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Driving Top Performance: What Are the Defining Metrics?. Sandy Elsass, President J.M. Woodworth RRG, Inc. Joe White, CPA, Principal LarsonAllen LLP Imaging 100 March 23, 2009. Where are Imaging Centers Today?. Approximately 5,114 diagnostic imaging centers in the US in 2006 [1].

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Driving top performance what are the defining metrics l.jpg

Driving Top Performance: What Are the Defining Metrics?

Sandy Elsass, President

J.M. Woodworth RRG, Inc.

Joe White, CPA, Principal

LarsonAllen LLP

Imaging 100

March 23, 2009


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Where are Imaging Centers Today?

Approximately 5,114 diagnostic imaging centers in the US in 2006[1]

[1] US Census Bureau


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Growth

  • Between 2002 and 2006, radiologists’ share of total imaging payments declined by 2.2% per year while the shares for other providers increased. For example:

    • Other specialty's’ share of payments grew by 3.2% per year

    • Independent diagnostic testing facilities grew by 3.0% per year, and

    • Cardiology by 2.4% per year. [4]

      [4] MedPAC A Data Book: Health care spending and the Medicare program, June 2008


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Number of centers and volume of scans

General

  • Imaging services paid for under physician fee schedule grew by 61 % from 2000 to 2005 (compared to 31% growth in physician services overall) [5]

  • Most costly services – MRI, CT and nuclear medicine – studies grew fastest [5]

  • Per enrollee cost for imaging services increased from $229(1997) to $463 (2006) in a study conducted in Washington State. [6]

    [5] Winter, Ariel and Nancy Ray, “Paying Accurately for Imaging Services In Medicare.” Health Affairs Vol. 27, No. 6 pp. 1479 -1490

    [6] Smith-Bindman, Rebecca, Diana L. Miglioretti, and Eric B. Larson, “Rising Use of Diagnostic Medical Imaging In a Large Integrated Health System.” Health Affairs, Vol. 27, No. 6, pp. 1491 - 1502


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Medicare spending

  • Imaging services paid for under the physician fee schedule doubled to $12.3 billion and resulted in increased Part B premiums -- $34 increase between 2000 & 2006 attributable to physician fee schedule imaging services for Medicare beneficiaries

  • Nearly 50% of $58B Medicare spent on physician fee schedule was for practice expense, which includes imaging and other medical equipment

  • Imaging spending breakdown:

    • 19% of MRI

    • 18% for Standard

    • 17% for CTs

    • 14% for Nuclear Medicine

    • 14% for echocardiography

    • 12% Ultrasound




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MRI in Tennessee

  • 7000 sites[8]

  • Number of scans has tripled[9]

  • From 2003-07, MRI growth was only 3% per year compared to 15% per year growth from 1999 to 2003[10]

  • 173 scans per 1000 Medicare beneficiaries in 2005 [11] vs. 0 scans per 1000 Medicare beneficiaries in 1985 vs. 50 scans per 1000 in 1995

    [8], [9], [11] Baker, Laurence C.; Scott W. Atlas, and Christopher C. Afendulis. “ Expanded Use of Imaging Technology And The Challenge of Measuring Value.” Health Affairs, Vol. 27, No. 6

    [10] Avalere report “Diagnostic Imaging: Spending Trends and the Increasing Use of Appropriateness Criteria and Accreditation”


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MRI in Tennessee

  • Avg. Medicare payment = $713 [12]

  • MRI scanners are used 91% of the time based upon a six-market survey of 133 physician offices and freestanding imaging centers in: Boston, Miami, Greenville, SC; Minneapolis; Phoenix and Orange County, CA[13]

    [12]Baker, Laurence C.; Scott W. Atlas, and Christopher C. Afendulis. “ Expanded Use of Imaging Technology And The Challenge of Measuring Value.” Health Affairs, Vol. 27, No. 6

