Post on 08-Aug-2020
Copyright 2017, Frank J. Lexa, M.D
Frank J. Lexa, MD, MBA, FACR
Professor and Vice Chair for Clinical Affairs and Operations, Department of Medical Imaging,
the University of Arizona-Tucson
Chief Medical Officer, The Radiology Leadership Institute and Chair, Practice Leaders
Commission, the American College of Radiology
Copyright 2017, Frank J. Lexa, M.D
Disclosures
• Dr. Lexa has no relationships with ACCME defined commercial interests.
Copyright 2017, Frank J. Lexa, M.D
Acknowledgments
• Member of the Scenario and Wicked Problems Action Group- ACR
• Members and staff of the Future Trends Committee-ACR
• Friends, family and Wharton colleagues who have helped supply and refine the strategic work that I do
Copyright 2017, Frank J. Lexa, M.D
Goals for This Session
• Briefing on the most important factors that will transform and (perhaps) destroy elements of US radiology
• Take a look at the horizon- what we know, what we think might happen
• Discuss what you should be doing now to prepare for a future that is very different than the one you thought that you would be living in
Copyright 2017, Frank J. Lexa, M.D
Shocks and Awe
1. Insufficient government support
2. Attempts to address value in health care systems
3. International Perspectives and Globalization
4. Shifting from Value to Volume in the USA
5. Devaluation of Radiology
6. Radiologist employment by hospitals & corporations in a consolidating world
7. Labor Issues
8. Disorganized Radiology
Copyright 2017, Frank J. Lexa, M.D
#1 Insufficient government support
• Many nations have cut back on support for radiology capital costs- imaging equipment, IT infrastructure- most of the EU has decreased (2013 compared with 2009)-especially- Greece, Italia, Portugal
• Reduced salary support
• Reductions in educational and training support
• Increased rationing of care, particularly expensive elements
Copyright 2017, Frank J. Lexa, M.D
Population changes that affect radiology:
Percentage of population that is paying for health care
costs for the whole society
Percentage of population with high health needs
Demographic effects
Copyright 2017, Frank J. Lexa, M.D
Western US: Decline in Reimbursement
Copyright 2017, Frank J. Lexa, M.D
Private Sector Mirrors and Side effects
• High deductibles- both volume reductions and reduced reimbursement
• Narrow networks and steerage
• Rationing within value based incentive plans
Copyright 2017, Frank J. Lexa, M.D
#2 Attempts to address value inhealth care systems
Copyright 2017, Frank J. Lexa, M.D
If value means outcomes/cost then some nations have problems
Copyright 2017, Frank J. Lexa, M.D
How do we measure value:Caveat-Do outcomes=value?
Gun violence
Recreational drugs
Smoking
Unsafe sex
Helmet laws, etc.
Copyright 2017, Frank J. Lexa, M.D
#3 International Perspectives and Globalization
• International comparisons on service, quality
and salary
• Heightened expectations from ROW
• Unfavorable cost comparisons
• Rationing
• Direct deflationary pressure
Copyright 2017, Frank J. Lexa, M.D
Global Pricing Comparisons
http://www.healthbase.com/
Copyright 2017, Frank J. Lexa, M.D
#4 Shifting from Value to Volume in the US
“FFS is the dominant physician payment method in the
United States,[1] it raises costs, discourages the
efficiencies of integrated care,….”
- 1 Robert A. Berenson & Eugene C. Rich (June 2010). "US approaches
to physician payment: the deconstruction of primary care". Journal of
General Internal Medicine 25 (6): 613–618
.
http://en.wikipedia.org/wiki/Fee-for-service
Copyright 2017, Frank J. Lexa, M.D
CMS- Mission Accomplished
HHS has set a goal of tying 30 percent of traditional, or fee-for-
service, Medicare payments to quality or value through alternative
payment models, such as Accountable Care Organizations (ACOs)
or bundled payment arrangements by the end of 2016, and tying 50
percent of payments to these models by the end of 2018. HHS also
set a goal of tying 85 percent of all traditional Medicare payments
to quality or value by 2016 and 90 percent by 2018 through
programs such as the Hospital Value Based Purchasing and the
Hospital Readmissions Reduction Programs. This is the first time
in the history of the Medicare program that HHS has set explicit
goals for alternative payment models and value-based payments.
News Release, HHS, Jan 26, 2015, www.hhs.gov/news
Copyright 2017, Frank J. Lexa, M.D
Value: Payment plans, organizations and informal contracts
• PQRS now MACRA/MIPS
• ACO- Medicare Shared Savings Model-Federal
• ACO-Pioneer Model
• Private sector ACOs,
• CCOs, CPCI
• Bundling Contract and other forms of at risk contracting
Copyright 2017, Frank J. Lexa, M.D
Real value creation vs. simplistic notions of radiology value
• Old PQRS system
• New MIPS system
Copyright 2017, Frank J. Lexa, M.D
Measuring Hospital Value?
