As Policies Evolve, Practice Leadership Must Remain Active

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 - Danny R. Hughes, PhD
Danny R. Hughes, PhD

As research director of a policy think tank dedicated to medical imaging, I’m frequently asked how radiologists—and their practices—will fit into the broader healthcare landscape once the current tumultuous healthcare environment evolves into stable equilibrium. Of course, whether we do see a stable equilibrium is a questionable assumption in itself, but it doesn’t hurt to put on our futurist hats and explore how this may look for radiology.

Although some folks foresee a substantive rethink of the ongoing transition from volume to value-based care, it’s hard to believe that this train is slowing down. Most of the quality programs that underpin this transition derive from earlier Centers for Medicare and Medicaid Services (CMS) programs initiated a decade ago to improve quality and control costs. That these programs will persist and continue to evolve beyond MACRA’s shelf-life is likely a foregone conclusion. Thus, regardless of what the future holds, it’s paramount for radiology practices to become engaged with quality reporting and work to improve their measures to be well-positioned in future reimbursement programs.

The future of alternative payment models is an area that is trickier to discern. HHS Secretary Tom Price, MD, has been vocal that CMS projects such as the comprehensive joint replacement program and other bundled payment demonstration efforts should not require mandatory participation. Given that most radiology practices simply participate in these models as fee-for-service providers anyway, it’s hard to assess the importance of any changes to the models.

However, although bundled payments were once seen as a growing mechanism for moving towards value-based care, they are now considered by health policy experts as an important—but relatively limited—tool that will ultimately comprise a fairly small share of future value-based payments.

Value-based models driven by redesigning care toward comprehensive, integrated care delivery systems are likely to play a larger role in the future of radiology. These models, such as Accountable Care Organizations (ACOs) or Patient Centered Medical Homes, place a premium on primary care providers to manage resources employed for patient care. Because of this, it is vital for radiologists to re-emerge as the “doctor’s doctor” and play a strong consulting role in patient management. Efforts such as the American College of Radiology’s Imaging 3.0 can educate radiologists on how to take active roles in patient care, but success in these organizations will require radiology representation in their leadership.

This is particularly true for ACOs. Currently, only 20 percent of ACOs have a radiology practice included in the organization. Although many have found mixed results in Medicare ACO performance, private payers are beginning to implement these models as well—and unlike Medicare ACOs, they offer additional incentives such as capitated payments for care coordination that can make them more attractive for participants. Whether ACOs live on or dissolve under their current administrative weight, the mantra of designing payment systems for “population health” rather than “patient health” that underlines the shift to value-based payments isn’t likely to go away. Thus, radiology participation is important to ensure a seat at the table for the next wave of models ahead.

As we look further into the future, one has to wonder just how far the push toward population health will take reimbursement. Unlike the previous areas discussed, this is almost purely speculative. With significant opposition to a single-payer system—and with the ACA essentially “doubling down” on insurance markets as the primary method for financing healthcare—I find it hard to believe we’ll be transitioning toward a universal payer/care model. In fact, I would argue that what we see in the trend of reforms is really a subtle nudge towards broad-based capitation.

Yes, capitated managed care comes and goes as the future of healthcare in predictable waves. However, one can make a case that we are being guided towards capitation through market incentives. It is no secret that physician practices are consolidating at a rapid pace. I argue much of this is a need to achieve sufficient scale to manage the cost and increasing regulatory burden of serving Medicare patients, with few dispensations for small practices and solo practices. Once larger practices are incentivized to voluntarily collaborate in models such as ACOs and bundled payments, it is a small step for these practices to formally merge into integrated networks—and they are already determining internally how to distribute the aggregate payments. Continuing down this slippery slope, it’s easy to imagine competition for capitated payments between the half-dozen or so national managed care systems that remain through this process.

Ultimately, whether radiology practices seek to thrive in this dystopian future or an alternative physician-led renaissance, active radiology practice engagement is the key to survival. What kind of engagement? Ensuring practice leaders stay abreast of healthcare policy and robust participation in hospital and health system leadership. If practices complacently sit still as healthcare policies continue to change, it could result in their practices—or even the entire specialty—being left behind.