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