Against the Sword of Damocles
As you read this, health care reform (at least the idea that a single, transformative bill will markedly and permanently reduce the problem of the uninsured in this country) is still an active prospect, and one to which the president and, quite independently, leaders in Congress have committed enormous political capital. While the importance of covering the uninsured, and even the important regulatory changes that will be required, are not to be understated, radiologists (and most physicians) are asking, “What does this have to do with me and my practice?” In short, the answer is: a lot. The prospect of collecting revenue from the previously nonpaying (usually read as self-pay) patient would seem to be a wholly good thing. Certainly, the ability to provide important imaging services to an additional group of individuals who will benefit from them should be a positive economic outcome for our practices. In this particular reform effort, however, there are many other moving parts, many of which will undoubtedly affect us. Paying for Reform While there is certainly an argument to be made for funding health care reform as we do other necessary aspects of government (that is, from general tax revenue or, when necessary, debt), the president and fiscally conservative members of both parties have committed themselves to making this expansion somewhat (or wholly) self-financing. The term bending the curve has come into broad use, and it translates, loosely, to bringing the cost curve for health care spending down so that savings from public sources (such as Medicare and Medicaid) can be reallocated to expansions of coverage. The side benefit of such a change is to reduce the cost of private-sector health insurance, thus providing help to employers and individuals. There are many ways in which we can bend the curve. Perhaps the most appealing is to improve the value delivery of health care (by removing no-value health care and/or reducing low-value health care). In practice, this means reducing or removing coverage for costly-but-ineffective interventions. We know, for example, that there are higher and lower utilization regions of the country, but that this variation has little effect on outcomes. If we can adopt the practices of the lower-cost regions, we will have saved a considerable amount. How might this play out in our practices? For one thing, we might find some of our services being crowded out as their value is questioned. If better screening of patients in the primary care and emergency-department settings is done, less imaging may result. On the other hand, high-value imaging may increase in frequency, and more patients will be covered and paying. If a concerted effort is made to reimburse for clinical encounters more than for procedures, this may adversely affect radiologists’ incomes as well. What are the main issues in play, and how might they affect us? The Public Option One of the more contentious issues is whether the government should step in and offer health insurance, directly, to the 160 million individuals who currently receive it through their employers or as self-employed individuals. The fear, of course, is that a government plan would exert ever-greater power through pricing (or by fiat) and would quickly devolve to the level of the Medicare fee schedule. If all private-pay patients were converted to a Medicare fee schedule, many of our practices would suffer financially. For those practices that are already heavily weighted toward self-pay/uninsured patients, however, this effect would be ameliorated. Ultimately, our ability to increase productivity has saved us from fairly aggressive price cutting by private and public payors, and I expect that this will continue. While this may be of little comfort to many radiologists, I would predict that salaries would suffer very little from the inclusion of this option in any health-reform proposal. Incentive Realignment Realigning provider payments and incentives for primary care is, without a doubt, one of the more critical areas of reform. If we are paid as part of a bundled payment or capitated altogether, we may be put in a position of risk. On the other hand, if such changes result in regaining lost turf or protecting radiology against self-referral, we will find our position in the future of health care preserved and protected. It seems likely that dramatic changes (as currently being suggested) will start with pilot or demonstration projects. In such situations, radiology must ally and collaborate with its clinical colleagues to rethink how to preserve radiology’s important role in diagnostic and therapeutic care delivery while also considering the evidence about low- and high-value health care. If we are unwilling to participate in this important dialogue, we will be left out, to our (and our patients’) great loss. Medicare Financing Least talked about is the impact that health-reform efforts will have on the Medicare program. There are three issues that require immediate attention and should (or might) be resolved by this effort: reform of the sustainable growth rate (SGR), the susceptibility of our reimbursement to the whims of lawmakers and our own lobbyists, and the imminent threat to the Part A program through its perpetual underfunding. Removing these very real threats may have a greater impact on our practices than any of the previously mentioned issues. While each one might represent a new challenge, the current threat to our practices and our patients is unacceptable. What happens in the absence of reform? Irrespective of whether true health care reform occurs, we will face the prospect of reduced Medicare reimbursement unless Congress acts to revise the SGR law (originally enacted in 1997). It is my opinion that we will suffer less in the context of true reform; in the absence of reform, it is likely that more aggressive efforts at containing costs will result in the usual practice of reducing reimbursement for the technical and professional components of imaging. Even with these changes, we still face the continued swinging of the sword of Damocles, with less and less rationality. What can you do? Rather than lobby in isolation, I argue that we need to collaborate with our clinical colleagues more. We need to present ourselves to the patient whenever possible, and should certainly encourage (rather than ignore) opportunities to consult with our referring physicians. This may be a nonremunerative activity in the short run, but clearly will pay off in the longer term. Finally, the opportunity to educate our state- and federal-based representatives (and their staffs) is paramount. We have lived much of our professional lives in darkness; now is the time to come out into the open and shine. Howard P. Forman, MD, MBA, FACR, is professor, diagnostic radiology and public health; professor and director, Yale MBA for Executives: Leadership in Healthcare; and director, MD/MBA program, Yale University, New Haven, Connecticut.