AJR: How to stop worrying and love the ACO model

An expert panel considered the role of radiologists in reducing healthcare costs and offered strategies for responding to the accountable care organization (ACO) model during a Masters of Radiology discussion. An article based on the transcript of the discussion appeared in the October issue of the American Journal of Roentgenology.

Alan Kaye, MD, of the department of radiology at Bridgeport Hospital in Westport, Conn., spurred the discussion and said radiologists need to honor their role as consultants, not merely interpreters focused on reporting findings. Radiologists also must uphold their ethical role by not taking advantage of their position as consultants to recommend additional studies because of financial incentives.

“In our practice, I am proposing that we modify our peer-review scoring method to include a zero category, which is used for an overcall by the interpreting radiologist,” said Kaye. “That way, we will be able to monitor and give feedback to our radiologists in what is becoming an oft-mentioned potential shortcoming of imaging.”

Norman J. Beauchamp, Jr., MD, MHS, of the department of radiology at the University of Washington in Seattle, said that ACOs could be seen as a welcome development for radiologists, allowing them to embrace their role as consultants.

“In the ACO model, the radiologist can bring value by playing the central role in ensuring that the appropriate imaging study is performed to address the clinical question as well as by ensuring that a study is not performed when it will not impact the clinical management of the patient,” said Beauchamp. “ACOs reward the radiologist for helping our clinical colleagues understand and embrace the rationale for the imaging recommendations we are providing so that they find our input essential in attaining the common goal of providing patient-centered cost-effective care.”

Adding to those sentiments, David B. Larson, MD, of the department of radiology at Cincinnati Children’s Hospital Medical Center, said radiologists should not instinctively oppose change that may not clearly benefit radiologists. Rather than resist innovations like teleradiology, radiology benefits management companies and ACOs, radiologists should embrace them early on so they can have a voice in how these innovations develop, rather than simply react to them.

Kaye said the American College of Radiology (ACR) is wrestling with the appropriate policy avenue for the college as it relates to the subject of ACOs.

“The ACR is now juggling with protecting fee for service, optimizing the reimbursement system for fee-for-service and focusing on ACOs,” he said. “Clearly we should be the leaders in what is appropriate in imaging not only in terms of the indication but also in terms of specific tasks.”

The conversation also covered broader topics such as the definitions of cost-effectiveness and quality care. Alexander Norbash, MD, of the department of radiology at Boston University Medical Center, said that not everybody accepts a linear relationship between cost and quality, and that all parties need to be on the same page on the basic terms used to describe these concepts.

Norbash also cautioned against blindly following regulations based solely on expenses, as that doesn’t lend itself to thoughtful discussion about what practices provide the best diagnosis. Likewise, Beauchamp said rigid adherence to only order tests based on evidence-based results would constrain and diminish the value of imaging.

“There is not and will not be adequate research funding to perform comparative effectiveness studies for all imaging studies for all indications,” he said. “Thus, consensus panels that review the existing literature and bring together broad expertise will frequently have to suffice.”

Beauchamp added that in certain areas where evidence does exist to show a study is inappropriate, radiologists should be stalwart in ensuring those tests are not ordered.

Compromise is the only way forward, according to Beauchamp, who said he was heartened by recent conversations with payors. He said common ground on appropriate approaches that serve patients and control costs are possible if all stakeholders are willing to continue having tough conversations.