Does the ACO Model Commoditize Radiologists?

October 30, 2014

Radiology continues to be cautious with new payment model, but might not be able to avoid it for long.

For U.S. healthcare, new payment models are no longer the catchphrases of the day. They’re also not yet realities. But that doesn’t mean health systems aren’t trying them on for size, searching for one that makes the biggest impact in controlling costs, and pumping up patient experiences.

The question is – what has this meant for radiology so far?

Accountable care organizations (ACOs) are at the top of the new payment model list, but there’s no consensus about whether they’re fulfilling patient-satisfaction and cost-savings goals. In fact, out of the 32 original Centers for Medicare & Medicaid Services (CMS) Pioneer ACOs from 2012 that opted to test this system design, only 19 remain active. The rest dropped out of the pilot, citing either too much financial risk or the inability to meet Medicare savings goals.

Radiology’s Participation
Although ACOs are being widely tested, radiology hasn’t jumped whole-heartedly into the process. According to the American College of Radiology (ACR), radiology’s participation, to-date, has been fairly minimal.

“Radiologists are working on being part of integrated care. It’s not due to their lack of trying – it’s more that the payers and the ACOs themselves have had a lot to do in trying to get started,” said Pam Kassing, senior economics advisor in the ACR’s Department of Economics & Health Policy. “They’ve been focusing more on the primary care aspect and what it can offer beneficiaries through a physician base and a central place of care.”

Once that groundwork is in place, she said, more attention will turn toward properly integrating specialties. But, in the meantime, it’s that lack of specialty focus that keeps many radiologists at bay, not wanting to step too far into the new payment model without clearer guidance. They’re cautious, she said, because they’ve yet to see how radiology can benefit from any shared-savings plans.

“It’s unclear whether radiology groups are hesitating or pulling out of the model, but they’re not aggressively moving toward it either,” she said. “How specialists can effectively participate in the program is something that needs to be figured out.”

The ACR, though, is erring on the side of caution and encouraging radiologists to prepare for the ACO payment model through its Imaging 3.0 initiative. Most importantly, Kassing said, radiologists must become more proactive and visible throughout their institutions – sit on committees, get involved in administrative discussions, and take greater roles in team-based care.

The ACO Challenge for Radiology
The idea of sharing savings (and risk) and providing more team-based, patient-centric care is an attractive one to many in the industry. But it also has the potential to place radiology – more than other specialties – in the delicate position of finding the right way to manage and offer its services. And, no matter what radiologists choose, they could experience a negative impact.

According to Steven Seltzer, MD, chair of radiology at Brigham and Women’s Hospital, the ACO model could produce one of two outcomes: referring physicians could see radiologists as unnecessarily rationing diagnostic imaging services or providers could be accused of promoting services without proper consideration of patient needs.

“In the ACO model, if things move all the way to putting the provider organization at risk and they get paid a fixed amount for the entirety of medical services provided, then radiology must do the right thing by the patient – not too little, not too much in providing diagnostic evidence for determining therapy,” he said. “We’re in a fascinating and intimidating transition between two economic models that are paradoxical. In one, the more do you do, the more you get paid. The other gives you a fixed amount, and the less better off you’re going to be.”

In addition, the shift to ACOs could push radiology from a profit center to a cost center, he said. This puts radiology at the center of patient-care decisions that could be tainted by an institution’s bottom-line concerns, such as electing to use cheaper, less-effective alternatives to imaging studies.  

With his colleague Thomas Lee, MD, another Brigham and Women’s radiologist, Seltzer wrote in a July issue of the Journal of the American Medical Association the best way for radiologists to maximize their role in this new model is to assume additional responsibilities outside reading rooms. Not only must they be appropriateness-criteria consultants, but they must also give referring physicians feedback on how they use imaging. They should take lead roles in implementing clinical decision support systems and develop image-guided interventions that are less expensive than invasive treatments.

