The Economics of Population Health Management

Elevating radiology’s role in these initiatives may require greater integration and accountability.

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The ACR Commission on Economics supports population health management (PHM). That may be the easiest position I have ever taken as chair of the commission. After all, who doesn’t want our population to be healthier?

The challenge lies in crafting economically viable policy that supports this societal goal. In this regard, radiology is far ahead, but we do have challenges. Clinical decision support (CDS), incidentaloma management, and screening studies all contribute to improved population health outcomes, but wide adoption has been slow. For instance, CT colonography has had a current procedural terminology code since 2010, but it remains uncovered by the Medicare program despite having recently received a U.S. Preventive Services Task Force grade of A. Implementation of CDS was statutorily mandated by the Protecting Access to Medicare Act of 2014 to commence in 2017, but it looks like it will be postponed to 2020 or later.

How can we accelerate the adoption of our initiatives so that they are more consistently paid for under fee-for-service legacy payment systems and integrated into new payment models? How do we make them indispensable, turning a simple imaging encounter into a positive experience for physicians and patients? I believe that two potential strategies may hold the answers: greater integration and increased accountability.

Today, diagnostic imaging is an integral part of almost all clinical conditions. Let’s now ask ourselves how we can elevate our role within the broader patient-care team, contributing to better patient outcomes. Using CDS puts our Appropriate Use Criteria front and center at the point of ordering. But what happens next when the ordering physician has additional questions? How available can we make ourselves for immediate consultation — either in person or electronically?

I know that we are busy keeping up with demanding worklists and procedure schedules and consulting at the point of ordering can distract from that focus. But, the radiologists I describe would have consulting as their primary responsibility. When necessary, that CDS consult supersedes other responsibilities. The referring healthcare professionals are as busy as we are, and when they ask for a consultation, they will expect immediate assistance and cooperation. On their worklist is the patient in the room next door. The next chapter for CDS in PHM may require an immediate, dedicated radiology presence.

The ACR has been a leader in the management of incidentalomas. Here, we can also be immediately available as consultants. Historically, our report (or maybe a subsequent communication) has largely completed our task. Could we assume greater accountability for follow-up, ensuring that patients receive proper notice, maintain their subsequent appointments, and see the right specialist (if necessary)?

Let’s now ask ourselves how we can elevate our role within the broader patient-care team, contributing to better patient outcomes.

It is not a small responsibility. This level of accountability requires additional professional resources. And we will need to advocate for additional reimbursement, maybe through an evolving new payment model. Payors may be willing to reimburse us more — but only in exchange for proven increases in quality and decreases in cost. In exchange, we will be expected to assume downside financial risk. In other words, this could mean putting our payment at risk, if we don’t succeed.

Screening studies are, obviously, important to PHM. From an accountability perspective, taking responsibility for identifying patients eligible for screening and ensuring proper follow-up is important. And, from an integration perspective, engaging patients at the time of their screening study better integrates us. Can we identify patients at increased risk, such as women with a family history of breast cancer in need of genetic screening or men screened for lung cancer in need of greater intervention for tobacco cessation? Although these activities may not be not directly related to radiology services, this level of accountability and integration affects the broader population health outcomes.

Previously in this column, I have written about the importance of local activities informing national policy. The population health initiatives I describe fit that model. We can test them locally, gain experience, prove their value, and expand them to viable national economic policy. All it takes is a willingness — and commitment — to making ourselves even more integral and accountable.

  By Ezequiel Silva III, MD, FACR, Chair

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