There is a popular perception that patients at public hospitals tend to receive lower quality care than those at privately owned healthcare organizations.
Public hospitals—relying on titrated budgets, due to increasingly scarce Medicaid funding —are correctly perceived as being at a disadvantage. These hospitals often maintain older capital equipment and tend to be at the mercy of people that make decisions on the basis of politics and not necessarily on the basis of care, need, nor even, in some cases, standard of care.
While many undeniable indicators validate this conclusion, I hope the underlying premise is flawed. Instead of seeking the lowest common denominator, I believe the moral imperative is that public sector hospitals should define and exemplify what excellence should be.
Today, more than ever, imaging plays a central role in the patient’s healthcare journey. In fact, very few patients who come into a hospital don’t need an imaging exam, and oftentimes, their treatment is dependent on the exam’s findings. However, there’s no denying that healthcare at a safety-net facility poses significant financial challenges; simply, the cost of providing care to the Medicaid population exceeds the reimbursement from providing care.
At Hennepin’s Upstream Health Innovations, our goal is to move care upstream: see patients in the ambulatory world where the per patient “expense minus revenue” is far less costly to the healthcare system than in the emergency room or in the hospital. Regardless of fee-for-service or managed care, the answer is the same for Medicaid: control costs by moving care upstream.
The role of imaging in redefining patient care standards
Across the nation, as hospitals are prompted to do more with less, and to do so more efficiently than ever, the challenges placed on imaging equipment have also increased substantially. Despite efforts to cost contain radiology, imaging has become indispensable to medicine, driving diagnosis, prognosis and treatment. Moreover, this trend will only continue as advancements in imaging technologies continue, provided such advancements positively impact health outcomes.
With this increasing role comes increasing responsibility: regardless of one’s reimbursement paradigm, equipment is expensive, and the justification for purchase – new or upgrade – needs to be grounded in reality. Among those realities are traditional factors: improved throughput, increased market share, new markets and replacement-required, all of which are used to support the ROI of an expensive capital outlay, such as a CT, MR or PET-CT scanner. The last of these, replacement-required, is often the bottom line for public sector, safety-net institutions that keep older equipment – and delay the introduction of technological advancements – far longer than do private and academic institutions. Additionally, for public sector institutions, again, regardless of fee-for-service or managed care, an often explicit goal is to increase market share of commercial pay patients.
To do this in the world of imaging, it is imperative that there be a perceived advantage, be it related to the equipment, the venue, the radiologists, the service, or patient satisfaction. At Hennepin, where Medicaid accounts for 52% of our patients, we have taken this challenge seriously, addressing each of these factors, partly to compete for commercial pay patients, but more explicitly, to set the bar of expectations. Specifically, we’ve focused on changing the perception of what it means to be a public hospital – demonstrating the influence of effective imaging technology to level the playing field between private and public, and prioritizing the patient experience above all.
When we invest in innovative equipment, higher-quality images are of course expected. However, in addition to the traditional considerations, today we are appropriately, also focused on outcomes: can we simplify insights and data gathering, can we not only enhance diagnostic confidence but introduce diagnostic certainty? Will we replace other costs if we add new technology? And, can we do this faster and improve the patient experience? In short, will these new technologies impact patients’ lives?
Imaging technology’s role in advancing patient care under a budget
In a trauma center’s radiology department, private or public, one of the most important pieces of equipment is the CT scanner. In the setting of trauma, seconds count, and the expectation is that the CT scanner must be extremely efficient (for greater throughput), reliable and that the software be easy-to-use. Beyond that, today’s CT scanner choice demands consideration of speed, detector length, reduced patient radiation and contrast dose, noise reduction, faster speed of reconstruction and minimizing tube cooling. And, in the last few years, the choice of CT scanners also now relates to spectral, or dual energy CT, which in many situations, offers a quantum leap from diagnostic confidence to diagnostic certainty.
At Hennepin, the acuity of patients and diseases that present to the CT scanners demands that our radiologists need to be both sensitive to life-threatening issues and specific about diagnoses. As a result, Hennepin benefits from the Philips IQon Spectral CT scanner which has fundamentally transformed our practice, much as it is fundamentally transforming medicine.
Until recently, some diagnoses have been challenging on conventional CT. For instance, differentiation of ischemic bowel, while sometimes possible, oftentimes is relatively silent on routine contrast-enhanced CT. With spectral, that diagnosis has become almost mundane – diagnoses can now be easily made, not only with confidence, but with certainty. In fact, many such diagnoses are now rather “binary” with the introduction of spectral CT.
Hennepin was the first Twin Cities health care facility to shift to spectral CT for most of its CT needs. Today, well over 70% of Hennepin’s CT scans are performed using a Philips IQon Spectral CT. Scanners are designed with a specific intention, be it speed, coverage or outcome. For our purposes, we’ve found that the IQon Spectral CT was designed as a spectral scanner from the ground up. This required decisions about tubes, anodes, rotation speed, detector length, reconstruction times, patient comfort, scanner software and image interpretation software. While decisions about one factor by definition impact other decisions, for our patients, the ability to always have spectral technology was the dominant factor and has proven to have had an immediate impact on patient care at Hennepin. For us, that is unequivocally the most important determinant.
Beyond CT, the choice of MR scanner is similarly important to a trauma center Iike Hennepin, albeit for slightly different reasons. For the outpatient MR scanners, Hennepin sought to make a statement about what can be achieved, if not expected, in the public sector. Situated immediately adjacent to two high utilizers of outpatient MR, the orthopedic clinic and cancer center, our goals were fairly clear. We needed not only a scanner that excelled at musculoskeletal imaging as well as routine imaging, but we needed the MR scanner to provide an incredible patient experience as well, so that we could successfully compete.
Moreover, we needed to dramatically enhance throughput, as we sought to try to offer “on-demand” MR scanning. To achieve that, we effectively needed to be able to complete MR scans in less than 15 minutes. As has been demonstrated elsewhere, approximately 15 minutes is the magic point, after which many patients start to fidget and wiggle, requiring repeat sequences and occasionally terminating exams prior to completion. Moreover, at that speed, we are finally able to accommodate “walk-ins” or “on-demand” scans.
Like the IQon Spectral CT, the Philips 3T MR Elition offered the right solution. While there are a host of advantages of this scanner, the introduction of Compressed SENSE has been game-changing. With this scanner, we routinely perform head scans in 9-10 minutes, spines in 11 minutes and joints in 12 minutes, reducing the chance of inconclusive images due to patient movement. To further improve the patient experience, we installed the Philips Ambient Experience, including the advanced head visor. Patients are consistently amazed and delighted by the immersive experience that Hennepin’s new outpatient MR offers.
The business case for investing in the patient experience
Patient-centered care is what we strive for. Importantly, if new technology is efficient and helps keep the patient calm and, if radiologists are able to make a difference with one scan, patients will leave not only satisfied – but also will become hospital ambassadors – as they spread the word about their experiences.
For public health care systems, it is well worth putting the time into setting a vision for what patient-centered care means to each stakeholder along the patient journey – from checking in at the front desk, to the waiting room, to the exam room, to rapid turnaround time and to offering a clear interpretation. As radiology departments rely on their imaging equipment to meet increasing demands, it is critical that technology supports the way radiologists work, and the way patients want to treated.
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