A private practice in Alabama invests in IT and relationships in advance of participating in a Medicaid regional-care organization.
Other than college football, the State of Alabama is not normally thought of as a change leader. Yet Alabama has joined a few other states in an attempt to control spending in Medicaid programs by turning to accountable-care organizations (ACOs). On May 17, 2013, Act 2013-261 became law. This law changes the Alabama Medicaid system from a fee-for-service to a managed care program, beginning in October 2016. Instead of contracting with commercial managed care organizations to deliver care to approximately one million Medicaid beneficiaries, the state is allowing the creation of locally run regional-care organizations (RCOs) to coordinate care delivery.
Why is Alabama embracing this change? Ultimately, the answer is money. More specifically, it is the increasing amount of public dollars allocated to Medicaid expenditures. In 2011, approximately one in five Alabama citizens qualified for Medicaid services. Medicaid covered 53 percent of births, 47 percent of children, and 67 percent of nursing home residents at a cost of $5.63 billion to which the state contributed $1.84 billion.
How will a State of Alabama RCO operate? Each RCO will have a medical director who is a primary care physician and a governing board of 20 members divided into two categories of risk-bearing and non-risk-bearing members. The governing board will determine how to apportion the payment among the providers for both at-risk and non-risk members.
Are there antitrust concerns about belonging to an RCO? The state has established legislation that specifically addresses this concern because physicians and hospitals participating in the RCO will be negotiating collectively and bargaining with one another to establish payment models for care delivery. Alabama, through a state action doctrine, provides a Certificate to Collaborate to protect appropriate and necessary collective bargaining.
Are organizations and physicians evolving quickly to respond to this change? Radiology of Huntsville (ROH) has anticipated this change to ACOs and the potential for risk assumption for more than five years and began laying the groundwork in the north Alabama market. ROH consists of 30 radiologists providing specialty radiology coverage to six Alabama hospitals, two breast centers, ten outpatient imaging centers, and multiple physician offices. ROH’s preparation for risk assumption began primarily by deploying technology in the practice and secondarily by working on key relationships with providers throughout the market.
Wiring the practice
ROH made a strategic decision to embrace teleradiology in the practice and throughout the radiology workflow approximately 10 years ago. The initial goal was to use teleradiology to facilitate workload balancing. Teleradiology technology evolved to enable subspecialty reading and consultations. Then, the technology created a conduit to provide off-site, after-hours coverage for outlying hospitals and providers.
ROH took the initiative to link the region’s hospitals and imaging centers to facilitate prior study availability for comparison of patient studies and is now connected to 32 healthcare facilities. In the last year, ROH, in conjunction with a regional radiology workflow information technology provider, moved the practice to a single voice-recognition platform with electronic report distribution to referring physicians and image and report access over the Internet, as well as a mobile-device application.
The combined effects of these decisions resulted in a radiology workflow that serves as a regional community PACS and ultimately a foundational component for any health information exchange (HIE). These efforts provided the tools to improve patient care via prior image and report availability for both radiologist and referring physicians alike. Efficient access to prior studies across the region allows clinicians to avoid unnecessary repeat studies, lowering costs while avoiding additional patient radiation exposure. The network also provides an efficient conduit for outlying hospitals to transmit images to specialists for review at the tertiary trauma center to allow appropriate management of costly patient transfers.
Referring physicians and their staffs all have access to results, either through the report portal for the patient reports or directly into the network for reports and images