JACR Feature: Revamping radiology to thrive in healthcare reform
“It’s a very difficult message [to broadcast],” Jeff Goldsmith, PhD, of University of Virginia's department of public health sciences and Health Futures, both located in Charlottesville, noted in an interview. “There is a non-incremental change taking place in the relationship of hospitals to their communities that is washing the message out.”
Radiologists are contending with immediate threats including declining volume, technical fee cuts and hospital acquisitions of referral sources and competitors. “They’re focusing on the leveling off in volume and not thinking about what they need to do to move the franchise forward,” opined Goldsmith.
The new era
Despite current day-to-day challenges, the longer term changes inherent in healthcare reform have been set in motion and will impact radiology.
Specifically, the Patient Protection and Affordable Care Act (PPACA) of 2010 reduces technical payments for imaging studies and espouses new Medicare and Medicaid payment methods that impact how imaging services are organized and financed, explained Goldsmith.
“The future of radiology as a discipline will rest largely on how the profession responds to challenges in three broad areas: advancing and leveraging technology, influencing the changing structure of professional imaging practice and inventing new economic models to support radiologic practice,” wrote Goldsmith.
Goldsmith referred to Lewis Thomas’ warning about “halfway” technologies, which mitigate disease symptoms without cure at great societal cost. He hypothesized that diagnostic radiology may be a “two-thirds” technology that provides exquisite images and eliminates many exploratory surgeries, but does not complete the circle. That is, “it is still not sufficiently developed to avoid triggering costly follow-up studies,” Goldsmith said.
Nevertheless, practices that prepare for and embrace clinical, technical and pragmatic innovation will be positioned for the inevitable changes of the next era.
Molecular probes that pinpoint the nature of a lesion could fill diagnostic gaps and also provide a sound foundation for the application of appropriateness criteria. Goldsmith identified the merging arena of theranostics that wed diagnosis and therapy as another promising advance that could cut costs, target and conserve resources and improve care. Another way to narrow and focusing imaging resources is through further applications of computer-assisted recognition software, he offered.
The change requires a shift in mindset and focus. “The profession devotes an extraordinary amount of its energy to fighting off incursions into its turf by other disciplines and not enough energy to expanding imaging’s technical capacity and usefulness,” noted Goldsmith.
The next evolution in the practice of radiology will be marked by the development of subspecialties. Goldsmith cited:
- Interventional medicine, exemplified by high-intensity focused ultrasound (HIFU) and catheter-based therapy;
- Surgical imaging, characterized by the integration of molecular probes, optical scanning and intraoperative imaging; and
- Molecular diagnosis and therapy, which pairs radiology with laboratory medicine and pathology in the use of molecular probes.
Goldsmith emphasized the interdisciplinary nature of evolving subspecialties. Several options for reorganizing services may be feasible and include establishing centers of excellence with radiology practices, developing new hospital-managed multi-disciplinary clinical centers or following the status quo and engaging in ongoing turf conflicts. The need to reorganize radiology education to prepare new physicians for emerging subspecialties underlies all of the various alternatives.
ACOs, bundled payments at a glance
Although future payment models remain works in progress, various options under consideration are expected to change radiology reimbursement.
Bundled, episode-based payment may be extended to radiology professional fees and outpatient preadmission workups and 30-day discharge follow-up studies, wrapping all services into a single, fixed payment. In fact, evolving imaging services that pair diagnosis and therapy may fit the bundled model.
“If we get bundling there will be tremendous incentives for radiologists to seek out organ systems and problem-centered partners and work with them to optimize episode costs,” explained Goldsmith. In this model, imaging can help narrow diagnostic uncertainty and reduce the defects of care—unnecessary testing, re-testing and re-admissions while also monitoring the effectiveness of treatment, said Goldsmith.
The accountable care organization (ACO), for example, aims to rein in Medicare spending via local control over expense, including imaging expenditures. Goldsmith believes broad-based population models such as the ACO present a more direct threat to radiology because the specialty will be viewed as a cost center rather than as a major player in the context of clinical processes.
Radiologists should expect the potential increased politicization of imaging and “anticipate the demands for an economic justification for the strategic use of imaging to maintain even the current levels of unit payment and be prepared to conduct the analysis of the impact of imaging on episode costs,” wrote Goldsmith.
An ongoing wave of adaption is in the works, concluded Goldsmith, who suggested that radiologists will need to leverage emerging technologies, while preparing and advocating for forms of care organization and payment models that reflect the value of radiology.