A Coordinated Effort
Now that the Patient Protection and Affordable Care Act is law, radiologists try to determine where they fit into accountable care organizations.
It's a maxim heard often these days: the health-care industry is transforming from a volume-based business into one predicated on delivering high-quality patient care. With the Supreme Court's decision to uphold the Patient Protection and Affordable Care Act (PPACA), and with President Obama's re-election last year, the act has become the law of the land.
One important part of the legislation involves the creation of institutions called accountable care organizations (ACOs). These entities are made up of doctors who coordinate care for at least 5,000 Medicare beneficiaries in order to streamline services and save the industry money. The physicians are then rewarded for these financial savings by sharing in them. But where do radiologists fit in?
The Central Node
Although the concept of shared savings in health care has existed for a long time, ACOs are only now in their infancy. HHS provided the framework for the adoption of ACOs in section 3022 of the PPACA in 2011, authorizing CMS to allow ACOs to contract with Medicare the following year. Since then, many physicians — including radiologists — have organized themselves into ACOs with the intention of raising the level of patient care while trying to rein in health-care expenditures. Since the law's inception, over 250 ACOs have come into existence.
With heavy emphasis placed on coordination of care, Jack M. Farinhas, MD, interventional neuroradiologist and associate professor at Montefiore Medical Center in New York City, notes that radiologists should see themselves as essential members of an ACO. "The radiologist is the central node to many clinical arms," he explains. For example, at Montefiore, he often reviews the exact same studies with neuroradiologists, neurosurgeons, and other medical teams. "Being in a central position, we can offer our expertise in a way that helps to coordinate communication among different groups within an ACO," he asserts.
Despite the fact that some radiologists see themselves as central to the success of ACOs, Congress' track record of cutting imaging reimbursements gives others pause. However, many radiologists perceive themselves inaccurately, says David A. Rosman, MD, MBA, medical director at Massachusetts General Imaging Worcester and associate director of business development at Massachusetts General Imaging at Massachusetts General Hospital. "We've been a target for reimbursement cuts from Congress. But the governing bodies of ACOs haven't targeted us in the same way. These groups are focusing on managing chronic diseases in an attempt to reduce the long-term costs associated with those diseases. Individual episodes like imaging do not cost as much as expenditures on chronic diseases like diabetes or coronary artery disease as a whole and thus are lower on their priority list." It's critical for radiologists to get involved now in the leadership structures and decision-making processes of ACOs, he says, before imaging becomes a target.
A recent article co-authored by Rosman, Farinhas, Christopher G. Ullrich, MD, FACR, and Geraldine B. McGinty, MD, MBA, FACR, noted, "The initial focus of ACOs has not been on decreasing imaging but rather has revolved around preventing readmissions and reducing lengths of stay."2 Since these are areas in which imaging often does not play a significant role, the authors assert, this dynamic has prompted many radiologists to sit back and watch how things play out. Adopting a wait-and-see approach will not, however, empower radiologists. "If we only get involved once we're targets, then it looks like we're only interested in participating in order to cover ourselves. Our input will be much more credible if we act now as part of the team," argues Rosman.
Tools of Success
If radiologists wish to assert themselves into the process of helping to coordinate care and also influence how they will be paid through their ACO, the time to do so is now. Fortunately there are strategies in place that can help doctors through this transition process. Two of the most significant of these strategies involve becoming a "good citizen" within the ACO and making the case for the adoption of clinical decision support software.
In a recent article on how radiologists can become good citizens within the medical community, authors Lee, Herrington, Donner, and Bluth emphasized the need to become part of medical boards and committees at the hospitals with whom they contract. They write, "In multidisciplinary institutions, radiologists serving on boards and hospital committees can advocate on behalf of their practices and help shape the institutional policies and practices with regard to medical imaging."3 This idea is in line with how doctors can ensure that their voices are heard within ACOs. "You've got to be active in your state medical society, not just your state radiologic society. It's all about being visible, and that way people will better understand your value."
In addition to becoming an active member of the medical community, radiologists can demonstrate their value to ACOs by promoting the use of clinical decision support software. ACR's clinical decision support technology, called ACR Select™ (www.acrselect.org), is the web service version of ACR Appropriateness Criteria® (AC). The software provides referring physicians with a tool for ensuring that they order the most appropriate study every time, allowing radiologists to assume a new role: that of peer-to-peer consultant.
