The Opportunity Knocks Now: Lead or Be Led

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Over the past decade, economic forces driving health care in the United States have removed many patient-care decisions from the hands of physicians. Fortunately, payment reform might change this. Physicians, including radiologists, have the potential to be rewarded for delivering appropriate, necessary care.

In medical imaging, radiologists are in the awkward position of receiving orders that referring physicians consider appropriate. In addition, we find ourselves being required to fill orders that are considered allowable by a radiology benefit management (RBM) company. This can be frustrating both to ordering physicians—who receive no reimbursement for time spent negotiating with an RBM—and to radiologists, who often lack adequate information to determine appropriateness.

To help solve this problem, recent legislation promotes quality and efficiency under accountable-care organizations (ACOs). You can become a leader in your organization by getting involved with evaluation, planning, and implementation of an ACO, thus positioning the radiology department in a prominent position in ACO discussions. You can help key decision makers in your organization understand that radiology’s role in the ACO will be critical to its success.

The Patient Protection and Affordable Care Act and the Health Care and Education Affordability and Reconciliation Act of 2010 introduced ACOs under the Medicare Shared Savings Program (section 3022), effective January 1, 2012. The ACO model is designed to change the traditional adversarial relationships between payors and providers to create a more collaborative, higher-quality, lower-cost health system for all.

To operate most effectively, ACOs will require sophisticated, electronic clinical decision-support tools. These tools exist to promote clinical efficacy. They use evidence-based medicine’s methods to reduce costs and improve quality, and are more efficient and provider friendly than current third-party call-center processes such as those administered by RBMs.

Under proposed ACO gain-sharing arrangements, payors and providers share in the savings produced by working together to streamline medical administrative processes. For an ACO with at least 5,000 Medicare enrollees, CMS will establish a three-year contract. Both parties agree on a historically based inflationary trend line. A target goal is mutually determined.

Any savings produced below that target trend may be paid by CMS to the ACO and shared among the contracted payors and providers. Medicare’s criteria on the amount to be reimbursed under gain sharing are determined by the HHS secretary and will focus on improved quality, outcomes, and efficiency. To optimize capabilities to report back to the secretary and to maximize reimbursement, ACOs will rely on IT, including electronic medical records with embedded clinical decision support.

Leveraging Software

With ACO gain sharing, new approaches will help radiologists and the broader health-care community more fully understand and address unnecessary imaging expenses. As ACOs develop rapidly in the coming years, clinical decision-support tools will electronically provide clinicians with the appropriateness criteria upon which to base efficient, outcomes-oriented ordering of diagnostic tests.

In a retrospective review of medical records, Lehnert and Bree¹ reported that nearly 26% of 459 nonurgent outpatient diagnostic-imaging tests ordered by primary-care physicians at a university medical center were unnecessary. The authors suggest that tools to help primary-care physicians improve the quality of their imaging requests could help improve both their choices in imaging examinations and their decisions to order imaging in the first place.

Is it likely that the 26% rate of unnecessary imaging holds true for your organization as well? That unnecessary expense might currently be costing your hospital or your at-risk physician group a significant amount of income. Could this loss be offset with the effective use of clinical decision support? Could an ACO’s use of clinical decision support help your organization optimize gain sharing—and more important, reduce unnecessary radiation exposure for your patients?

The ACO model offers radiologists the opportunity to reclaim both clinical and financial control of patient care. New radiology decision-support systems offer a necessary platform for maximizing reform-based gain-sharing revenue for both ACO payors and providers.