Radiology and the ACO: Early Experiences

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Source: ACO-map-2.jpg - ACO Map Jan 2014
Figure 1. Medicare ACOs are expanding their reach with 23 Pioneer and 343 Shared Savings Program ACOs as of January 2014. Pioneer ACOs (Blue); Shared savings ACOs 2012 cohort (Red); Shared savings ACOs 2013 cohort (Purple); Shared savings ACOs 2014 cohort (Green).

Healthcare in the U.S. is shifting toward management of population health, and several models for radiology practice involvement have emerged

As accountable care organizations (ACOs) take root in communities around the country, radiology is slowly but surely finding its footing in the emerging ACO care delivery and payment paradigm. “There’s tremendous focus across the healthcare industry in realigning incentives to get away from fee-for-service economics,” Rob Lazerow, practice manager, The Advisory Board Company, Washington, DC, says. “There is continued growth in ACO participation, with 606 ACOs established at last count. Some of the movement is on the Medicare side and some is on the private side—organizations are asking whether they should build models like this with employers or even start their own health plans.”

Many ACOs got their start participating in the Medicare Shared Savings Program, such as the John C. Lincoln ACO in Phoenix, Ariz. Nathan Anspach, CEO of John. C Lincoln, explains, “Considering the growing size of our primary care group, we thought the ACO model made good sense for us. Our CMO began getting groups of radiologists and other specialists as well as primary care physicians together to look at the most effective ways to manage chronically ill patients, and that approach has been very successful for us so far.”

In an example of a slightly different approach, James Whitfill, MD, former CMIO with Scottsdale Medical Imaging in Scottsdale, Ariz., now serves as CMO for a new, physician-led clinically integrated network called Scottsdale Health Partners. One year ago, it entered into a collaboration with Cigna to launch an accountable care initiative. “We were looking for a way that community physicians could remain independent and not have to sell their practices to a health system, while coming together in a way that brings the benefits of being in a larger organization,” he says. Independent physician groups and hospitals coordinate around quality improvement and cost savings, but continue functioning under separate tax IDs.

“If you think about the capital a hospital or health system would need to have on hand to buy up 300 physicians, it would be significant,” Whitfill notes. “So we are seeing more and more examples like this, where there is a way to build a coordinated care network without physicians having to become employees.”

Interestingly, utilization management of medical imaging appears not to have emerged as an ACO priority to date. In an article1 on radiology’s potential role in ACOs, Suresh Mukherji, MD, MBA, FACR, chairman of the radiology department at Michigan State University, East Lansing, looked at the initial impact on imaging among institutions participating in the CMS Physician Group Demonstration Project. He found no significant impact on utilization attributable to the model itself.

“Utilization has decreased, but I don’t think it’s because of the ACO model,” Mukherji says. “When I was on the board participating in the precursor to our ACO, there were never statements made specifically about reducing imaging—every specialty feels it is in the crosshairs. ACOs, at least so far, are focusing less on tests patients get from radiologists and more on the providing optimal care for a variety of chronic disorders such as chronic heart failure and diabetes.  The intent is to avoid initial hospitalization, readmission, and complications.”

Models for radiology participation

Consulting on and providing feedback for imaging appropriateness, however, is likely to be a key component of radiology participation in ACO models. For instance, in the AtlantiCare ACO, Egg Harbor Township, N.J., where radiology services are provided by Atlantic Medical Imaging LLC, Galloway, N.J., that is precisely the course of action.

“The path we are going down is how radiology can add value to ACOs by participating in and providing utilization management,” Robert Glassberg, MD, CEO of AMI, says. “We’ve worked with a private vendor to acquire a decision-support module that we plan to use to provide the right medical imaging exam at the right time and place.”

Dan Lyons, MD, medical director at AtlantiCare, adds, “We’re all committed to the triple aim of reducing cost while enhancing quality and the experience of care. What the radiologists have done is offer to create a partnership with our primary care physicians. It’s not always easy for them to know how to order the right test at the moment of care.”