In Search of Shangri-La: Alternative Models of Imaging-service Delivery

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For decades, the radiology practice partnership model has been the dominant form of imaging delivery. Change, however, is afoot. Health-care reform and other factors are driving the development of new imaging-delivery models that merit a close look, if imaging providers are to weather the storm of change that is remaking the health-care landscape.

Radiologist Lisa Bielamowicz, MD, is managing director and national imaging practice leader for the Health Care Advisory Board and Technology Insights programs of The Advisory Board Company (Washington, DC), a global research, technology, and consulting company. She says that savvy health-care providers must recognize that the final rule1 implementing the Medicare Shared Savings Program (MSSP) is likely to kick-start the formation of MSSP accountable-care organizations (ACOs). Chalk it up, for the most part, to the many provider-friendly changes made (and features added) between release of the proposed and final rules.

“The overall structure of the program has not changed, but CMS has scaled back many of the obstacles to operating in ACO mode and made the concept of participation more appealing to providers,” Bielamowicz notes. The reduction in the number of mandated quality-reporting measures tops the list of compelling revisions.

Other attractive changes specify that providers can band together into an MSSP ACO without assuming any financial risk during the initial three-year contract period; allow for a prospective beneficiary-identification process, with retrospective reconciliation; and provide access to previously unavailable, identifiable patient-claims data generated under Medicare Parts A, B, and D. CMS also has reduced, through a revision of fraud and antitrust rules, the legal risks inherent in forming and operating ACOs.

While the ACO model, as a whole, is in its infancy, some of its pieces are beginning to take shape, and providers have begun to move along the establishment continuum. Premier, Inc (Charlotte, North Carolina), a member alliance of more than 2,500 hospital systems and 76,000 outpatient facilities, currently has 20 to 30 provider partners with which it is collaborating on ACO formation. It is also assisting another 53 provider partners in determining whether following such a path would work well for them—and, if so, how to proceed.

Josh Bennett, MD, MBA, serves as Premier’s partner for integrated care and delivery. He notes that no matter what the overall ACO structure will be, it is important to recognize that the general model brings with it a spate of additional reporting requirements. “For ancillary functions in a high-value network—and radiology is among them—there is significant mandatory reporting around patient satisfaction with the care at the imaging site,” he explains, “l look at everything from the experience at the registration desk to whether the radiologist had contact with the patient (and the caliber of that contact).”

Reports required under the ACO umbrella must also cover instances of unnecessary or duplicated imaging services and whether alternative studies to those deemed inappropriate could have been ordered. Moreover, the MSSP demands information pertaining to adverse affects and conditions noted during imaging procedures: “the gamut, from the fact that a patient became extremely agitated in the middle of an exam to an adverse reaction to a contrast agent,” Bennett says. Documentation regarding quality assessments and improvements—such as peer audits of radiologist’s reports—falls into this category as well.

At the same time, lines are being written into the ACO script from an accountability standpoint. The expectation is that participating radiologists will undertake initiatives aimed at achieving radiation-dose reduction: for example, adhering to the use of doses as low as reasonably achievable, or ALARA, as well as to the Image Gently guidelines for pediatric imaging.

Similarly, a proactive approach to ensuring exam appropriateness is expected. Bennett says, “ACOs are holding radiology and radiologists to a high standard and, when selecting from among providers in a particular community, will partner with the one that offers not just the most cost-effective services and best clinical outcomes,” Bennett says, but the highest degree of imaging appropriateness.
“This is going to become even more important as ACOs shift from fee-for-service and volume-based incentives to quality- and value-based incentives,” he believes.