Regional Radiology in a Rural State: Implementation and Growth

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1 Regional Radiology in a Rural State: Implementation and Growth Jocelyn D. Chertoff, MD, MS, MHCDS Chair, Department of Diagnostic Radiology Vice President, Regional Radiology Service Line Dartmouth-Hitchcock Medical Center Geisel School of Medicine at Dartmouth

2 Regional Radiology in a Rural State: Implementation and Growth Jocelyn D. Chertoff, MD, MS, MHCDS Chair, Department of Diagnostic Radiology Vice President, Regional Radiology Service Line Dartmouth-Hitchcock Medical Center Geisel School of Medicine at Dartmouth

3 Objectives Participants will learn about the process of developing a rural network of integrated Radiology practices be able to discuss the issues of culture and relationships in combining academic and general radiology practice be introduced to the IT issues involved with integrating practices be able to describe a regional staffing model

4 Disclosures None

5 We thought about doing something with Regional Radiology, but we decided it was too hard

6 Brief History The process began under the leadership of Cliff Belden Intense pressure to increase RVU/FTE No opportunity to increase RVUs internally Reducing FTEs in a small academic department Negatively affect delivery of quality subspecialty care Negatively affect call coverage Negatively affect job satisfaction Negatively affect teaching Negatively affect academic productivity

7 Grow the Pie Macroeconomics: growing the economy thereby creating more wealth and work opportunities vs. redistribution of wealth. Negotiation: Change the frame from a zero-sum, win-lose game to a win-win scenario where both sides can benefit

8 First Steps Negotiations initiated by three very small, remote hospitals for D-H to take over Radiology services Enrollment of a 5 person team in the MHCDS program Cliff Belden Chair Jocelyn Chertoff Vice Chair for Operations Casey Grigsby Director of Outreach Tamara Heath Finance Mary Beth Eldredge - IT

9 Master of Health Care Delivery Science MHCDS Tuck School of Business and The Dartmouth Institute for Health Policy and Clinical Practice The Dartmouth Institute's advanced research expertise in health care outcomes The Tuck School's proven success in teaching leadership and teamwork, finance, and operations Rational Radiology Action Learning Project (ALP)

10 The state of radiology services in the region was a natural effect of a fee for service environment Situation Fragmented Delivery System for Radiology services resulting in inefficiency and waste -Limited incentives for organizations to work together -Narrowly focused radiology groups -Services do not align with optimal patient needs -Average Patient Drives 70 minutes to their MRI or CT Appointment

11 Creating regional engagement infrastructure required a foundation for building relationship and developing trust allowing quality improvement and a sustainable future Historically, we (Radiology groups) have never met as a cohesive unit; we used to simply compete and think our own organizations were the best. Over this past year, we have been able to come to the table with common goals and interests, knowing that we cannot succeed, as our payment models change, without working together. - Clifford Eskey, MD

12 Next Steps (done) Analysis of the volumes and staffing needs of the 3 small hospitals, including On site daytime requirements Day, evening and night time volumes Business and operational plans Recruitment and hire of 3 Emergency Radiologists (9 pm to 8 am) Development and implementation of IT to allow remote reads in our very rural state

13 Goal: Right size the regional radiology delivery system as we move towards new payment models Recommended Strategies Reduce excess capacity and redistribute services Regional strategies will have variable financial impacts based on health care payment models Required Engagement Change requires building relationship and developing trust Desired State An optimized regional radiology service will ensure access to quality, value-added imaging for our patients

14 Implementation of regional strategies will have variable financial impacts based on health care payment models Recommended Strategies Long Term Financial Benefits Payment Model Impact Standardize Reduce Capacity Perform Locally Cost per Unit Margin per Unit Improved Utilization FFS = D-H Net of $2m Regional Net ACO/Capitation = from $$ to ($$) Standardize Maintain Capacity Regionalize Cost per Unit Margin per Unit Improved Utilization FFS = D-H Potential Net Regional Net ACO/Capitation = from $$ to ($$)

15 Growth We had a single, long standing outreach location Initially, we added 3 small hospitals Staffing model: 2 Radiologists, 1.4 FTE, 5 total days on site across 3 locations Currently 6 integrated regional practices Stepped Integration with a group that reads for 4 hospitals Integrating with 3 D-H practices in Southern NH Negotiating to increase our service/volume for the VA

16 Business Plan We created an in-depth 5 year Business Plan Analysis of 27 local practices, including projected annual studies, wrvus, net revenue, annual margin and confidence to close Threats, Barriers and Opportunities Resource needs Next Steps

17 Business Plan Summary we must able to respond quickly and nimbly to the changing landscape We need approval and support for this plan goes beyond the scope of what has previously been done by a department in this institution. We need specific resources We need senior leadership to be able and committed to addressing institutional barriers

18 What are the Issues?

19 What are the Issues? How much time do you have? Shameless promotion: Michael Recht and I will cover this information in a NEW case for The 2016 AUR Radiology Management Program

20 IT Issues Does the hub have the IT infrastructure and support? Are there significant IT changes coming, either at the hub or the spoke? Image storage (VNA) Connectivity Speed Communication Relationships Full members of the practice? Pay scale Credentialing Academic affiliations/titles Independent relationship between the radiology practice vs hospital relationships

21 Issues Culture Best practices/uniform protocols Referral patterns Academic vs. private practice Reporting of and agreement on critical findings/incidental findings Work expectations and respect Billing Flat fee vs professional billing Technical billing (relates to hospital relationships) Who does the billing?

22 Issues Staffing Hub as nighthawk Integration of regional radiologists into workflow Interim Solutions Change paymaster/take on billing as first step Independent workstation Partial arrangements to build relationships Skillset reads only, e.g. MRI/PET-CT Second opinions Evenings and nights only Prelim vs final reads

23 Issues Quality Troubleshooting problems TAT expectations 24/7 service, but evening and night reads are not subspecialty (relates to staffing and size) Get the right study in front of the right radiologist in a timely fashion regardless of where it originated

24 Turn Around Time

25 Turn Around Time

26 Issues Other What gets done at the different locations, what back-up is needed Specialist vs generalist: reads, hires, job satisfaction Benefits and wellness programs the same at all locations? Transportation and travel Hospital regulations: online vs. in person information sessions Risk management Economies of scale/vendors Development Differences in pricing and reimbursement Contracts 20/80 rule

27 Change is Hard 18 Add staff Add staff WORK/RADIOLOGIST (PAIN) Time in Plan

28 Make it work ays_b.php&usg= bpodiy8dglzxs2xzjmhwehgqv4=&h=340&w=222&sz=64&hl=en&start=57&sig2=gmnc9a7vxynlysb0z9w30a&zoom=1&tbnid=4beabk5cp3lwlm:&tbnh=169&tbnw=110&ei=d1sftavyoy_b8qps7ycvaw&prev=/search%3fq%3dtim%2b gunn%2bmake%2bit%2bwork%26hl%3den%26biw%3d1251%26bih%3d668%26gbv%3d2%26tbm%3disch0%2c1737&itbs=1&iact=hc&vpx=709&vpy=163&dur=305&hovh=247&hovw=161&tx=111&ty=137 &oei=afsftyn6a-sv0qg0r-chbq&page=4&ndsp=21&ved=1t:429,r:11,s:57&biw=1251&bih=668

29 If things start happening, don't worry, don't stew, just go right along and you'll start happening too. It's not about what it is it's about what it can become. Dr. Seuss

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