What Payors Want From Radiology

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What, exactly, do patients, employers, and insurers want from radiology? All too frequently, the answer is more expertise, at a lower price. This familiar tug of war between payors and providers continues to reverberate throughout the health-care community. While a resolution is not likely soon, more understanding among all parties can help smooth the road ahead. In the case of insurance companies and physicians, the relationship has rarely been harmonious, largely due to different notions of what constitutes quality. When AmeriHealth NJ and Radcon signed a three-year contract in July 2012, their leaders attempted to address this conflict, right from the start. The agreement includes a quality initiative to improve patient care by making health care more patient centered, reliable, accessible, and safe. Robert M. Glassberg, MD, president of Radcon, is determined to make these noble goals a reality. As a regional imaging entity operating through a network of 263 radiologists in 46 imaging centers (representing 19 practices, in 11 counties, across Southern and Central New Jersey), Radcon has a lot of moving parts. Glassberg also serves as president of one of the member practices in this network, Atlantic Medical Imaging, LLC (Galloway, New Jersey). This 40-radiologist group operates nine full-service outpatient imaging centers and serves two hospital campuses. Under specific terms of the agreement, Radcon and AmeriHealth NJ will agree on a set of quality, service, and/or value measurements, establish baselines for each, and then engage in continuous quality improvement. The network and payor will share the data with each other to support the common goals of improved quality of care, customer service, and cost effectiveness. Paul Portsmore, vice president of health services for AmeriHealth NJ, says, “As reimbursement gradually moves toward being based on outcomes and performance, it’s essential for payors and providers to work together to ensure access to the highest standard of care, which is what our members deserve.” Glassberg is determined to fill that tall order, and he has vowed that the transition from quality assessment to quality initiative will be in full swing after three years. “Step one is for us to make sure the providers and the payor are on exactly the same page, with regard to what should be tracked to make sure we’re defining things such as value and cost effectiveness the same way,” he says. “We have a pretty good idea of some of the measurements we’ll use, but we don’t have a comprehensive list yet.” Sacrificing Quality These days, insurers might not get everything that they want from radiology groups, but where do they draw the line? “The answer is determined by subscribers—specifically, by the point at which insurance companies have trouble selling their plans, either directly to employers or to individual patients,” Glassberg says. “At some price point, payors will not be able to sell their plans if their networks do not include providers of a certain level of quality. They can’t simply sacrifice quality. They do recognize that below a certain price point—if it comes with a sacrifice in quality—it is bad business.” When it comes to trust, it appears that payors are increasingly willing to place faith in radiology benefit management (RBM) companies. The RBM position continues to gain traction with some commercial payors, and not everyone is wholly opposed to the trend. For his part, Glassberg can see why insurers want to continue down the RBM road. “Payors feel that putting utilization management back in the hands of imaging providers is too much like letting the fox guard the henhouse,” he says. “That doesn’t mean that they won’t ever do it, but they are jaded by the history of utilization management in the pre-RBM days.” Glassberg believes, he adds, “that radiology, as a profession, should include the responsibility of utilization management.” The RBM middlemen, however, will not go away quietly. “We opened that door by not doing utilization management properly, but the RBM industry does provide some value for us, too,” Glassberg says. “For example, RBMs are currently helping to steer imaging from higher-priced hospitals to lower-cost freestanding outpatient centers, where quality and service are often better. From the standpoint of our private outpatient practice, I guess it’s sort of a love–hate relationship. We have some common interests with the RBMs, and we have other areas where we’re competitors or adversaries.” No Excessive Use Like insurers, employers are deeply concerned about overutilization of radiology services. Unnecessary imaging studies lead to higher premiums, which affect employee benefits and companies’ bottom lines. Helen Darling, president and CEO of the National Business Group on Health (NBGH), helps large employers find benefits for their employees and families. As a nonprofit membership organization, NGBH seeks top-notch care at reasonable rates. Neither is any small feat in today’s health-care world, but Darling believes that identifying and sticking to objective standards of appropriateness could solve many problems. “We have complete faith in the ACR guidelines,” she says. “We should provide coverage relative to the guidelines: no more, no less.” Problems arise, she says, when physicians fail to refer appropriately, based on those guidelines. “If everybody follows the evidence-based guidelines, we don’t have to sacrifice anything,” Darling says. “If we get it right, we won’t be drowning in health-care costs.” Ultimately, Darling’s employer members are not hesitant to pay premiums for excellence, but they need to know that radiologists and referring physicians have an appreciation for the costs involved. “Employers