Q&A | ACOs: Not Just Primary Care

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Jonathan Breslau, MD

With the Jan. 1, 2012, deadline approaching for hospitals to re-launch themselves as accountable care organizations (ACOs), experts admittedly do not know what to expect, a scenario made even more uncertain by a divided and indebted Congress. Reformers hope that ACOs will cut wasteful spending while improving patient outcomes, and many hospitals have demonstrated their eagerness to capture some of the shared savings offered by Medicare.

In a March 3 article published in the Journal of the American College of Radiology, Jonathan Breslau, MD, a radiologist at Radiological Associates of Sacramento Medical Group in Calif., argues that much is at stake for radiology in this changing system, and unless radiologists increase their involvement, much also may be at risk.

Q. Can you begin with the basics? What is an ACO?

A. Breslau: An ACO is a physician-centric organization that is philosophically aligned around the idea of improving healthcare value and focused on primary care, with robust IT support. Monarch Health Care in Orange County, Calif., Geisinger Clinic in Danville, Penn., and Kaiser Permanente are good examples.

Outside of these virtuous organizations, ACOs are primarily a theoretical concept. The point being, we still don't know if this is something that could be rolled out in a widespread fashion in the U.S. in many different healthcare environments.

Q. What do you anticipate for the first few years of ACOs?

A. Breslau: The motivation to have ACOs is a good one—which is, we spend too much money on healthcare. It's not fundamentally a bad idea. It's just that there are too many different forces working in different ways, probably with irreconcilable goals.

ACOs should be viewed both with a high level of cynicism and a high level of interest. I think in reality we're not going to see that much real meaningful action. And the longer that doesn't happen, the less likely it is that ACOs will ever be pervasive. I think the idea that most providers are going to be ACOs in five years is very unlikely. But the idea that a healthcare organization can exist to improve value, where value is better care at lower costs, should be taken seriously.

Q. How do you see radiology fitting into the ACO structure?

A. Breslau: My read of the situation is that radiologists are very aware of the term, and they're concerned both that it might be Armageddon and that if they look too closely, it will be too scary.

Many organizations are unquestionably trying to put together ACOs. I don't think radiology will fare well if we adopt a head in the sand approach, because ACOs will get started with or without us. The same goes for Acute Care Episodes demonstration projects and other new payment models.

The incentives for shared savings can be set up in ways that put radiologists' economic opportunities at risk. If radiologists' compensation is geared toward reducing imaging, and radiologists have little control over reducing imaging, and I don't think that's unlikely, then radiologists will lose out. That's my concern.

Q. What do you think is at stake for radiologists and what can they do to further radiology's position within the ACO?

A. Breslau: The first thing radiologists need to do is participate in discussions at their institutions on any new payment model. Radiologists should make sure they're in the room and saying, "We'd love to focus on assuring that only appropriate imaging tests are done."

But the financial risk for overuse of imaging needs to be spread appropriately, otherwise we're just going to lose. (The same holds true for underuse of imaging, by the way.) One way to do this is for academic radiology to foster comparative effectiveness research that demonstrates that the appropriate use of imaging reduces costs or improves outcomes, or both.

On the individual level, radiology can have a central role in improving value in these healthcare organizations. Radiologists can use a skill they have but don't really get to use much, which is to really guide the appropriate workup of individual patients. Frequently, we're just the recipients of imaging requests, where we can increase that to really serve as consultants. There is no question radiologists can provide real value in the primary care environment.