Radiologists Experiencing Mixed Results with ACOs: Accountable Care Is Alive, Well—and Unpredictable

As a collectively key component of the Affordable Care Act, accountable care organizations (ACOs) entered the present decade looking poised to enjoy a long and dominant run in the driver’s seat of U.S. healthcare economics. Many providers—not just primary-care “gatekeeper” docs but specialists too—had the sense they’d better join, align with or otherwise befriend an ACO if they wanted to remain enduringly relevant and maximally reimbursable. Today, the buzz is centered on CMS’s Quality Payment Program (QPP), with its MACRA and MIPS alphabet soup hogging the spotlight.

And rightly so, say some experts, as the risk/reward proposition of voluntary ACO participation has often been dicey, while the Medicare-mandatory QPP promises bigger bonus potential.

However, the two are not mutually exclusive, and nobody is predicting the demise of ACOs. They’re here to stay, most observers agree, even if they continue to rise, fall and shape-shift individually or collectively in a post-Obamacare landscape.

But durability does not confer indispensability, especially for specialists in group practice. Going forward, should radiology practices opt in to an ACO if they haven’t already done so? Or would they be better off staying out and concentrating their administrative energies on the QPP (as well as the approaching clinical decision-support requirements in the Protecting Access to Medicare Act)? And what about radiologists who are presently participating? Should they stay in, get out or postpone the decision?

There is no one-size-fits all answer to any of these questions. Market conditions vary regionally and locally, as do ACO availability and population health status. A look back at the ACO timeline may help light the way forward.

ACOs, Then and Now

The term “accountable care organization” had been bandied about for several years before it got catapulted into ubiquity by the ACA. Like private and public health maintenance organizations, which date to the 1970s, modern ACOs would get providers to share info and better coordinate preventive, diagnostic and therapeutic care so patients weren’t left on their own to navigate the system for each episode of care—which consumers tend to do inefficiently, cost-ineffectively and not always as safely as they should.

With high hopes for reducing Medicare spending, the federal government approved the applications of 32 Medicare “Pioneer” ACOs in late 2011. This group was made up of organizations already familiar with coordinated care and financial risk-sharing. Private payers also began setting up ACOs, or expanding similar setups while re-badging them “ACOs.” In 2012, the Medicare Pioneers were incentivized to report on metrics such as hospital readmissions and shared decision-making. That year and into 2013, bonus payments were based on both achieving good outcomes and demonstrating the ability to properly report.

Since then, the ACO picture has mushroomed into a mighty hodgepodge. By the end of the Pioneer program’s fourth performance year, 2015, only 12 of the original 32 had stuck it out. However, some of those moved into one of several dozen “next generation” ACO models. And hundreds more provider organizations—including many with scant risk-based reimbursement experience—hopped aboard, both during and since the Pioneer period, through the Medicare Shared Savings Program (MSSP). This rewards ACOs that cut costs while demonstrating patient-centered care and documenting clinical quality.

As reported by independent health researcher Paul Keckley, PhD, in Hospitals & Health Networks, there are now somewhere between 850 and 1,300 ACOs in operation¹. Most on the public side are MSSP participants, and more than 28 million patients are served by some type of ACO—8.3 million through Medicare, 2.9 million through Medicaid and 17.2 million through private insurers.

“The most recent data seems to confirm that ACOs are not going away,” Keckley tells Radiology Business Journal. “But their usefulness as a way to reduce Medicare spending is probably not as strong an accelerator as their usefulness providing an organizing framework so that doctors can improve quality and share risk.”

For primary-care doctors and other ACO helmsmen, Keckley suggests, cost reduction will remain an important consideration, but will likely fade as a primary expectation. That’s because participation is expensive, with IT costs and consultant fees adding up fast, and because the low-hanging fruits—wasteful utilization, inefficient processes and such—have already been picked.

Going forward, how and to what extent ACOs inform providers’ contracting and population-health strategies “will change,” Keckley says, “as regulations like MACRA kick in and as employers, insurers, Medicare and Medicaid assess their value.”

Uncertainty and Frustration

One thing is for sure: Radiology practices that proactively go or stay all in with an ACO will be trailblazers. Despite the maturing of the Medicare ACO model, only 20 percent of existing ACOs have any radiologist participation at all, according to CMS data crunched by the Harvey L. Neiman Health Policy Institute in a study still pending journal publication as of press time.

“Anecdotally, if you talk to radiology practices, you find that probably half of them think they are participating in ACOs,” says Danny R. Hughes, PhD, the institute’s senior director of health policy research and senior research fellow. “To be formally participating, they have to have some kind of contract or arrangement, shared savings components, and be taking on some of the risk.” In reality, he adds, many radiologists who think they’re in are merely getting referrals from ACO hospitals and providers while still getting paid on a fee-for-service basis. They’re neither taking any risk nor sharing any savings.

Meanwhile, Hughes says, a theme common to his conversations with radiology practice managers is the frustration they feel over the lack of ACO bonus payments—and that’s coming from the 1 in 5 who are officially participating.