want radiologists to have strong principles and adhere to guidelines for appropriateness,” Darling reiterates. “They want to be certain there is not excessive use.” If insurance companies can’t keep down costs, large pension funds might bypass them and contract directly with health-care providers. One entity considering such a move is the California Public Employees’ Retirement System (CalPERS), the largest public pension fund in the United States (with assets totaling $233 billion). Bill Madison, information officer for health care in the CalPERS Office of Public Affairs, says, “At this point in the process, we can’t say whether we are going to contract directly with radiologists or radiology centers, or include those services via contracting directly with hospital, medical, or physician organizations that have existing radiological-service arrangements.” Follow the Money When the Center for Medicare and Medicaid Innovation (CMMI) awarded $8.4 million to the Altarum Institute, CMMI was looking for ways to limit unnecessary medical imaging in Southeastern Michigan. Altarum Institute is a nonprofit health-systems research/consulting organization. In partnership with the network of United Physicians (Bingham Farms, Michigan) and the Detroit Medical Center PHO, Altarum Institute is trying to find ways to drive wider adoption of ACR appropriateness criteria and to promote better patient education on when a study might be unnecessary. Educating referring physicians to recognize when a patient’s history might be sufficient to preclude additional imaging studies is another priority. If all goes well, the three-year project will embed clinical guidelines in the image-ordering process, leverage health information exchange (HIE) capabilities to increase awareness of past imaging results, and use patient-education campaigns to offset patient-induced demand for medically unnecessary imaging. Dan Armijo, vice president, information and technology strategies, Altarum Institute, says that the federal dollars signal a concerted effort to determine the best form of utilization management. Essentially, government wants more effective utilization management from the radiology industry, and it is willing to spend money to find the best way to get there. According to Armijo, the idea is to do advanced clinical decision support in the context of a whole community, using ACR guidelines to support evidence-based decision making and increased provider awareness of past imaging studies. What if decision support turns out to be ineffective? “Whatever we find, we find,” he says, “but we feel this is going to be part of the answer.” This summer, the ACR announced that it had entered into an exclusive agreement with a Massachusetts startup to provide a technical platform, support, and licensing of the appropriateness criteria under the name ACR Select, which will be marketed to EHR companies and other vendors of health information systems in an integration-ready form. The idea behind the ACR’s appropriateness criteria and decision support is to provide information to clinicians at the point of care, making it easier for them to make the right decisions. Armed with proper criteria and information, referrers can be clearer about the clinical value of an exam and can have a better discussion with patients about rewards and risks. Whether It Works The ACR and the Medical Imaging & Technology Alliance recommend the use of evidence-based decision support—along with patient education, dose management, and accreditation—to advance appropriate utilization. It all sounds perfectly reasonable, but the CMMI investment is an attempt to find out whether the practice matches the theory. “The mere fact that CMS funded our effort, in partnership with the ACR, might be a hint that it agrees,” Armijo says. “It wants to evaluate the impact of decision support in the community setting to promote the use of guidelines developed by the radiology community about appropriateness.” Armijo continues, “We are talking about giving ordering physicians the tools to increase some aspects of utilization and decrease others. It’s not about reducing the total number of images, but using the diagnostic tools in the most effective manner possible.” Another part of Armijo’s mission is to increase providers’ awareness of past imaging studies using HIE mechanisms. In combination with a robust IT infrastructure and EHR adoption, this will allow ordering physicians to gain a greater awareness of prior studies and avoid duplication. Decision support might also loosen the grip of RBMs, which are approving or rejecting imaging requests based partly on appropriateness criteria, but also on insurer-specific criteria. “Along with the ACR, we put forward to CMS that we could investigate this matter on a large scale—3,000 physicians and more than a million patients in Southeastern Michigan,” Armijo explains. He continues, “Let’s implement decision support and provide some targeted guidance at the point of ordering. When someone who is not a physician is trying to influence decisions and saying you can’t order a test, let’s see if we can demonstrate that decision support reflects the appropriateness of imaging studies.” At its most basic level, government scrutiny stems from 2005, when significant growth in advanced imaging studies for Medicare enrollees was observed. CMS wants to pay less in all areas, including radiology. Like other medical specialties, radiology must invest time and resources in justifying its cost. Fortunately, an objective and focused justification might ultimately work wonders and prevent further cuts. “Just because there is growth in imaging does not mean it is inappropriate imaging,” Armijo says. “Technology changes, equipment becomes modernized, and there are new approaches to diagnosis.”