Trends in Health Care ReformCreating a growing need for physician extenders and efficiency in healthcare.Steven K. Zegar, RPA (CBRPA)BOD, CBRPAPresident, ISRPAPresident, ARPE

Topics for DiscussionThe Need for Health-Care Reform1. Entities in Health-Care2. Objectives for Reform3. Major areas of policy reform Universal and Socialized Health-Care1. NICE2. Universal Health Care SystemsEvolving Role for Physician Extenders1. History2. ARPE

The Need for Health-Care Reform

Universal and Socialized Health-Care

Evolving Role for Physician Extenders

The Need for Healthcare Reform“The greatest threat to America’s fiscal health is not Social Security. It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”President Barrack Obama March 2009

Entities in Health-Care Insurers don’t want competition from government.Physicians want caps on malpractice.Employers don’t want to be forced to offer medical coverage to workers

Insurers don’t want competition from government.

Physicians want caps on malpractice.

Employers don’t want to be forced to offer medical coverage to workers

Entities in Health-Care Hospitals want to stave off Medicare cutsDrug companies want to charge what the market will bearDevice companies want to limit the constraints to innovate and compete in the market place.

Hospitals want to stave off Medicare cuts

Drug companies want to charge what the market will bear

Device companies want to limit the constraints to innovate and compete in the market place.

Let’s face it we will always need medicine

Three Objectives for ReformMust secure coverage for all Americans

Three Objectives for Reform2. Must dramatically reduce the cost of health-careRural areas growingUnderserved areas are increasingPeople are doing more crazy things

Rural areas growing

Underserved areas are increasing

People are doing more crazy things

Three Objectives for Reform3. Must maintain or improve current levels of careDue to our legal system we still practice too much defensive medicineImaging is out of countrol

Due to our legal system we still practice too much defensive medicine

Imaging is out of countrol

Preventive medicine or preventive care Primary prevention avoids the development of a disease. Most population-based health promotion activities are primary preventive measures. Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptoms. Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease-related complications

Escalation of Health-Care CostsWe’re getting more and more intensive (sophisticated) treatments, but also the wrong services.The cost of services vary on a regional basis.We’re not doing enough prevention (17-33% of Americans are obese).We’re not managing diseases effectively. Lack of coordinated care among physicians.Lack of an adequate Health IT network.Labor represents the biggest cost, but 35% of it is in operational inefficiency, at a cost of $11 billion each year.

We’re getting more and more intensive (sophisticated) treatments, but also the wrong services.

The cost of services vary on a regional basis.

We’re not doing enough prevention (17-33% of Americans are obese).

We’re not managing diseases effectively.

Lack of coordinated care among physicians.

Lack of an adequate Health IT network.

Labor represents the biggest cost, but 35% of it is in operational inefficiency, at a cost of $11 billion each year.

Three Major Areas of Policy ReformMeasurement of Quality and EffectivenessEvidence basedBetter results at a lower costTransparent measuresPayment ReformFrom pay for reporting to pay for performance.Shared savings opportunities.Have to be able to measure.Benefit ReformPatient accountabilityIdea is to get patients to share in the savings.People will change their behavior if they see a financial benefit.

Measurement of Quality and Effectiveness

Evidence based

Better results at a lower cost

Transparent measures

Payment Reform

From pay for reporting to pay for performance.

Shared savings opportunities.

Have to be able to measure.

Benefit Reform

Patient accountability

Idea is to get patients to share in the savings.

People will change their behavior if they see a financial benefit.

Measurement of Quality and EffectivenessEvidence basedBetter resultsTransparent measures

