Read Advisory Board's take: Key takeaways for providers and imaging centers

Upon learning that roughly half of employees who went to specialized hospitals for back surgery found out they didn't actually need it, Walmart has started encouraging its workers to go to high-quality imaging centers, to ensure better, more accurate scans, Phil Galewitz reports for Kaiser Health News.

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About Walmart's COE program

About six years ago, Walmart launched its Centers of Excellence (COE) program, which aims to control mounting health care costs and improve health outcomes.

Under the program, Walmart covers the full cost of travel and treatment for employees seeking certain cancer evaluations, organ transplants, and common surgeries such as heart, hip, knee replacement, and spinal procedures. In January, Walmart made the COE program a requirement for employees seeking spinal surgery.

And Walmart executives say the COE program has been a major success. Internal data show between 2015 and 2018 nearly half of the Walmart employees who had spinal surgery or a medical evaluation without surgery did so at a COE site. Of those who did have a spinal surgery, the patients who did so at a COE site spent 14% less time in the hospital and faced a 95% lower risk of readmission than those treated elsewhere.

How second opinions at COE sites helped Walmart—and employees

In addition, Walmart has found that about half of patients who went to COE sites for back surgery turned out not to need the procedure after all. In many of those cases, patients had gone to a local provider who recommended surgery before seeking a second opinion at one of Walmart's COE sites, where providers were able to find less invasive, but equally effective, treatment options.

Studies have shown that each workday in a typical radiology practice comes with a 3% to 5% error rate, Galewitz writes, though other research has found error rates can reach up to 30% on more advanced images like CT scans and MRIs.

According to Vijay Rao, chair of radiology at Thomas Jefferson University Hospital, these errors can happen for a variety of reasons. For example, a radiologist may not be able to devote enough time to reading each image. "It's just a lot of data that crosses your eye and there is human fatigue, interruptions, and errors are bound to happen," Rao said.

In addition, sometimes technicians may not position the patient correctly in the imaging machine, or a radiologist may not have enough expertise or experience to accurate read the image, Rao said.

Ready-to-present slides: Imaging market trends for 2019

Walmart's latest push

With those findings in mind, since March, Walmart has been encouraging employees to seek diagnostic imaging at one of its 800 high-quality imaging centers.

Lisa Woods, senior director of benefits design for Walmart, said, "A quality MRI or CT scan can improve the accuracy of diagnoses early in the care journey, helping create the correct treatment plan with the best opportunity for recovery." She added, "The goal is to give associates the best chance to get better, and that starts with the right diagnosis."

The list of imaging centers was developed for Walmart by Covera Health, a health analytics company. To make the list of providers, Covera had independent radiologists evaluate a sampling of patient care data for each imaging center to determine their error rates. Then, using statistical modeling along with other information on equipment, physicians, and the centers' use of industry-accepted patient protocols, Covera was able to assess each center's rates of accuracy.

As a condition of being a part of the list, each imaging center has agreed to routinely send samples of patient images and reports to Covera.

According to Covera CEO Ron Vianu, the company expects to have about 1,500 imaging centers on the list by the end of the year.

Walmart employees are not required to use one of listed imaging facilities. However, if they choose not to, they do have to pick up more of the bill themselves (Galewitz, Kaiser Health News, 5/15).

Advisory Board's take: For hospital leaders

Rob Lazerow, Managing Director, Health Care Advisory Board

Walmart's new program to identify and direct volumes to preferred imaging providers builds on the success of their existing orthopedics Centers of Excellent (COE) program. As this new imaging-focused model matures, I'm curious to see if it will ultimately follow the same evolutionary path as the orthopedics model. For that program, Walmart started by waiving employee's portion of the bill for select orthopedic procedures at the COEs—effectively making them free—to encourage employees to choose a preferred site. Next, they raised the price of seeing a non-COE hospital to further increase the pricing differential. Finally, they mandated that employees only visit COE organizations this year, rendering all other hospitals out-of-network for these orthopedic procedures.

Regardless of exactly how the imaging program matures, hospital and health system leaders need to prepare for two realities:

1. Employers are growing more assertive in controlling their health spending. Shifting employees to high-deductible plans (HDHPs) did not yield sufficient savings, so employers are now layering more active steerage models—including the COE approach—on top of HDHPs. Providers must recognize that employers are asserting more control over employees and recognize their emerging role as drivers of market share.
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3. Given this newfound activism, leaders need to develop a clear and compelling value proposition for employers. Employers (and the third-party network aggregators who help assemble these custom networks behind the scenes, in this case Covera Health) have more control over today's spending. Regional or national COEs have the potential to redraw the traditional lines of competition, and hospitals and health systems stand to gain—or lose—lucrative volumes as a result.

To learn more about engaging employers and wining lucrative volumes, download the second volume of our new three-part series on Re-igniting the Growth Engine, Winning Increased Share of Lucrative Patient Volumes.

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Advisory Board's take: For imaging providers

Matt Morrill, Senior Consultant, Imaging Performance Partnership

Steerage (trying to influence a patient or provider's choice of imaging provider) is certainly nothing new in the imaging field—though its intensity has stepped up dramatically recently with actions from United Healthcare and Anthem to deny covering some imaging in HOPD settings. To date, however, this steerage has been based solely on cost and aimed at addressing the wide price variation we often see with outpatient imaging exams (like lower limb MRIs).

What's game changing about Walmart and Covera Health's imaging Center of Excellence (COE) partnership is that it focuses on imaging quality, not cost. And quality in imaging is something that's been historically difficult to define—ask 10 radiology directors what quality means, and you'll get 10 different answers. In fact, the prevailing view is that services like MRIs and CTs are essentially commodities. In other words, an MRI at one provider is basically interchangeable with an MRI from another.

If Covera Health's solution—which uses an algorithm to determine diagnostic error rates—can truly differentiate imaging centers based on quality, it would go a long way in completing the hard-to-define value equation (quality/cost) for imaging. High-quality imaging providers may be able to push back against price cuts or even command a price premium. On the other hand, high-priced, low-quality imaging providers could be exposed and possibly pushed out of the market. Time will tell if Covera's solution itself can accomplish these goals, but in the near-term, this is an exciting development on the march to transparency in imaging.

What can imaging providers do in the meantime?

1. Register for the Imaging Performance Partnership's National Meeting, which will host several sessions focused on navigating payer and employer steerage;
2. Use our Consumer Results Portal to explore how consumers consider quality metrics and other drivers of patient choice; and
3. Use our imaging metric selection tool to find quality metrics to track, or meet internally with stakeholders to devise a strategy for defining imaging quality at your organization.

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