    [13] Winter, Ariel and Nancy Ray, “Paying Accurately for Imaging Services In Medicare.” Health Affairs Vol. 27, No. 6 pp. 1479 -1490


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CT in Tennessee

  • 10,000+ units nationally [14]

  • 2200 new procedures per year between 1995-2004[15]

  • 547 CT scans per 1000 Medicare beneficiaries in 2005 (doubled from 1995) [16]

    [14], [15], [16] Baker, Laurence C.; Scott W. Atlas, and Christopher C. Afendulis. “ Expanded Use of Imaging Technology And The Challenge of Measuring Value.” Health Affairs, Vol. 27, No. 6


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CT in Tennessee

  • Avg. Medicare payment = $308 [17]

  • CT scanners are used 73% of the time on average based upon a six-marker survey of 133 physician offices and freestanding imaging centers in: Boston, Miami, Greenville, SC; Minneapolis; Phoenix and Orange County, CA[18]

    [17] Baker, Laurence C.; Scott W. Atlas, and Christopher C. Afendulis. “ Expanded Use of Imaging Technology And The Challenge of Measuring Value.” Health Affairs, Vol. 27, No. 6

    [18] Winter, Ariel and Nancy Ray, “Paying Accurately for Imaging Services In Medicare.” Health Affairs Vol. 27, No. 6 pp. 1479 -1490


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DRA in Tennessee

“DRA cuts drove reimbursement below replacement cost for equipment.”


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Future Medicare Payment Methodologies in Tennessee

Questions being raised about whether Medicare is overpaying and if this drove the proliferation of imaging centers in the US.

  • By 2010, CMS will complete all RVU changes for physician work, and direct and indirect practice expenses for physician services.

    • 9% reduction in practice expense RVUs for imaging services. [23]

    • 8% reduction for major procedures [24]

    • 7% increase for practice expense RVUs for evaluation and management (E&M) [25]

    • 3% increase for other (nonmajor) procedures and tests[26]

      [23], [24]. [25], [26] Winter, Ariel and Nancy Ray, “Paying Accurately for Imaging Services In Medicare.” Health Affairs Vol. 27, No. 6 pp. 1479 -1490


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MedPAC in Tennessee

  • “Proposed Medicare cuts are based upon bad data; they are throwing away all the work done on RVUs.” – Bob Baumgarner, CDI

  • “If approved, it is estimated to result in a 25% decrease in the technical component of Medicare imaging payments.” – Doug Smith, Barrington Lakes

  • Negative correlation between equipment utilization rate and Medicare’s technical component payment (particularly for procedures with expensive equipment). A higher utilization rate means more procedures are being done, which lowers the equipment cost per scan and decreases the technical component (total estimated cost per procedure). At a utilization rate of 90%, it is estimated that MRI and CT payments would be cut by 40%.[27]

    [27] Michael R. Mabry, Executive Director, Radiology Business Management Association in an email sent to RBMA Practice Management Forum on January 21, 2009.


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Obama’s FY2010 Budget Proposal (2/27/09) in Tennessee

  • Proposal: “Ensure that Medicare makes appropriate payments for imaging services through the use of radiology benefit managers.”

    • GAO recommended strategy based upon private sector’s successful use of prior authorization/RBMs

    • Estimated to save $70M over 5 years, $260M in 10 years through the use of prior authorization

    • Legislation is unclear about to whom (ordering physicians vs. physicians with financial interest) or to which facilities (hospitals vs. outpatient clinics) prior authorization will apply

    • Industry would prefer use of “appropriateness criteria” as envisioned by pilot program provision in Medicare Improvements for Patients and Providers Act of 2008


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Commercial Insurers in Tennessee

Commercial Insurers’ approaches to Independent Imaging Centers benefit varies state by state

“You have to fight plans to get them to pay you right. In some markets, that means putting a gun to their head before they will pay you.” –Anonymous


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Commercial Payors in Tennessee

  • RBMs pushing folks from hospitals to imaging centers because it is cheaper.

