On June 28, the Supreme Court ruled that the individual mandate contained in the Patient Protection and Affordable Care Act (PPACA) is not unconstitutional, interpreting it as a tax. Based on the mandate, in 2014, US residents will be required to buy health insurance (or will face a tax penalty that will slowly increase over time). Pat Basu, MD, MBA, CMO of Virtual Radiologic (vRad) and a former Obama-administration White House Fellow, says, “The eventual positive impact on utilization could be large, but you will not see 30 million additional insured patients in early 2014. The fine in the first year is relatively low, so I think a lot of younger individuals just won’t comply.” Further, Basu predicts, the impact of the mandate on imaging might be small, at first. “The primary age group we’re talking about is between 26 and 45, and that age group is currently not using much medical imaging—but its members are also the fastest-growing users of it,” he says. “In the near term, the PPACA may not have a gigantic effect on radiology practice patterns. In the long run, however, it almost certainly will.” Impact of the PPACA In fact, Basu’s prediction is that other pressures on utilization may mitigate some of the uptick in imaging volume caused by the newly insured population. “Other utilization methodologies will encourage more use of plain film and ultrasound,” he says. “Before, where a patient might have received a plain film, ultrasound, CT, and then MRI, soon, you will be seeing more of one or the other and less of both. For instance, in stroke imaging, over time, more patients may go straight to MRI instead of starting with a CT.” He adds that this trend is likely to be underscored by the ACR® decision-support module, which discourages using multiple modalities, depending on the clinical scenario at hand. As the tax penalty becomes more punitive and more individuals become insured, Basu anticipates that imaging volume on the outpatient side will increase slightly, but only enough to counterbalance the decreases in volume seen in recent years. “Outpatient imaging might only decrease by 1% instead of 5%,” he says. “I think the PPACA will add low single digits of volume growth to outpatient imaging, based on health-care economic studies (as well as the experience they have had in Massachusetts).” On the inpatient side, Basu also does not anticipate dramatic change, even in the increasingly imaging-intensive emergency-department setting. “I think emergency-department imaging volume will continue to grow at a relatively modest rate,” he says. “Clinically, emergency departments are very dependent on medical imaging, so that will continue to drive volume—but utilization oversight on the emergency-department side is increasing as well, so overall, I think it will only come out to a slight net uptick in emergency-department volume.” Future Practice Patterns Although Basu sees little cause for panic in the implementation of the individual mandate, he does believe that radiology practice patterns are set to experience a shift, in coming years. “In general, what you are going to see are more referrals coming from primary-care physicians and physician extenders—not because of the PPACA, but because of other economic factors,” he says. This will mean more time spent on conversations with referrers, Basu says, shifting radiologists’ roles and altering how they are likely to spend the day. “When I consult with an orthopedic surgeon, our conversation is very focused, and my value add is very specific,” he says. “We are done relatively quickly. My conversation with an internist, pediatrician, or even a nurse practitioner is going to be different. Is this an infection? Is it a tumor? I’ll be recommending laboratory tests and consultations from other specialties. The consultative approach is much heavier.” Basu notes that although the initial impact of the PPACA on volume might be small, there are likely to be further legislative measures to come, and these can be expected to target systemic costs and reimbursement. “In general, we are seeking to improve the equation of access and quality while controlling costs,” Basu says. “The health-reform package does a lot to increase access, and it does a moderate amount to increase quality, but it doesn’t do a lot directly on the cost side. For that reason, I think there will be some future legislation related to controlling costs—the cost-cutting pressure will not stop.”Cat Vasko is editor of Medical Imaging Review and associate editor of Radiology Business Journal.