The are over 1000 hospitals in the US that
currently market themselves as being “Top 100”-1
1-The Digital Doctor- Robert Wachter page 40
There are only 5,686 hospitals in the US
Copyright 2017, Frank J. Lexa, M.D
Do Health Care Expenditures Create Value?
Copyright: Frank J. Lexa, M.D., MBA, 2012
“There is no correlation between the heightened
spending and the health of the country’s citizens.”
- Lei Haihao, deputy director general of
the Beijing Health Bureau
Burkitt L. “China Calls for Health System Overhaul.” WSJ. July 25, 2012:A10.
Copyright 2017, Frank J. Lexa, M.D
The McNamara Fallacy1. Measure whatever can be easily measured
2. Disregard whatever cannot be measured easily
3. Presume that whatever cannot be measured easily is not important
4. Presume that whatever cannot be measured easily does not exist
• Perverse blindness to economic reality-fjlCoined by sociologist Daniel Yankelovitch, cited at http://chronotopeblog.com/2015/04/04/the-mcnamara-
fallacy-and-the-problem-with-numbers-in-education/ accessed on 3-23-2016
Copyright 2017, Frank J. Lexa, M.D
Challenge #5 Devaluation of Radiology
Copyright 2017, Frank J. Lexa, M.D
Throwing Down the Gauntlet
We suggest that Medicare immediately expand the current program
nationwide. As soon as possible, Medicare should extend competitive
bidding to medical devices, laboratory tests, radiologic diagnostic
services, and all other commodities.12 Medicare's competitively bid
prices would then be extended to all federal health programs.13 To
oversee the process, we recommend that Medicare establish a panel
of business and academic experts. Finally, we recommend that
exchanges — marketplaces for insurance starting in 2014 — conduct
competitive bidding for these items on behalf of private payers and
state employee plans. N Engl J Med 2012; 367:949-954September 6,
2012DOI: 10.1056/NEJMsb1205901
Authors on next slide
Copyright 2017, Frank J. Lexa, M.D
Labor- Changing relationships of primary and specialty MD’s
Copyright 2017, Frank J. Lexa, M.D
Devaluation of specialists(and radiologists in particular)
Copyright 2017, Frank J. Lexa, M.D
#6-Radiologist employment by hospitals
& corporations in a consolidating world
• Will corporate employment change the nature of radiology
• Will independent practice of radiology survive-the Australia story
• What motivates corporations? What motivates venture capitalists and private equity investors?• The story of a neuroradiologist in the world of VC
Copyright 2017, Frank J. Lexa, M.D
Hippocrates vs. Corporate cultureDeclaration of Geneva, WMA
• At the time of being admitted as a member of the medical profession:
• I solemnly pledge to consecrate my life to the service of humanity;
• I will give to my teachers the respect and gratitude that is their due;
• I will practise my profession with conscience and dignity;
• The health of my patient will be my first consideration;….
Copyright 2017, Frank J. Lexa, M.D
Private Equity and Venture Capital
Top three drivers of behavior in private equity investment firms
Return on investment
Return on investment
Return on investment
Copyright 2017, Frank J. Lexa, M.D
Hospital Consolidation-
Mergers and “non mergers”
• 2015 and 2016 saw continued M and A activity on the hospital
side along with concomitant activity in “non mergers”-
• Affiliations and partnerships
• (lower level of scrutiny from FTC)
• Strategic drivers:
• Growth
• Cost reduction
• Population health and other value based care participation
Copyright 2017, Frank J. Lexa, M.D
Hospital Consolidation-
Mergers
Copyright 2017, Frank J. Lexa, M.D
Hospital Consolidation-
Mergers
https://www.nurses.com/doc/hospital-merger-acquisition-according-kaufman-analysis-0001
Copyright 2017, Frank J. Lexa, M.D
Hospital Consolidation-
Mergers
https://aharesourcecenter.wordpress.com/category/health-care/hospitals/mergers-and-
acquisitions/
Copyright 2017, Frank J. Lexa, M.D
Payer Consolidation attempts
in 2016 and outcomes
• Aetna/Humana -37 billion merger- stopped due to Federal
ruling
• Anthem/Cigna- 54 billion- DOJ suit to stop acquisition of
Cigna. Turned into a hostile takeover by Anthem. Ended in
2017
• Centene/HealthNet- 6.3 billion dollar merger. Large medicaid
mco.
Copyright 2017, Frank J. Lexa, M.D
Matters of SizeFrom Radiology Business, Radiology 100 lists
Copyright 2017, Frank J. Lexa, M.D
Matters of SizeFrom Radiology Business, Radiology 100 lists
More impressive to look at reduction in the small ones
Copyright 2017, Frank J. Lexa, M.D
Matters of Size
What is a Dunbar number and why does it matter?
