CHICAGO--The unsustainable cost trajectory in healthcare is well-known, but much less understood are strategies for practices to thrive as government and payors step up efforts to bend the cost curve. Experts examined the drivers and impacts of the cost curve conundrum during a session on Nov. 28 at the 97th Scientific Assembly and Annual Meeting of the Radiological Society of North America (RSNA).

Rob Kulis, MBA, of MEI Healthcare Group in Coral Springs, Fla., explained one of the basic drivers of rising costs. Baby boomers are characterized by a sense of entitlement with respect to healthcare. That attitude, coupled with the sheer size of the generation, creates an overwhelming and unsustainable demand on the healthcare system.

The data are compelling. “Right now, the U.S. spends $100 billion [or 1 percent of GDP] on imaging annually. [An article in] the Journal of the American College of Radiology estimated that 25 percent of that amount is unnecessary,” said David Gruen, MD, director of women’s imaging at Western Connecticut Healthcare in Danbury. “If we could take that away we could bend the curve nicely.”

The challenge for radiology rests in who determines which exams are unnecessary. “It will have to come from within radiology, or it will be imposed upon us,” cautioned Gruen. Radiologists, he said, need to make the shift from saying “yes” to nearly any and every imaging exam to saying “no.”

At the same time, healthcare organizations and radiology practices will grapple with multiple unknowns. For example, no one knows the cost or protocols to manage a 70-year old woman who survived breast cancer at age 40 or how to manage a patient 20 years after a second myocardial infarction.

In addition to patient care pressures, practices will need to contend with technology demands. As imaging migrates from CT and MRI to newer molecular imaging technologies, there will be increasing cost demands with these new technologies, predicted Gruen.

Initial attempts at bending the costs curve, the Deficit Reduction Act (DRA) and radiology benefits managers (RBMs), will be followed by additional initiatives such as accountable care organizations (ACOs).

One plus might be that unlike these early efforts, which were imposed on radiology, is that newer efforts may be at least somewhat collaborative. That is, radiologists might have a voice in decision making.

“Our biggest threat is that we are not at the table with those creating ACOs. Our challenge is to figure out how to add value in this environment,” said Gruen. Radiologists, who have thrived in the fee-for-service reimbursement model, may struggle in the ACO model, partially because the ACO and fee-for-service models are wholly incompatible.

For example, in the current fee-for-service model, the most likely suggestion for a patient experiencing shoulder pain is an MR arthrogram of the shoulder with pre- and post-contrast and 3D reconstruction. According to recently released American College of Radiology (ACR) appropriateness guidelines, that recommendation earns a whopping value of a 1 (or not indicated). The appropriate, and also more cost-effective, study is a plain x-ray of the shoulder.

“Radiologists are going to have to be the people that say that is not a data-driven decision,” said Gruen.

This cultural shift must be paired with a practice management shift that emphasizes alignment and integration with hospitals and other providers, rather than independence. In fact, experts predict a shift to an employee-based model in radiology, said Kulis.

Kulis and Gruen concluded with a brief look at what ACOs mean for imaging. Five likely outcomes are:

• Slight downward pressure on utilization;
• Imaging likely will not be the first target for savings;
• Alignment is likely to increase referral capture;
• Satellite imaging center strategies will be revised; and
• Robust integration will be required.