Challenges Trends and Strategies in Modern Healthcare

Ryan Garland, MHA BS RT(R), is a dedicated healthcare professional serving as the Service Line Director for Radiology, Imaging, and Respiratory at Northshore Edward-Elmhurst Health. With a background in Radiologic Technology and a Master's in Healthcare Administration, he brings expertise in managing and advancing crucial medical imaging and respiratory services.

Please tell our readers about your journey in the industry.

Over the course of my 23-year journey in the industry, I began as an X-ray tech, ventured into special procedures, and gradually progressed to roles such as supervisor, manager, and system manager overseeing multiple hospitals. Subsequently, I ascended to the position of director, followed by system director, and eventually took on the role of a service line director, overseeing radiology, imaging, and respiratory services for two hospitals and 17 satellite facilities. We conduct nearly 600,000 imaging procedures annually, handle level two trauma cases, and maintain ACR accreditation across our hospitals and campuses for quality assurance.

What are some of the challenges and recent trends existing in the marketplace today?

One of the prevailing challenges in the current marketplace is the anticipated shift away from the fee-for-service model, where organizations incentivize providers based on the volume of services provided, such as ordering imaging. The industry is moving towards a population health approach, where healthcare providers are remunerated based on the number of patients they serve within a specific population. However, this transition has yet to fully materialize.

In addition, there is a growing trend among insurance companies to mandate patients to opt for more cost-effective care alternatives. This often involves steering patients towards facilities with lower out-of-pocket costs, such as independent imaging centers rather than hospital outpatient departments. Responding to this trend, some organizations have engaged in joint ventures to become majority shareholders in standalone facilities, offering a more affordable option for certain patients. This strategic move aims to cater to individuals directed towards lower-cost care by payers or those who may be self-paying and seeking a more economical solution within the network.

This diversified approach is crucial to address concerns related to patients potentially forgoing necessary medical procedures due to financial constraints. By adapting and expanding their portfolio of care options, organizations can ensure that patients, particularly those unable to afford procedures in a hospital setting, still have access to essential testing through more cost-effective alternatives. Ultimately, this shift in the healthcare model aims to enhance patient outcomes and contribute to the overall effectiveness of care delivery.

What is your piece of advice for your peers and aspiring professionals in the industry to navigate the aforementioned changes?

The PAMA Act included a provision for automated use criteria, which was originally slated to be implemented about three years ago. However, this has consistently been delayed. The requirement was for a clinical decision support system to be in place, ensuring thorough clinical reasoning before a payer would approve an order made by an ordering physician. Essentially, it acted as an additional layer of pre-authorization, particularly for high-end imaging, such as CT, MRI, nuclear, and PET scans. While pre-authorization was also required for certain ultrasound imaging, this has been discontinued for Blue Cross Blue Shield community patients.

Although we initially prepared for the implementation of the Automated Use Criteria (AUC), it has now been indefinitely postponed. This news has been well-received by imaging managers and administrators nationwide, as the initiative posed significant challenges in terms of implementation. Despite the frustration caused by the hours and resources invested in anticipation of its activation, there is also relief that the potential penalties for non-compliance—where either the patient or the radiology department would not receive payment—have been put on hold. The responsibility for implementing AUC rested with the ordering provider, but there was a lack of incentive for them to adhere to the criteria. In light of the indefinite postponement, there is a collective sense of relief among industry professionals.