Seltzer acknowledged, however, that for more rural-based providers, reaching those goals in the near future will be difficult. His hope is that smaller, hospital-based departments and community practices will implement the electronic medical records needed to support clinical decision support tools, as well as embrace the call for more consultative services.

There is, though, a more immediate – and frequently discussed – risk to radiology, said John Lohnes, Jr., MD, president of the Wichita Radiological Group in Kansas, an organization associated with a physician-owned ACO. There is the imminent likelihood that radiology will no longer be viewed as a traditional medical specialty.

“The biggest problem I see for radiology within the ACO model is that, more often than not, we’re viewed as a hired service. We have the potential to be further commoditized,” he said. “And, if CMS and others go through with bundled payments, from my perspective, that will lead to even greater commoditization of practices.”

One Practice’s Success Story
Because the onus is on radiology to demonstrate its worth under the new ACO model, Omaha-based, private practice Radiology Consultants of the Midwest took steps to ensure its surrounding medical partners recognized its importance. 

“The idea is to make radiologists valuable,” said Patricia A. Helke, MD, Radiology Consultant’s past president. “And, the way you do that is by providing service, so we’ve made a concerted effort to try to provide the best service to our local health system and patients.”

To do this, each of the practice’s 26 providers did as Seltzer suggested. They pivoted from solely being image readers to being more engaged consultants who had greater interaction with referring physicians, as well as patients. An internal committee also launched a three-pronged, hyper-focused initiative that included call reporting, concierge radiology, and traveling interventional radiology to cultivate stronger relationships with referring providers.

With call reporting, each practice provider calls a targeted number of referring physicians monthly to relay clinical findings. Initially, providers concentrated on conveying the most critical results, but over time, they’ve transitioned to calling with less significant findings. According to Helke, most referring physicians have been receptive, leading to closer – and, in some cases, new – relationships.

The concierge service works much like a radiology house call – providers visit referring physicians’ offices on various days to read images. The program is tailored with subspecialty radiologists reading exams in their expertise areas. This move offers several benefits, Helke said. Not only can the radiologists offer more timely feedback, but they also talk face-to-face with the referring physician about appropriate imaging and findings. Additionally, in a step that could increase patient satisfaction, the radiologist gets in-person interaction with patients.

The traveling interventional radiology component works much like the concierge program – interventional radiologists provide their services to local physicians’ offices and hospitals that don’t have full-time interventional radiologists on staff.  According to Erik A. Pedersen, MD, Radiology Consultants’ chief information officer, these radiologists have increased their case load by offering their services to referring physicians a few days a week.

Overall, the benefits from this three-pronged initiative have been considerable. To date, Radiology Consultants has seen a 10% increase in referrals. It’s also not uncommon for referring physicians to call with questions about appropriateness or to get second-reads of images their patients have received elsewhere.

“We get lots of phone calls and lots of referring physicians who drop by the department to have us look at cases,” said Pedersen, who is also radiology department chair at Bergan Mercy Medical Center and Boys Town National Research Hospital. “It shows that the relationship is solid, and the physicians trust that what we’re recommending is going to help answer their questions.”

According to Helke, patient approval ratings have skyrocketed to between 90% to 95% because they’re getting their results faster, and they can connect the radiologist’s name with a face. In addition, by compartmentalizing reads and giving providers the latest voice recognition software, the practice has sliced its turn-around time from a day to an hour.

Even though ACOs aren’t the official payment model for the healthcare system, many hospitals and larger health environments are moving in this direction. And, as healthcare goes further down this path, it’s likely, Lohnes said, that the industry’s smaller partners will lag behind the bigger institutions that have already started down the ACO integration path. But overall success is still possible.

“As radiology moves forward as a general entity, we have to be willing to accept risk and learn how to handle that if we’re going to maintain our independence and our standing as physicians,” he said. “By doing so, we’ll be higher on the food chain. That’s where we want to be – that’s our long-term goal.”