Accountable Care Realities

The 2012 Moreton Lecturer shares insights on the accountable care organization model.accountable care realities

In 2012, James L. Reinertsen, M.D., the founder of the independent consulting and teaching practice The Reinertsen Group in Alta, Wyo., will present the AMCLC 2012 Moreton Lecture, "Possible or Passable? Setting Aims for Accountable Health Care."

Reinertsen has extensive experience both as a practicing physician and a health-system CEO and is considered an expert and thought James Reinertsenleader on health-care topics. He is a senior fellow at the Institute for Health Care Improvement in Boston and won the 2011 John L. Eisenberg Individual Achievement Award for his U.S. and international influence in patient safety. Here, Reinertsen discusses the accountable care organization (ACO) model and radiology.

Q: What is an ACO?

A: In most instances, the doctors, hospitals, and other providers in a community voluntarily come together into a new organization called an ACO. They choose to take responsibility for cost and care of an attributed population of patients. ACO participants do this because they believe they can deliver high-quality care while lowering the cost trajectory for that community. Working together, they plan to deliver high-quality care over the next several years at a lower cost than historical trends and, in doing so, share the savings.

Q: What was your initial reaction to the ACO model?

A: The notion that a community-wide cluster of health-care providers could come together and take responsibility for the quality of care for a specific population has always appealed to me. I've seen it work in countries like Sweden and Denmark. Overall, it's a better way to organize the system than to have individual providers take their best shot at providing better care without a sense of coordinated responsibility.

However, in the ACO model, providers don't know specific information about the population they are responsible for — only that they are accountable for the cost and quality of the care of this group. And the patients aren't informed that the doctors are responsible for their costs. In other words, it's a secret arrangement that doesn't make any sense to me at all. If doctors are going to be responsible for a population, they at least ought to know their phone numbers; there ought to be some understood and implied contact between the doctors and the population. And that's not the case with ACOs, which I think is a fundamental design flaw.

Q: What will define the relationship between radiologists and ACOs?

A: Imaging finds itself in an interesting spot related to ACOs, and I think radiologists will play a big role [in these organizations]. For example, they could help reduce the cost of overused services. If you look at the American health-care system, there are two main sources of excess costs. First, our individual U.S. hospitals and doctors charge more for services than in any other country in the world. The other big difference [between U.S. health care and other countries] is the number of procedures we perform for patients; imaging is a prominent example.

If an ACO is going to be successful, its members — radiologists included — are going to need to work together to limit the number of unnecessary imaging studies. This translates to a very difficult problem for the imaging community, since most radiologists are not the ones ordering the exams. So, the ACO model will need to create a meaningful dialogue between radiologists and the rest of the health-care community. Hopefully, everyone can say, "Let's figure out the right number and time to do imaging procedures." It will require a real shift in imaging's perceived role, but I think radiologists will step up to add their voice in that dialogue.

Q: What will be more difficult about the ACO model for radiologists?

A: If radiologists perform 20-30 percent fewer imaging studies (which many predict will occur), radiologists' incomes will go down. The more challenging issue for the radiology community will be to discipline those within a given community who are doing the most unnecessary procedures. But they won't be alone; we need to have that same discussion professionally within the surgery realm and many other high-cost procedural areas.

Q: How can ACR members adapt to the new model?

A: The model was intended to empower providers, as opposed to health insurance companies, to take charge of the system. The broader radiology community and the College have done a good job of initiating the conversation about unnecessary imaging. Now it needs to happen individually in each community. The alternative — to do nothing and accept the relentless ratcheting down of fees for imaging procedures — is not all that attractive. So I think exceptional leaders will need to take a progressive stance and change the payment models for radiology in each community.

By Alyssa Martino

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