they go to one of 16 approved hospitals across the country.
More recently, Walmart expanded the program to cover diagnostic imaging through a multiyear partnership with Covera Health. The 1.1 million people on Walmart's medical plan now have access to Covera Health's Radiology Centers of Excellence Program, which supports better outcomes through a nationwide network of vetted radiologists who have access to ongoing quality monitoring and actionable feedback.
Referring to the radiology partnership in April, Lisa Woods, senior director of U.S. Health Care at Walmart, noted that many associates who travel to a Center of Excellence do so because of false positive images or a bad read. The Radiology Centers of Excellence Program will start with about 50,000 procedures at approximately 800 imaging centers nationwide, focused specifically on MRIs and CT scans. "It's the right machines and the right readers, with negotiated rates," Ms. Woods noted in April.
Mr. Vianu says Walmart and Covera are setting out to solve a problem that patients may not even know about. "If they perceive radiology as a commodity and have a poor outcome, they would either think it's [the fault of] one of the other physicians in the continuum of care or they would just say, 'I'm unlucky. I just didn't get better.' Maybe the reality is they are being treated for the wrong thing because they didn't really have the right specialist within the world of radiology examining their studies," says Mr. Vianu. "By working with very innovative payers like Walmart and the provider partners we have across the country, we are alleviating this problem in a way that isn't super visible to them."
The plan? For Walmart associates to undergo diagnostic imaging at one of the roughly 800 approved centers and have greater likelihood of an accurate diagnosis, greater likelihood of effective treatment recommendations, better outcomes and overall improved wellbeing. "All of that has to happen without patients having to think too much," says Mr. Vianu.
What this means for radiologists, hospitals and health systems
Mr. Vianu is careful to point out how badly radiologists want to eliminate variation within their work but face numerous obstacles to doing so.
One complication is the traditional patient-radiologist relationship. It is uncommon for radiologists to directly communicate with patients about their imaging exams. Instead, radiologists usually discuss the results with the physicians who ordered the exams, and those physicians then communicate the result to the patient. Although many radiologists support the concept of communicating more directly with patients, they report time and workload constraints complicate efforts. Their lack of direct communication with patients can further complicate the lack of visibility radiologists have into patients' entire care episodes and what treatments are recommended and received subsequent to the diagnostic imaging.
"Today, the world of radiology has a very meaningful challenge around its understanding of value, because there is no clear conception of quality. Radiologists, at least from my perspective, are incredibly intellectually curious and incredibly caring and really genuinely trying to solve this problem," says Mr. Vianu.
Covera equips participating radiologists with a clinical analytics platform that was created in partnership with practicing radiologists. Covera's analytics team has developed first-of-its-kind clinical datasets around radiological quality based on years of medical records and radiology scans from tens of thousands of patients, which then informs physicians with actionable insights to improve their practice.
Walmart's COE program has attracted robust interest from hospitals and health systems. There are 6,210 hospitals in the U.S., and Walmart has deemed only 16 of them good enough for its 1.1 million employees in need of certain medical procedures or services.
But before hospitals immediately cache Walmart's COE listing as an iteration of U.S. News & World Report's Best Hospitals Honor Roll — a highly anticipated annual list of the 20 top hospitals in the country — or some sort of immutable ranking, Mr. Vianu points out distinctions in the partnership with Covera. Given Walmart's geographic distribution and place in rural America, the retailer's health benefits team wants to bring solutions that elevate associates' options for local care — not shun local healthcare providers.
"Walmart was keen on a partnership approach with providers. It's not about looking at a map and figuring out which providers are the best. They can't move around millions of people across the country for imaging. So, they said, 'Is there ultimately a way we can partner with the physician community to help them get better? Because that's where our patients live — next to these physicians,'" says Mr. Vianu. "They are fundamentally about identifying who is in that community and working with them to understand what quality they are delivering today and how they get better — and the provider community is incredibly receptive to that."
As for Covera's plans moving forward, Mr. Vianu says the company has seen a lot of unsolicited interest from self-insured employers, insurance carriers and various state and federal agencies. "Our hope is over time this will be something adopted in a much more significant, widespread fashion."