Few practices these days can claim a pedigree that reaches back to the Great Generation, but Strategic Radiology’s newest practice, 44-member Asheville Radiology Associates, is one of them. Located in North Carolina’s western Blue Ridge Mountains in Asheville, county seat of Buncombe County, the practice was founded by three radiologists in 1944.

ARA’s growth over the years is a classic, textbook study of consolidation in independent radiology. The practice took a new name and a leap in size when Asheville’s two native groups merged in the mid-90s to form a 15-20-radiologist practice at the request of the two competing hospitals, also newly merged. Bryon Dickerson, MD, ARA president, joined the practice in 2002, fresh out of an MSK fellowship at Wake Forest University.

By the time Dickerson joined the group, ARA was using four disparate PACS and four different dictation systems that employed manual transcription. He spearheaded an initiative for unified PACS and dictation systems referred to as the Holy Grail.  Dickerson earned the confidence of his fellow shareholders when he managed to accomplish the integration, and ultimately was elected president in 2009.

Growth occurred several ways, Dickerson recalls.  “Early on, it was our reputation,” he says. “We were the largest group in Western North Carolina, and some of the regional hospitals were staffed by one- or two-person radiology groups, and they were feeling overwhelmed. They approached the group, and we ended up bringing them in by different mechanisms. Overall, we incorporated five hospitals that way.”

IT as Growth Engine

The relationships that were built while working with the hospital to implement a single reading and dictation platform also helped fuel the practice’s growth. When Mission Health became a system, many regional hospitals were already referring into the main campus through their connections with ARA radiologists. “The hospital CEO saw the consolidation trend and began scooping up these hospitals that had very strong ties to Mission because of our efforts,” Dickerson observes. “If we read a CT at one of these regional hospitals and there was acute appendicitis, the PCP wanted to know who to call, and we had the general surgeon’s pager number.”

Once Mission had captured those hospitals already serviced by ARA, the administration asked ARA to be the sole provider for Mission Health. “This was great for us and made it even easier to serve the small hospitals because Mission was supplying the IT backbone,” Dickerson recalls.

The imaging IT project offers a good example of the give-and-take required to build a successful relationship with a health system. The hospital deferred to the practice on IT choices, and ARA abandoned its request to create a IT joint venture when it became clear that bureaucratic processes would delay the launch of the project

While Mission Health picked up the tab for the PACS, ARA agreed to hire all of the system’s transcriptionists with the understanding that they would be paid severance from Mission Health and that ARA would replace them over time by technology. The original seven or so transcriptionists have evolved to a single editor and a voice recognition system, saving the hospital $600,000 the first year and providing a financially appealing transition to the new digital world.

A Culture of Quality

A cornerstone of the practice culture is quality, and Dickerson describes Mission Health as high-end academic without the large academic center. University of North Carolina Chapel Hill medical students rotate through Mission Health—called the Asheville campus—and ARA participates in the teaching program. “It’s not an overwhelming number of students, so it is a nice blend,” Dickerson says.

ARA has demonstrated its commitment to quality with the following quality milestones:

• One of the first practices in the country to adopt the American College of Radiology (ACR) eRadPeer peer-review program, maintaining the practice of reviewing at least 3% of all cases;
• The first practice in North Carolina to become accredited as a Breast Imaging Center of Excellence (BICOE), providing advanced breast imaging to patients, including MRI, breast tomosynthesis, automated breast ultrasound, and contrast-enhanced spectral mammography.
• The second site in North Carolina to become accredited by the ACR as a Diagnostic Imaging Center of Excellence (DICOE).  In 2015, ARA sold its outpatient imaging assets to Mission Health, and the system granted ARA a contract to manage imaging services.

“We think these accreditation and quality standards will become more important as we enter into MIPS/MACRA quality payment programs,” Dickerson asserts. “Quality standards will gain importance not only for our patients but for reimbursement as well, which will make it possible for us to continue to lead at the vanguard of emerging technologies.”

Subspecialized Coverage

Another component of ARA’s quality commitment to patients, referrers and its health system is a deeply subspecialized practice. A comprehensive stroke center of excellence, Mission Health needs 24/7 neuro-interventional coverage, and ARA provides that. “You wouldn’t want to be anywhere else in Western NC than Asheville if you were having a stroke,” Dickerson says. “Our neuro-interventionalists are top-notch, they are phenomenal.” With a new recruit soon coming from Charlottesville, VA, ARA will have four neuro-interventionalists.

“We go through a rigorous approach when hiring radiologists,” Dickerson says. “We don’t have a lot of turnover, so once we hire someone they are usually here for their career. Only a handful of physicians have left, and that is because we put a lot of effort into recruiting the right physicians.” 

In addition to diagnostic and interventional radiology services, ARA includes four vascular surgeons. Although a bit out of the ordinary and challenging at times, the arrangement has enabled the practice to approach vascular care with a multidisciplinary lens for the past 10 years. “We are not so different from each other that it is hard to recruit,” Dickerson explains. “Vascular surgeons do procedures, but the procedures are surgeries. ARA’s vascular surgeons lead the state in complex open surgeries. The group’s multidisciplinary approach to vascular care is working well due to open and transparent lines of communication.”

Joining SR

Asheville hired a new CEO recently, Eric Weber, MBA, former CEO of another Strategic Radiology member practice, Central Illinois Radiological Associates. Shortly after arriving, Weber began to lobby for membership in SR.

“When Eric started talking about SR, one of the appealing things to me is the ability to benchmark our practice against the highest quality groups in the nation,” Dickerson shares. “As a quality-driven organization, our management contract requires a number of different dashboards. Being able to demonstrate quality to our health system partner is of high value for us.”

Another factor in ARA’s decision to join SR is the opportunity to participate in the Strategic Radiology Patient Safety Organization. The SR-PSO is the only radiology-specific PSO listed by the Agency for Healthcare Research and Quality in the nation. “The fact that SR has its own recognized PSO was important to us,” Dickerson concludes.