Evidence based

Better results

Transparent measures

Public Reporting and Pay for Performance in Hospital Quality ImprovementABSTRACTBackground Public reporting and pay for performance are intendedto accelerate improvements in hospital care, yet little is knownabout the benefits of these methods of providing incentivesfor improving care.Methods We measured changes in adherence to 10 individual and4 composite measures of quality over a period of 2 years at613 hospitals that voluntarily reported information about thequality of care through a national public-reporting initiative,including 207 facilities that simultaneously participated ina pay-for-performance demonstration project funded by the Centersfor Medicare and Medicaid Services; we then compared the pay-for-performancehospitals with the 406 hospitals with public reporting only(control hospitals). We used multivariable modeling to estimatethe improvement attributable to financial incentives after adjustingfor baseline performance and other hospital characteristics.Results As compared with the control group, pay-for-performancehospitals showed greater improvement in all composite measuresof quality, including measures of care for heart failure, acutemyocardial infarction, and pneumonia and a composite of 10 measures.Baseline performance was inversely associated with improvement;in pay-for-performance hospitals, the improvement in the compositeof all 10 measures was 16.1% for hospitals in the lowest quintileof baseline performance and 1.9% for those in the highest quintile(P<0.001). After adjustments were made for differences inbaseline performance and other hospital characteristics, payfor performance was associated with improvements ranging from2.6 to 4.1% over the 2-year period.Conclusions Hospitals engaged in both public reporting and payfor performance achieved modestly greater improvements in qualitythan did hospitals engaged only in public reporting. Additionalresearch is required to determine whether different incentiveswould stimulate more improvement and whether the benefits ofthese programs outweigh their costs.Peter K. Lindenauer, M.D., M.Sc., Denise Remus, Ph.D., R.N., Sheila Roman, M.D., M.P.H., Michael B. Rothberg, M.D., M.P.H., Evan M. Benjamin, M.D., Allen Ma, Ph.D., and Dale W. Bratzler, D.O., M.P.H.

Payment ReformFrom pay for reporting to pay for performance.Shared savings opportunities.Have to be able to measure.

From pay for reporting to pay for performance.

Shared savings opportunities.

Have to be able to measure.

Benefit ReformPatient accountabilityIdea is to get patients to share in the savings.People will change their behavior if they see a financial benefit.

Patient accountability

Idea is to get patients

People will change their behavior if they see a financial benefit.

Leading causes of preventable deaths in the United States in the year 2000.Smoking 435,000 deaths or 18.1% of the total deathsOverweight and Obesity 365,000 deaths or 15.2% of the total deaths.Alcohol consumption 85,000 deaths or 3.5% of the total deaths.Infections 75,000 deaths or 3.1% of the total deaths.Toxic agents 55,000 deaths or 2.3% of the total deaths.Motor vehicle collisions 43,000 deaths or 1.8% of the total deaths.Incidents involving firearms 29,000 deaths or 1.2% of the total.Sexually transmitted infections 20,000 deaths or 0.8% of the total.Illicit use of drugs 17,000 deaths or 0.7% of the total deaths.

National Institute of Healthand Clinical Excellence (NICE)Created a decade agoEstablished to ensure that every British pound spent buys as many good years of good quality life as possible.Uses evidence of cost effectiveness to decide what to pay for.Addresses the question:“How much is life worth?”British government needed a standard method of rationingMany countries either influenced by NICE or setting up something similar.Congress is considering an institute that would compare the effectiveness of new medical technologies

Established to ensure that every British pound spent buys as many good years of good quality life as possible.

Uses evidence of cost effectiveness to decide what to pay for.

Addresses the question:“How much is life worth?”

British government needed a standard method of rationing

Many countries either influenced by NICE or setting up something similar.

Congress is considering an institute that would compare the effectiveness of new medical technologies

France & Universal Health-CareDominance of office-based private practice for ambulatory careThe mix of public and private hospitals, the widespread use of cost sharingThe predominant practice of direct payment from patient to doctor, and the reliance upon financing derived from payroll taxes - resemble elements of the U.S. health system.Practice liability is greatly diminished by a tort-averse legal systemMedical schools, although extremely competitive to enter, are tuition-free

Dominance of office-based private practice for ambulatory care

The mix of public and private hospitals, the widespread use of cost sharing

The predominant practice of direct payment from patient to doctor, and the reliance upon financing derived from payroll taxes - resemble elements of the U.S. health system.

Practice liability is greatly diminished by a tort-averse legal system

Medical schools, although extremely competitive to enter, are tuition-free

UK Universal Health-Care SystemUK began offering free health-care in 1948Health services employs 1.5M people (biggest employer in the country).Has tripled investment in the health infrastructure over the last 12 years.Has a budget of 100B Pounds and a deficit of 15B Pounds ($24M).NICE weeds out drugs that are too costly

Health services employs 1.5M people (biggest employer in the country).

Has tripled investment in the health infrastructure over the last 12 years.

Has a budget of 100B Pounds and a deficit of 15B Pounds ($24M).