As a consultant, the radiologist can help guide the referring physician during complex encounters in which the AC do not provide clear guidance, or when a referring physician wishes to override criteria for compelling clinical reasons. This will help the ACO hold down imaging costs and will contribute to shared savings. According to Farinhas, although some radiologists worry they'll be displaced by software, these fears are premature. "There will always be a place for radiologist expertise in complex clinical scenarios, but we need to be proactive here and offer our expertise in a human way. We cannot allow our expertise to be automated by computer software. This is our opportunity to manage utilization while securing our place in the center."
Assuming an expanded role as not only an imaging expert but also a consultant can potentially open a new revenue stream for radiologists, who have seen their Medicare reimbursements fall year after year. However, figuring out how to be fairly compensated as a consultant within the ACO framework presents a challenge. "It's been difficult for radiologists to develop what I would call the 'arithmetic' of how we are valued within an ACO," explains Ullrich, a private practice neuroradiologist at Charlotte Radiology PA in Charlotte, NC, and chair of the ACR Utilization Management Committee. "There is no formula we can point to today and say, for instance, 'Radiologists deserve eight percent of the cash flow.' In reality, what occurs in virtually all of these organizations is that you're actually paid on a fee-for-service basis coupled with some type of utilization management strategy." Ullrich says that the ACR and RBMA are both actively examining valuation metrics to assist members in their local negotiations.
Multiple Channels of Income
Although many different ACO payment models provide radiologists with shared savings opportunities,3 McGinty agrees that, at least for the foreseeable future, most of them will continue to incorporate some form of fee-for-service. "Radiologists will likely get paid at the time of service on a fee-for-service basis," she notes. "Then a percentage of the savings that they share in will come at the end of the year and the goal is to participate in the distribution of the savings."
She highlights examples of patient scenarios that reflect how radiologists in ACOs might be paid in a hybrid fee-for-service and shared savings model:
If my group is part of an ACO, a portion of our patients, though by no means at all, will be Medicare patients that are in the ACO's shared savings model. We're committing to giving those patients high value care for the year and also delivering that care at a lower cost. My group will get paid to deliver the service on some kind of discounted fee-for-service basis, but at the end of the year, if there are savings, our ACO will get some money back, so we will negotiate to share in the distribution of those savings. Our ACO may also have negotiated a bundled payment with commercial payers for procedures such as hip replacements, and the radiologists in my group will share in that payment based on a negotiation that recognizes the cost and value of the imaging care we deliver. Our group will likely also still see fee-for-service patients who are not in the shared savings model and are not part of any bundled payment plan, although I expect the relative numbers of those patients to decline over time.
McGinty asserts that although most of the shared savings models hold the possibility for all of the doctors at a given ACO to benefit from these savings, radiologists need to be on the alert for payment models that are high risk. Among the most potentially troublesome models are those that incorporate capitation, according to McGinty. "When considering a capitation agreement you need to have a very good understanding of the cost and level of care you've historically provided to the patient population for which you are about to assume risk. Otherwise you may find yourself floundering as many did in the old managed care days," she says. "You've also got to have some ability to manage imaging utilization within the population for which you are at risk. With good planning, a capitated arrangement can allow a stable income stream and align incentives, but you've got to go into it with your eyes open."
Whether they lobby to be paid through capitation or another model, radiologists working with ACOs would be wise to make their voices heard now. Radiologists can demonstrate their value to these organizations in a multitude of ways, including joining a hospital committee or meeting with hospital administrators to discuss the implementation of ACR Select software. Despite the tectonic changes transforming medicine, becoming involved in a shared savings or integrated payment model such as an ACO can offer an opportunity for radiologists to reassert their central role in quality patient care.
1. Centers for Medicare & Medicaid Services. “More Doctors, Hospitals Partner to Coordinate Care for People with Medicare.” Available at http://bit.ly/ACRCMS. Accessed June 17, 2013.
2. Rosman DA, Farinhas JM, Ullrich CG, McGinty GB. “Accountable Care Organizations: Is the Radiologist at Risk?” JACR. Published online May 10, 2013.
3. Lee CI, Herrington WT, Donner EM, Bluth EI. “Citizenship in Radiology: Defining a Concept and Proposing Its Measure.” JACR. Published online April 15, 2013.
4. Becker’s Hospital Review. Punke H. “5 Payment Models for ACO Providers.” Available at http://bit.ly/ACOPayModels. Accessed June 17, 2013.
By Chris Hobson