JACR: Much at stake for rads in the ACO
As concern heightens that the accountable care organization (ACO) model will infringe on radiology’s independence and economic sustenance, radiologists must respond by informing themselves on and participating in the changing structure of healthcare, including fundamentally re-evaluating their relationships with primary care physicians and leading the drive against inappropriate imaging, argued the authors of a review article published in the March issue of the Journal of the American College of Radiology.

With the Jan. 1, 2012 ACO deadline fast-approaching, myriads of providers have yet to prepare for shifts to the ACO model or even to understand what the transition will entail, and radiologists stand among the uninformed and in the crossroads of this dramatic transformation. Some radiologists have taken prominent roles, nevertheless, by expressing concerns that the ACO will “expedite the demise of unrestricted volume-based fee-for-service reimbursement in existence since the early 1990s, eliminate the opportunity for radiology practices to maintain independence, and place radiologists at an economic disadvantage,” according to Jonathan Breslau, MD, from Radiological Associates of Sacramento Medical Group in Sacramento, Calif., and Frank J. Lexa, MD, MBA, from the Wharton School at the University of Pennsylvania in Wynnewood.

“Now, to anticipate payment changes, radiologists must understand the structure of ACOs and learn how they may participate in, and benefit from, this care model.”

Slowing the growth of healthcare spending while producing improved outcomes drives the ACO, with the model based on data revealing that lower per-capita Medicare expenditures are associated with higher quality of care; that is, more services do not equal better care, and perhaps the contrary. And as providers shift to ACOs and pursue savings by way of accountability, evidence-based medicine and reporting, the Centers for Medicare & Medicaid Services (CMS) is prepared to split the savings with ACOs.

While effective primary care represents the cornerstone of the ACO, radiologists by no means stand at the periphery. “Because the ACO model and its shared savings is predicated on reducing unnecessary referrals and diagnostic testing, radiologists can play a crucial role in designing and maintaining ACO care processes,” Breslau and Lexa wrote.

“In an accountable care environment, radiologists can and must help emergency physicians, hospitalists and primary care providers reduce utilization and move away from over-ordering imaging tests.”

The authors recommended several means by which radiologists can smother the growth in unnecessary imaging. Case-by-case consulting with physicians stands as one potential option; but perhaps more effective is radiology’s leadership in education and appropriateness research. “[R]adiology must develop a leadership role in research that supports appropriate imaging,” the authors contend. Promotion of decision support tools and the American College of Radiology (ACR) Appropriateness Criteria, not only in the ACO(s) in which radiologists participate but also in the community, represent two additional and accessible avenues.

“The nature of the working relationship between radiologists and the clinicians who request their services needs to be re-evaluated in the context of the ACO,” Breslau and Lexa continued. ACOs will stand to benefit from reduced utilization, meaning that primary care physicians will encounter incentives to reduce referrals, for which radiologists play a crucial role in offering guidance: to facilitate appropriate referrals and reduce unnecessary ones, all the while ensuring that patients experience no losses to the quality of their care.

Radiology’s position within the ACO must be a reciprocal one. “[R]adiologists’ incomplete control over the utilization of imaging” must be acknowledged for two reasons. First, cutting unnecessary imaging depends in large part on primary care physicians. Second, radiologists cannot be pinned under the threat of moral hazard, as bearing responsibility in the ACO for reducing utilization while bearing culpability in the courtroom if an unperformed exam ends in litigation.

“The perception within the culture of radiology is that it is often safer to just say yes to a request for noninvasive imaging than to engage in a debate with a clinician about the strength of the indication for the test. This belief is strengthened by emergency department physicians and others who have learned that the most efficient way to get a test performed is to make threats about how not doing a test will put the radiologist at risk for a suit if there is an adverse outcome,” explained Breslau and Lexa.

Much about the ACO model remains uncertain, the authors argued, which is a call to radiologists to participate—in coordination with other providers. “However, a few things are near certainties,” Breslau and Lexa concluded, “including the declining viability of the volume-driven reimbursement model and the need to assist clinicians, especially in primary care, to order the right test at the right time for the right patient.

“Radiologists and their groups need to be cognizant of these issues and to pay close attention to this rapidly emerging model.”