Aligning Incentives in Health Care
The recent SGR legislation brings us one step closer to a blueprint that works for stakeholders throughout the health care system.
In March of this year, I had the pleasure of attending the Oklahoma Radiological Society Meeting. We had a great discussion with radiologists about issues facing their practices and how the College was advocating in Washington on their behalf.
At the time, Congress was considering the Protecting Access to Medicare Act of 2014 (H.R. 4302), the latest in a series of patches to the Sustainable Growth Rate formula. The goal was to prevent deep cuts in Medicare physician payments. Needless to say, our conversation focused largely on the politics of health care reform, including such topics as our political leaders' inability to reform the SGR formula and the possiblity of enacting legislation that promotes improvements in patient care.
Policy-makers in both Congress and the Obama administration believe that many of the current financial difficulites in Medicare are due to increases in the volume of services being provided to Medicare beneficiaries. While it is easy for decision-makers in Washington to say we need to provide more value and efficiency in health care instead of more volume, the current strategy of repeated cuts to fee-for-service payments creates a perverse incentive to continually increase volume.
This brings to mind a quote attributed to Russian leader Nikita Khrushchev: "Call it what you will, incentives are what get people to work harder." The value proposition of health care reform — better health at a lower cost — will be difficult to achieve until policy-makers recognize that the key is to align physicians' incentives with those of the payers and health systems. To begin that process, on April 3, 2013, when the House of Representatives Energy and Commerce Committee and Committee on Ways and Means first released their plan for Medicare payment reform, one of the tenets of SGR reform was to include incentives based on adhering to physician-developed performance measures.
Back in 1890, in The Picture of Dorian Gray, Oscar Wilde wrote, "Nowadays people know the price of everything and the value of nothing." That timeless statement resonates with me. Despite all of the technological advances and clinical capabilities we have achieved in imaging, the increase in the use of imaging because of these capabilities has resulted in payers reducing the payments for individual imaging services. Unfortunately, at this point, the policy-makers believe the only way to increase value is to lower the unit costs for imaging. It's like Henry Ford said, "If I had asked my customers what they wanted, they would have said faster horses." And so in order to prevent Congress from taking the path of faster horses instead of true innovation, it's up to us as radiologists to develop and promote innovative solutions. Otherwise, we are likely to see continued unit cost reductions. So with Congress now suggesting that physicians step up and create value-based initiatives for quality metrics for their specialty, I'm reminded of what Steve Jobs once said, "A lot of times people don't know what they want until you show it to them." Translation: in dealing with members of Congress, the burden lies upon us to show what works, not necessarily what they are expecting to see.
As part of the Imaging 3.0™ strategy, the ACR wants to show policy-makers radiologist-led initiatives and tools that improve the value of imaging to patients and health systems. In moving to value-based care, it is imperative that we assure patients, payers, and policy-makers that the care radiologists provide is beneficial, safe, and appropriate. One way we can do that is to promote the use of appropriate use criteria, such as the ACR Appropriateness Criteria®, to policy-makers as an alternative to call-in prior-authorization programs. During the legislative process for SGR reform, the College was successful in getting Congress to agree to language that mandates physicians ordering advanced imaging consult physician-developed appropriate use criteria. (For more about the SGR legislation, see page 10.) We were able to get this language included in the legislation because the ACR Appropriateness Criteria are well respected and constantly updated based on the best available evidence. Another key was the ACR informatics effort that has made the appropriateness criteria a clinically consumable product, called ACR Select™. And, finally, we were able to successfully influence this legislation thanks to the unending and doggedly persistent efforts of the ACR government relations team, who ensured that the language made it through all the iterations of the legislation.
As a result of this legislation, our specialty has planted a flag in the sand as a leader in providing value-based medical care. Thanks to everyone who has made this possible, including the tireless ACR staff and physician volunteer leaders in quality and safety, informatics, and governemnt relations. This was truly a win for radiology and for our patients.
By Bibb Allen Jr., MD, FACR