  • Some plans in some states are offering “take it or leave it” rates

    • Doug Smith in reference to Highmark in Pennsylvania

    • Susan Cox, OIA confirms seeing it in several places.

  • In MI & MD, state health plans and some commercial carriers are establishing thresholds for an imaging center to be in the plan’s network. (Doug Smith)

  • Health plans in a number of states (IL, OH, IN, MS, NY, MI and others) are using “patient steering mechanisms” to drive utilization by offering patients lower co-pays and deductibles for using certain providers. (Doug Smith)


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Commercial Payors in Tennessee

Hospitals’ leverage with insurers usually places independent imaging centers at a disadvantage.

  • Hospitals can threaten to drop out of insurer’s network, if the plan doesn’t accept their conditions of participation – rates.

  • Rob Peter to Pay Paul: Insurers claim they must slash reimbursement to independent imaging centers to make up for steep increases they must pay to hospitals for imaging services.

  • Example of an exception: Hospitals used its leverage to insist that insurers reimburse their outpatient imaging center the same as the hospital.


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Allowable by Zip Code in Tennessee

Source LarsonAllen – Compiled from Ingenix Software


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Ranking- The Index in Tennessee


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Trends: Where are Imaging Centers headed? in Tennessee

Volume is declining

“Is anybody else seeing their volumes down?”

RBMA list serve posting

  • Fewer elective services due to the economy and imaging services are often considered elective.

  • Given the slumping economy and patients’ increasing responsibility to pay a larger portion of the cost of services due to high deductibles, co-insurance or co-payments, imaging centers are seeing declining volumes.

  • Hospitals and imaging centers alike are experiencing a “traffic slowdown.”

  • Estimated 8-15% decrease and even greater decline in elective procedures. People are “living with the pain.”

  • Exception: Volume per imaging center continues to grow in those markets with CON laws where the number of centers is restricted.


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Accreditation in Tennessee

  • Mandatory Accreditation in 2012: The American College of Radiologists negotiated mandatory accreditation in lieu of further cuts and to test the use of appropriateness criteria in 2010 for Medicare program. Move away from IDTF?

    • Appears to be a contracting bias against IDTFs in areas with a lot of competition (Doug Smith)

    • Some Imaging Centers are moving toward more physician-owned centers where the radiologist submits a global bill and pays a management fee.


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Imaging Equipment in Tennessee

Imaging equipment vendors are trying to entice imaging centers in these economic times by:

  • Lowering prices (i.e., Phillips, GE, Siemens)

    • Phillips and GE introduced low-cost, high-performance units

    • Siemens 1.5T Essenza price is less than $1M

  • Designing new, lower cost equipment

    • Siemens offering entry-level, upgradeable gamma camera

    • Toshiba’s Aquilion Premium (160-channel CT scanner) can be upgraded in the field to its 320-channel Aquilion One.


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The Consumer in Tennessee

  • High deductibles, co-payments, co-insurance.

  • Customers asking, “What is your price?”

  • TV advertising campaign that states the hospital charges 3 times their imaging center’s price for the same scan; Why would you go to the hospital?

  • Same imaging center offers customers preliminary results of their scan before they leave the center.

    • If the news is bad, they consult with the referring physician first to see if s/he wants to deliver the news or have this done by center staff.


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Medicare Spending Per Beneficiary - 2005 in Tennessee

$10,300 to13,900

$8,600 to 10,300

$7,800 to $8,600

$6,900 to 7,800

$5,200 to 6,900

Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.

Note: The data are for Medicare spending per beneficiary in the fee-for-service program on the basis of beneficiaries’ residences and adjusted for age, sex, and race. The geographic unit is the hospital referral region, as defined by the Dartmouth Atlas of Health Care. Areas labeled "Not Populated" include places without residents, such as national parks, forests, lakes, and islands.


