Point, Counterpoint, Recommendations, and Action
In January, I reported the news from the October Board of Chancellors meeting, and I outlined the elements of discussion contained in three point-counterpoint sessions, on RBMs, self-referral, and our identity as radiologists.
As I noted, the presentations and discussions each lasted for an hour and resulted in robust discussion among members of the Board and the Council Steering Committee (CSC). This month, I would like to share with you the content and results of those discussions, the recommendations for action, and the steps we have thus far taken to implement those recommendations.
The discussion on whether the ACR should modify its longstanding position not to endorse or collaborate with Radiology Benefit Management (RBM) companies was lively and reflective of the two extremes supported by the presenters. Opinions ranged from, "Don't fight it — it's inevitable," to "RBMs are taking our money — why should we collaborate with them when we should be the ones working on shared savings?" The central theme from both sides, however, was the need for radiologists to take a more active role in utilization management. The debate was on whether radiologists could or should do it on their own, or whether they, through the ACR, should align this process with RBMs.
It was agreed by all that universal use of computerized order entry with decision support based on the ACR Appropriateness Criteria® is the desired goal and, if that goal can be achieved through a detente with RBMs, a compromise position could be taken. Therefore, the recommendation of the Board and CSC was for the ACR to reach out to selected RBMs and engage in discussions on potential collaboration. The basis for selection will be the willingness and ability of the RBM to comply with the guidelines as stated in the joint ACR/RBMA Best Practice Guidelines on Radiology Benefit Management Programs.
With input from the ACR Executive Committee, an RBM has been selected and a meeting has been scheduled. The platform for discussion will be the best practice guidelines and, if agreement on business principles and models can be reached, there may well be an opportunity to collaborate with this RBM in an exciting new utilization management program that exclusively uses a decision-support system software product developed and owned by the ACR.
The second point-counterpoint session permitted the Board and CSC to revisit one of the ACR's most important issues: self-referral. While this issue is like motherhood and apple pie to radiologists, the presenters created a better sense of awareness of how the issue, and our advocacy related to it, is perceived by others who also have a big stake in the issue, including those who control legislation and policy. Opinions were more uniform in this discussion, noting that ACR cannot abandon this issue. However, the discussion did recognize the political reality in the need for non-radiologist allies on payment-reduction issues and the fact that the direct confrontational approach we have taken thus far has not produced significant results.
While about 60 percent of the Board and CSC members were in favor of a full-speed-ahead approach rather than deprioritizing this issue, there was consensus that our efforts might well be more productive if we changed our tactics. A recommendation was made that the ACR should frame its advocacy more around patient safety and high-quality patient care than around global health-care cost issues. Specifically, it was recommended that we seek to engage other champions of this cause besides ourselves — for example, the Institution of Medicine — and that we also look to patient advocacy groups as champions with a theme of protecting the patient.
The third point-counterpoint session dealt with the vexing issue of defining and validating our identity as radiologists. Are we on an inexorable march to extreme subspecialization or is there still a role for the general radiologist? While all who discussed the issue understood and supported the need for increasing subspecialization in radiology, there was consensus that a general radiologist provides necessary value to the practice of radiology and should be supported by the ACR. Perhaps the core comment of the session was, "Why do general radiologists need support? Because they are us."
It was noted that as practices become larger and accountable care becomes embedded, there will be an even greater need for radiologists who understand the entire spectrum of benefits that imaging can offer and are capable of leading primary caregivers on the correct path to precise and efficient diagnosis. It was recognized that the new residency training and examination orientation will likely provide the framework for the "specialized generalist" but that a more focused approach to this concept might be needed, such as is provided by one training program that offers a general radiology fellowship. Therefore, the Board and CSC recommended creation of a task force to examine how we can reinvent the general radiologist. A task force report is forthcoming in the next few months.
Last year, a senior officer of another radiological society said, "There is no organization in radiology that can turn words into action as fast as the ACR." In my opinion, he is absolutely correct.
By John A. Patti, M.D., FACR
Chair, Board of Chancellors