Copyright 2017, Frank J. Lexa, M.D
Value, service and
size in medicine
Copyright 2017, Frank J. Lexa, M.D
#7 Labor issues
2015 results
Chen, J and M Heller, “How Competitive in the Match for Radiology Residency?
Present view and historical perspective”, JACR 11(5) p 501-6, 2014
Copyright 2017, Frank J. Lexa, M.D
#7 Labor issues
2015 results
Chen, J and M Heller, “How Competitive in the Match for Radiology Residency?
Present view and historical perspective”, JACR 11(5) p 501-6, 2014
Copyright 2017, Frank J. Lexa, M.D
#7 Labor issues
1- Are there enough radiologists in the labor pool now
2- Do radiologists want to provide the types of services that hospitals want in 2016- call coverage, specialty coverage, etc.
3- Do enough medical students want to become radiologists and are they the right people?
4- Shortage in US of US medical school graduates interested in diagnostic radiology in past few years
Chen, J and M Heller, “How Competitive in the Match for Radiology Residency?
Present view and historical perspective”, JACR 11(5) p 501-6, 2014
Copyright 2017, Frank J. Lexa, M.D
>2X Studies Between 1999-2010
McDonald RJ et al. Acad Radiol 2015
Copyright 2017, Frank J. Lexa, M.D
6X Images Per Exam from 1999-2010
McDonald RJ et al. Acad Radiol 2015
Copyright 2017, Frank J. Lexa, M.D
~10X Images Interpreted Between 1999-2010
McDonald RJ et al. Acad Radiol 2015
Copyright 2017, Frank J. Lexa, M.D
Burnout is not the same as unhappiness, but that is part of it
• Unhappiness is highly individual, subjective and ultimately an existential issue. Not always addressable by changing the work environment. Best that you can do is provide a work environment that allows people to be happy and not one that makes a reasonable person unhappy at work and in bad cases beyond
• Gunderman RB and D Moneva “Unhappiness and the Radiologist” JACR 13(5) p 582-584, May 2016
Copyright 2017, Frank J. Lexa, M.D
Unhappiness is a big issue for us. Likert scale by specialty:
Peckham, Carol Physician Burnout: It Just Keeps Getting Worse. Medscape. Jan 26, 2015, accessed on May 9, 2016 at
http://www.medscape.com/viewarticle/838437_2
Gunderman RB and D Moneva “Unhappiness and the Radiologist” JACR 13(5) p 582-584, May 2016
Copyright 2017, Frank J. Lexa, M.D
Burnout is prevalent in US medicine including radiology:
Peckham, Carol Physician Burnout: It Just Keeps Getting Worse. Medscape. Jan 26, 2015, accessed on May 9, 2016 at
http://www.medscape.com/viewarticle/838437_2
Copyright 2017, Frank J. Lexa, M.D
Misperception: focus on lagging (late) indicators of burnout
• Dysfunction at work:
• Poor performance
• Malpractice
• Overt anger- yelling, throwing, verbal and physical abuse
• Inappropriate behavior
Copyright 2017, Frank J. Lexa, M.D
High Burn-Out in Neuroradiologists Overall
Compared with five years ago, have you
experienced
J.Y. Chen and F.J. Lexa Baseline Survey of the Neuroradiology Work Environment in the United States with Reported
Trends in Clinical Work, Nonclinical Work, Perceptions of Trainees, and Burnout Metric American Journal of
Neuroradiology July 2017, 38 (7) 1284-1291; DOI: https://doi.org/10.3174/ajnr.A5215
Copyright 2017, Frank J. Lexa, M.D
Serious Practice and Specialty Issues Are Developing through Cut-Backs of Sustaining Activities
Over the last few years, how often do you have to cut back on the following
things because your clinical duties leave you inadequate time?
0%10%20%30%40%50%60%70%80%90%
100%
Always
Frequently
Sometimes
Rarely
Never
J.Y. Chen and F.J. Lexa Baseline Survey of the Neuroradiology Work Environment in the United States with Reported
Trends in Clinical Work, Nonclinical Work, Perceptions of Trainees, and Burnout Metric American Journal of
Neuroradiology July 2017, 38 (7) 1284-1291; DOI: https://doi.org/10.3174/ajnr.A5215
Copyright 2017, Frank J. Lexa, M.D
#8 Disorganized Radiology
➢More than 50 organizations in the US alone send representation to
the Intersociety meeting each year
➢Overlapping missions, costs, meetings, journals etc.
➢Both academic and private practices are reducing both money for
supporting these organization and money and time for attending their
meetings
➢Most will be weakened and some will be lost
Unsustainable Number of Organizations
In Radiology
Copyright 2017, Frank J. Lexa, M.D
Thanks!