Many changes mandated by the Patient Protection and Affordable Care Act (PPACA) are already underway, but health care still has time for a deep breath before the biggest change of all: In 2014, the insured-patient base is set to explode, driven by limits in payors’ ability to deny coverage, by expansion of Medicaid, by the launch of state health-insurance exchanges, and by the hotly debated individual mandate.
Ed Gaines, JD, CCP, chief compliance officer for Medical Management Professionals, Inc (MMP), Atlanta, Georgia, says, “The Supreme Court could do any number of things—it could even simply strike down the individual mandate and leave the rest of the bill, but we would still be left with the other 90% of the iceberg, and if the risk pool is not mandated through the individual mandate to purchase health insurance, the numbers do not look very good.”
Missy Lovell, MBA, MMP’s compliance manager, says that the radiology groups that the company manages are taking a variety of approaches to preparing for the influx of newly insured patients. “They are leveraging new technology for more efficiency and are looking at creative scheduling based on patient flow,” she says. “They are focused on spending more time on the front end and on serving patients, which they hope will lead to less time spent on the back end.”
Gaines warns, however, that the potential repercussions of the change might be more serious than groups are anticipating. “Nobody talks about the Massachusetts experience when we are discussing where reform is headed,” he says, “but the state has a version of what we are all going to have, and we can see what radiology’s future might look like there.”
Amping Up Efficiency
Groups are preparing for the expanded patient base by upgrading their technology, in terms of both modalities and software, Lovell says. “The first thing groups may be doing is upgrading their equipment to accommodate more volume, while providing higher-quality images and services,” she notes. “They are also moving to expand their PACS to all of their locations, so that they can use teleradiology to manage their days more efficiently and balance the load.”
One potential problem that groups foresee is recruitment, which is leading to changes in the way that centers are staffed, Lovell says. “It can be difficult to recruit radiologists in subspecialties—and for various locations—even now, and groups are gearing up for that even more, in the future, with the larger patient volumes and declining revenues,” she says. “We are going to see the use of physician extenders and midlevel staff (such as nurse practitioners, physician assistants, and radiologist assistants) increase.”
Also on the chopping block are current scheduling methods. “They are looking at staffing providers according to patient ebb and flow, and in imaging centers (where they can revise patient-service hours) they might move to offering extended night and weekend hours—not just your standard Monday through Friday, 9 am to 5 pm,” she says.
Lovell adds that groups are preparing for the change by improving administrative efficiency, to ensure that payment is as prompt as possible. “We will see groups working more with their hospitals or imaging centers to ensure that good, up-front data gathering and dictation are performed—so they spend less time having to deal with denials, preauthorization issues, and repeated dictations,” she says. “This will also enable them to maximize reimbursement by having fewer denials.”
Massachusetts As Crystal Ball
Gaines notes that radiology, like the rest of the health-care system, is likely to face several unintended consequences arising from the increased patient base created by the PPACA—and that this hypothesis can be proven by what has transpired in Massachusetts since the state adopted universal health care, in 2006. “When we look at what has happened in Massachusetts, we see health plans are responding to the expansion of coverage by charging an increased premium to patients who want access to high-cost hospitals,” he says.
Gaines points out that these high-cost facilities were defined recently by Blue Cross Blue Shield (BCBS) of Massachusetts as including such leading Boston institutions as Brigham and Women’s Hospital and Massachusetts General Hospital (MGH). “If a BCBS member decides to go to MGH for an MRI exam, BCBS will charge $450 more than if he or she had gone to a community hospital that it has determined to be a lower-cost facility,” he says. “Brigham and Women’s Hospital and MGH are world-class medical institutions. Is it fair for BCBS to classify them in this way and charge me more because I want world-class care for me and my family?”
The result, Gaines says, is the steering of patients toward imaging centers and IDTFs. “If it is going to cost the patient more out of pocket, as is the case in Massachusetts, hospital-based providers have to be looking at how efficient they are in overall cost and quality,” he says. “The insurers are responding by breaking this down on cost alone.”
Gaines notes that another result of reform in Massachusetts was a 9% uptick in emergency-department visits; this will have ramifications for radiology, once insurers start trying to control the new influx of patients. For patients whose problems are not acute, he says, “We are seeing a lot of experimentation by state plans to try to keep patients out of the emergency department.”
He adds, “The difficulty is that a lot of times, those policies become a blunt instrument. It leads to gatekeeper, ask-a-nurse programs where you have to get prior authorization for any imaging, and those programs are going to become even more prevalent.”
He concludes with the prediction that most of the PPACA’s mandates are here to stay, meaning that radiology needs to begin preparing for a future of even tighter reimbursement and greater scrutiny from payors. “Even if the entire law were struck down, I still think we would see bundled payments and accountable-care organizations garnering bipartisan support,” he says. “CMS can demonstrate that these programs save real money, and I just do not see them going away—whether or not the PPACA is overturned (as a whole or in part) by the Supreme Court.”
He adds, however, that if radiology groups seize the opportunity to demonstrate high quality at a lower cost, they can take advantage of the reform package’s emphasis on program integrity. He says, “It is a yin–yang symbol: both positivity and threat. It can be a huge opportunity.”
Cat Vasko is editor of ImagingBiz.com and associate editor of Radiology Business Journal.