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Mayo Clinic in Tennessee

  • $6,900,000,000 in revenue

  • $200,000,000 net income

  • $3,000,000,000 in net assets

  • $55,000,000 in interest and dividends, $120,000,000 capital gains

  • $265,000,000 in contributions in 2005;$373,000,000 in 2007

  • $1,600,000,000 endowment as of 12/31/07

Source: www.guidestar.org


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Cleveland Clinic Foundation in Tennessee

  • 2006 Data

  • $1,900,000,000 in equity

  • $66,000,000 public support

  • $54,000,000 indirect public support

  • $91,000,000 in grants

Source: www.guidestar.org



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Major equipment vendors won’t even finance own equipment. in Tennessee

More upfront capital is required for new acquisitions or projects. This is the result of not only the economy but the fact that imaging centers are going under and now pose a greater financial risk.

Capital Markets


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Interest Rates in Tennessee



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Metrics of Top Performers in Tennessee

  • Customer satisfaction: patient and referring physician

    • “Retail-focused, patient-friendly needs to be part of the culture.” - Doug Smith

    • All surveyed centers focus heavily on patient satisfaction surveys. Some Centers ask each patient at every visit to complete a survey.

  • Strong partner: Needs to have influence in the given market.

  • Same store sales growth year to year

  • Number of new referral sources monthly


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Metrics of Top Performers in Tennessee

  • Turnaround time – drives referrals

    • Norm = 2-4 hours

    • Best practice = 2 hours or less (Doug Smith)

    • OIA facilities goal is 24-hour turnaround or less for most centers and studies

      • MRIs are faster

      • Mammography is quick

  • Expenses per CPT code/ profitability per modality

    • Important to understand where the profitable modalities are, even if you keep the losers.

    • “This needs to be a focus of any successful practice and needs to be tracked down to the CPT code level.” Many of the chain imaging centers are just starting to do this.– Doug Smith


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Metrics of Top Performers in Tennessee

  • Billing Cost per procedure

    Based upon RBMA 2007 Imaging Center Performance Survey Results:

    • Mean appears to have increased significantly between 2004 and 2005 ($6.95 to $10.75)

    • Range is $5.40 for Top performers to $15.87 for centers in the 25th percentile

    • The 2007 Mean was $10.38.


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Metrics of Top Performers in Tennessee

  • # of Procedures per Imaging Machine

    Example:

    • Pre-DRA needed 4 – 4.5 MRIs per day

    • Post – DRA need 8.5 -9.5 MRIs per day to break even.


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Metrics of Top Performers in Tennessee

  • # of Procedures per Tech


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Metrics of Top Performers in Tennessee

  • Total RVUs per Imaging Machine.


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Critical Success Factors in Tennessee

  • Multi-modality

  • Community/strategic partnerships: Strong partner in the market.

  • Volume/demand in the community: Is there a backlog in the market?


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Critical Success Factors in Tennessee

  • Strong IT system – EMR, teleradiology, and physician ordering

  • Referrals or collaborative relationships with all constituents including payer, patient and referring physicians.

    • Who refers depends on the market, it may be the physician (e.g., Virginia), the patient (e.g. Philadelphia), or the “gals up front” in the doctor’s office - Susan Cox, OIA


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Critical Success Factors in Tennessee

  • Turnaround times

  • Rates from insurers: often not known until days before opening; vary significantly by market even though markets may only be a few miles down the road (Susan Cox, OIA)

  • Good data/benchmarking drives improved performance and greater profitability:

    • Compare to other imaging centers within your group, state or nationally.

    • Understand billing cycle, what you should be paid by insurers, what needs to be documented to be paid.


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Critical Success Factors in Tennessee

In other words, customer service – patients, physicians -- that leads to referrals is the key.

For example, if your competition’s turnaround time is better and they have an integrated IT system that allows the referring physician to submit an order online and receive the results through a portal before the patient leaves the imaging center, your competition will likely get more referrals and therefore, increased volume.


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Key Factors Influencing a Diagnostic Imaging in TennesseeCenter’s Market Position

What is your differentiator?

What is your value proposition?

