ACOs: Rules of the road for rads

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As the accountable care organization (ACO) model gathers momentum, radiologists have been a bit perplexed as to how to approach ACOs. The American College of Radiology created the Radiology Integrated Care Network (RICN) to illuminate the situation. The RICN encouraged radiologists to be proactive participants in ACOs in an opinion piece published in the May issue of the Journal of American College of Radiology.

David A. Rosman, MD, MBA, from Massachusetts General Hospital in Boston, and colleagues offered definitions for ACOs and capitation. “The term accountable care organization refers to a team, likely made up of hospitals, physicians, and other providers, that will work together to coordinate care for a population and, in doing so will take on some amount of financial risk for providing that care.”

Capitation extends the risk and “refers to a per-member, per-month payment methodology whereby there is full risk bearing for the provider system opting to cover a beneficiary’s life.”

Thus far, ACOs have demonstrated minimal cost benefit to involved health systems, government and payers. However, compliance with quality metrics has been positive.

Despite the weak evidence, if the ACO model fails, the alternatives may be less appetizing, and include further cost reductions through capitation, bundled payments, additional quality metrics, single-payer insurance and more.

The focus of ACOs, according to Rosman et al, is on curbing hospital readmissions and shortening length of stay at acute care and skilled nursing facilities. Another emphasis is optimizing care for high-risk patients, including individuals with congestive heart failure, diabetes and coronary artery disease.

The authors noted that appropriate imaging and lower utilization are not interchangeable and asserted that lower imaging use may drive up costs. That’s because discharge may be delayed, preventable admissions may occur and patients may be assessed inaccurately, which could result in inappropriate management.

Potential pluses for radiology in the ACO model are the specialty’s relatively high fixed and low variable costs, independence from expensive consumables, manageable productivity and production orientation.

However, radiologists have tended to steer clear of the ACO planning and implementation processes. The RICN recommended a more strategic approach. “It is easiest to integrate and become an integral part of the ACO decision-making team when not actively defending our turf.”

Rosman et al offered that radiologists are best equipped to manage imaging in an ACO model, and their diagnostic expertise gains value as primary care increasingly relies on physician extenders who cannot complete radiology’s tasks.

The authors offered pointed advice for radiologists. “The most fundamental [way to make a difference now and in the future] is simply forging better personal and service relationships with other clinicians and health care administrators.” This includes serving on committees, sharing expertise in radiation safety and imaging operations and providing policy guidance.

“Doing all of this is no guarantee for success, but not doing this invites failure. Radiology will be at the kitchen table or on the menu; you want to be there before radiology is served as the main course.”