NICE weeds out drugs that are too costly

Reform = Physician Shortage A study by the Robert Graham Center and the National Association of Community Health Centers concluded that 15,585 more primary-care providers would be needed in order for health centers to serve 30 million new patients. It takes six years to educate a nurse practitioner and a dozen years to produce a doctor. Even if Medicare funding for residency programs is increased, if medical schools increase their enrollments by the 30 percent recommended by the Association of American Medical Colleges and if financial incentives to enter primary care are put in place, it will take years to build the health-care system into the new model. The time for physician extenders of all medical backgrounds has come.

Where Physician Extenders PerformOperating room (OR) IR and clinical practiceIndependent practice without a physician present Independent practice with a physician in attendance Practicing “incident to” as attending physician

You will see more of them

Responsibilities of a Physician Extender1. Performs tasks usually performed by the physician2. Works under the supervision of a physicianCan provide initial and continuous patient care assessments4. Can perform a variety of procedures, including non-vascular invasive and vascular invasive

Professional Labels:An Evolutionary processRadiology Assistant – mid 1970sProgram conducted at University of Kentucky, Duke University and at Downstate University in NYPhysician Extender – early 1990sLabel first used by the PEW FoundationPrimary Care Provider – early 1990sReferenced in the PEW Foundation documents on changing the health care systemRadiology Practitioner – 1995-1996Title given at the ASRT Educational Consensus Conference Radiology Practitioner Assistant –1997Title selected by RPA students at Weber State University in 1997Radiologist Assistant – 2002 Title selected by ACR/ASRT/ARRT to closely align the position with the radiologist.

Practice in England1981 – RADS or “red dot” system1986 – Study on 1,628 patients, technologists had an error rate of 4.5%1991 – Research on 3, 994 patients demonstrated same results1995 – College of Radiographers policy1999 – Report on 11,322 trauma patients All reports demonstrated the capabilities of technologists to have a more active role.

Experience in the United States1969 – Technologists can perform fluoro exams as efficiently as radiology residents1975 and 1981– validated previous studies on technologists capable of doing fluoro1985 -- U of Texas study again validated the research1994 – UCLA Med Center – Mammographers can evaluate mammos as effectively as radiologists.

Specialization???CardiovascularNuclear Medicine Ultrasound MammographersYes, specialization will occur in the future.

Factors Affecting Changein Medical Imaging ServicesCommunity-based health care system instead of hospital focused systemExpansion to health care affiliates, both local and remote sites Changes in policies for reimbursementTeleradiology –resulting in expansion of practiceDemographic changes in society and in radiology

Recognition of Physician ExtendersA Physician Extender…Can contain costs...Increase efficiency…Provide quality patient care… Can perform many of the procedures physicians now perform…Provide a means of expansion…Is an efficient utilization of manpower.

Can contain costs...

Increase efficiency…

Provide quality patient care…

Can perform many of the procedures physicians now perform…

Provide a means of expansion…

Is an efficient utilization of manpower.

Development of the Academy for Radiology Physician Extenders The ARPE was developed to encompass all physician extenders in the radiology sciences. The ARPE board works closely with other societies in the development of educational conferences and workshops.The ARPE offers an annual educational symposium that offers up to date conference talks and hands-on vascular workshops.The ARPE will offer a yearly scholorships and educational grants for research

The ARPE was developed to encompass all physician extenders in the radiology sciences.

The ARPE board works closely with other societies in the development of educational conferences and workshops.

The ARPE offers an annual educational symposium that offers up to date conference talks and hands-on vascular workshops.

The ARPE will offer a yearly scholorships and educational grants for research

Academy for Radiology Physician ExtendersMISSION STATEMENT Education and experience are key elements to personal and professional growth, enhanced capabilities, and expansion of knowledge, leading to the primary responsibility of health professionals in providing quality patient care.

The 2009 ARPE Educational SymposiumWhat?? ARPE Educational SymposiumWhen?? October 1-3rd, 2009Where?? DoubleTree Hotel, Nashville, TNWhy?? To learn and gain hands on experience on current practices in the radiology sciences.

SummaryThe need for health-care reform is nowCoverage for all Americans will create a physician shortagePhysicain Extenders have proven

The Four Pillars of Health ReformPeter Orszag – Director of OMBHealth ReformFinancial incentives to provide better care & reduce unnecessary/ excessive careHealth Information TechnologyComparativeeffectivenessresearchPreventative and wellness efforts