  • Volume

    • Should only enter the market if hospital and existing imaging centers can’t meet the current demand – Doug Smith.


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Key Factors Influencing a Diagnostic Imaging Center’s Market Position

  • Referrals/ number of referral sources

    • “This is attained through better equipment, better turnaround time, and quality; there is no price competition, as price is set by Medicare and other prices are a derivation of that.” – Anonymous

    • As market tightens, some imaging centers are employing unique and sometimes questionable marketing strategies.

    • Contests for physician offices: the office with most referrals will receive a restaurant gift certificate for all office staff and physicians.

  • Multi-modality vs. single modality center

    • Some states are denying accreditation to imaging centers that don’t meet certain criteria (e.g., offering at least five modalities).


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Key Factors Influencing a Diagnostic Imaging Center’s Market Position

Patient experience:

  • “If the patient has a bad experience, they will tell the referring physician and that can result in fewer referrals to your center.” – Doug Smith

  • Look at every aspect of the experience for improvement, such as:

    • Hours of operation: Evenings, weekends, early morning hours to accommodate work schedules

    • Ease of scheduling appointment

    • Well-lit, free parking

    • Patient feels welcome

    • Clean center

    • Onsite preliminary results

    • Physician access to study before patient leaves center, electronic portal


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Key Factors Influencing a Diagnostic Imaging Center’s Market Position

  • Quality, engaged radiologists

    • Sub-specialized

    • Personal, professional and financial investment in the business

  • Turnaround time: quicker than the competition

  • Price – becoming more of a factor as consumers bear more of financial burden of care (high deductibles/co-pays/OOP costs) - Doug Smith

  • Competitors in the geographic area – What is your differentiator? How are you different?


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Key Factors Influencing Clinical Outcomes Market Position

  • Quality of radiologists: sub-specialized, fellowship-trained

  • High quality, accredited equipment– how many slices? Right equipment for need


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Key Financial Benchmarks of Top Performers Market Position

  • “Imaging Centers are high, fixed-cost businesses… Margin comes from cost and price improvement and maxing out utilization” -- Doug Smith, Barrington Lakes

  • “Be more deliberative about necessity of equipment capital costs. Don’t buy new equipment just to have new equipment…might be able to achieve goals by merely upgrading existing equipment.” – Doug Smith

  • “Just reducing operational costs is not enough, if no comfort in the top line.” – Doug Smith

  • “Metrics have a growing importance in this economy. However, the problem is getting good data [benchmarks].” – Richard Townley, AGI

  • “Imaging Centers need this information [benchmarking data] to demonstrate their value to payers.” - Richard Townley, AGI; suggest starting by tracking your own centers data year over year.


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How does your Imaging Center compare? Market Position2007 Mean Volume

Source RBMA Imaging Center Survey 2007:


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How does your Imaging Center compare? 2007 Volume for Imaging Centers in the 75th Percentile

Source:

Source RBMA Imaging Center Survey 2007:


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How does your Imaging Center compare? 2007 Volume for Imaging Centers in the 25th Percentile

Source:

Source RBMA Imaging Center Survey 2007:


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Salaries & Benefits Imaging Centers in the 25th Percentile

Source:

Source RBMA Imaging Center Survey 2007:


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# of CPT codes billed per FTE Tech Imaging Centers in the 25th Percentile

Source RBMA Imaging Center Survey 2007:


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# of CPT Codes Billed per imaging machine Imaging Centers in the 25th Percentile

Source RBMA Imaging Center Survey 2007:


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Total RVU per imaging machine Imaging Centers in the 25th Percentile

Source RBMA Imaging Center Survey 2007:


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The Importance of Knowing & Managing Your Center’s Costs Imaging Centers in the 25th Percentile

“An imaging center chain had a net of roughly 30% prior to DRA. After DRA, their net dropped to approximately 10%.

By implementing a plan that looked at the costs of discreet units of service, they were able to identify which services were profitable and which ones weren’t.

They focused their business development efforts on profitable services and within 1-2 years their net had climbed back to an acceptable level”


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The Importance of Knowing & Managing Your Center’s Costs Imaging Centers in the 25th Percentile

Let’s look at five areas where per procedure costs vary significantly among Imaging Centers to demonstrate how an imaging center could improve its bottom line:


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What are Other Imaging Centers Doing Successfully? Imaging Centers in the 25th Percentile

Organizational Culture: The Customer Experience

  • Retail-focused patient experience “from the parking lot to the front desk to the techs to the radiologists need to be more patient friendly”, Doug Smith, Barrington Lakes

    • Windows in all imaging rooms so patients can see outside (CDI)

    • Patients permitted to bring iPod or own music to imaging room (CDI)

    • Convenient scheduling process

    • Respect patient’s time: short wait times

    • Offering financing options to patients (Barrington)

    • Extended Hours of Operation = More patient convenience (Barrington, Metro Imaging)

    • Customer advocates to help customers determine their out of pocket costs based upon their insurance coverage, deductibles, etc. (CDI)

    • Metro Imaging in St. Louis, MO offers its OnSite Results program where patients can receive preliminary findings before they leave the imaging center.


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What are Other Imaging Centers Doing Successfully? Imaging Centers in the 25th Percentile

Organizational Culture: The Customer Experience

  • Turnaround times:

    • Two hours or less turnaround time on reports for most aggressive imaging centers

    • OnSite preliminary results for patients (Metro Imaging, St. Louis, MO)

    • Physician access to findings by the time patient leaves the center. (OIA)


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What are Other Imaging Centers Doing Successfully? Imaging Centers in the 25th Percentile

Organizational culture: Customer Experience

  • All staff trained in Disney customer service model (CDI) – Metro Imaging in St. Louis, MO has a “Disney-oriented culture.”[28]

  • Corporate office conducts appearance and safety checks of all newly-acquired facilities to make sure environment is pleasing to customer/patient (CDI) – No boxes of files in the hallway; patients don’t need to see that…

  • Staff rewarded for customer-focus: Quarterly bonuses provided based upon: Volume, Cost, Patient Satisfaction and Profitability of imaging center - “Staff is rewarded when the center makes money.” – Bob Baumgarner and Jim Stanley, CDI.

  • Collections’ staff reward system for meeting collections targets, including: jeans days, cash, activity days, or time off. (OIA)

    [28] Christine Keefe, Metro Imaging profile by Tina DuBuque; St. Louis Business Journal, June 6, 2008


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What are Other Imaging Centers Doing Successfully? Imaging Centers in the 25th Percentile

Operations

  • Tracking cost per unit of service delivered

  • Fully-integrated IT system with Electronic Medical Record, teleradiology for electronic transfer of images, and on-line physician ordering with built in pre-authorization and scheduling. (CDI)

  • Peer review of radiologists and opportunities to learn from national pockets of expertise (CDI)


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Pillar 1: Imaging Centers in the 25th Percentile

Pillar 2:

Pillar 3:

Pillar 4:

Pillar 5:

Pillar 6:

Provide Best Patient Experience

Achieve Market Leading Quality

Earn Employee Pride

Enhance Physician Engagement & Pride

Grow Patient Service Volumes

Strengthen Economic Vitality

Performance Pillars:

The Strategy Planning Process Suggests 3-5 Imperatives to be Achieved in each of These Six Performance Pillars


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In Conclusion Imaging Centers in the 25th Percentile

The economics of imaging centers will continue to be challenging in the future.

Market Leaders who:

  • are efficient,

  • have benchmark data,

  • have market data,

  • have quality indicators

  • access to affordable capital

  • are customer focused

  • have strategic partners

  • Will be very successful!


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Thank you…. Imaging Centers in the 25th Percentile

Thanks for including us in your conference today.

Joseph White

jpwhite@larsonallen.com

Sandy Elsass

selsass@usre.com