The data are starting to show that “radiologist participation in ACOs doesn’t seem to generate a lot of savings for radiologists, because they are often participating in environments where it is very difficult to generate savings in the first place,” Hughes says. “And if the hospital system [running the ACO] feels it can generate a lot of savings on its own, they’re not even going to bother with radiologists. That way they can retain all the savings they generate.”

None of this seems to bode well for those hoping for, or banking on, the long-term growth of radiology participation in ACOs.

Quickly Diminishing Returns

One radiology practice that has seen the ACO experience from both sides now, the up and the down, is 21-rad Wichita Radiological Group (WRG) in Kansas. WRG joined a physician-led, MSSP ACO covering 16,000 patients in 2013. The practice entered hoping to achieve quality improvement and to realize shared savings with financial rewards on par with other specialists in the ACO. WRG also wanted to eventually develop a clinically integrated network—complete with insurance offerings—by leveraging its ACO-based referrer relationships with self-insured entities such as school districts and commercial concerns.

Alas, it was not to be. In the first year, the ACO saved a tidy $5 million, but CMS frustrated participants’ expectations when it didn’t adjust for high-cost outliers and told the ACO it had failed to qualify for a refund. In year two, with the easy weeds already pulled, the ACO saved only around $700,000. This was not enough to bring in return dollars. In the end, WRG’s success at generating savings by being part of a larger organization and having stronger purchasing power did earn around $2,500 per physician in reduced fees and refunds. But on the whole, the pieces didn’t add up for WRG. The group withdrew from the ACO prior to the start of performance year 2016, and the American College of Radiology (ACR) detailed the experience for two Imaging 3.0 case studies.^{2, 3}

“One of the biggest problems is that, from a primary care perspective, you can’t save the same dollar twice,” says John Lohnes Jr., MD, WRG president. “It was a matter of diminishing returns. Then they wanted to go to a bigger risk-sharing arrangement, and there were some problems with the RFPs.”

Meanwhile the most challenging difficulty turned out to involve the most foundational ACO principle: the sharing of information. WRG had a data-mining program capable of facilitating population-based analyses from within the ACO—but electronic medical record vendors Lohnes prefers not to name were less than cooperative in rounding out that input with other needed data.

“These vendors never followed through with their original commitment to make that data available to us,” he says. “They held the [relevant] information as proprietary. It was disappointing.”

Fortunately, there’s been a real upside to WRG’s unsatisfying ACO experience: readily repurposed processes and learnings. For example, as the group set up for life inside the ACO, Lohnes went through all its imaging protocols and made sure these aligned with ACR’s decision-support guidelines. “A lot of that can be used for MACRA,” Lohnes says. “By using the same criteria we’d set up for participating in the ACO, we saved ourselves several steps on MIPS. It’s been easy to port over some of the MIPS criteria, where they are the same ones we’d been using for the ACO.”

Applying ACO learnings to other cost- and quality-management programs turns out to be a common theme among ACO-experienced radiologists. And so does having a seat at the hospital table—something ACO participation inevitably occasions.

“When there was a new committee forming, we made sure we had a radiologist on that committee. Utilizing that same approach, we will continue to be involved, as we were even before the ACO,” says Lohnes. “Yes, it’s some extra work, but as a radiologist, you are an integral part of the whole medical enterprise. Your involvement is part self-protective, but it’s also in the best interest of the patient. That’s a nice place to sit. You can stay above the self-interest fray because you’re focusing on the patient.”

‘A Great Thing to Aim For’

Of course, participating in any program aimed at curtailing utilization, even if only indirectly, is going to present radiologists with some thorny questions. And some of these only begin with, “Are we doing the best we can for the patient?”

“It’s hard to put your finger on how much imaging is defensive imaging,” Hughes says. “It’s hard to put your finger on how much unnecessary imaging occurs that you could remove.”

Radiologists have a lot to consider with every decision they make, Hughes adds. “If something happens to that marginal patient and you are the person who pushed back on getting that image, that is certainly something you have to worry about,” he says. And that’s before worrying about generating enough savings to offset the fees you would have generated through utilization.

ACO participation or no, Hughes says it can be a difficult environment to navigate. “But it can be useful and instructive for radiology practice managers to reach out to ACOs in their communities where ACOs exist,” he says. “In theory, and in a perfect world, no one can argue that having increased communication among providers is bad for patients. It’s a laudable concept and a great thing to aim for.”

Activities Already On the ‘Should’ List

Geraldine McGinty, MD, MBA, vice chair of ACR’s Board of Chancellors, offers a similarly qualified approval of the ACO concept. She points out that the kinds of things radiologists would do in an ACO—benchmarking quality, participating in registries, documenting index checks on radiation dosage—are the kinds of things they should be doing anyway.

“We have all been in a situation where a referring physician says, ‘I want this study, and the patient wants it too,’” McGinty says. “That’s where it comes back to Imaging 3.0, where you are building relationships with people. If you are suggesting another test, they know you. They know that you are coming at it with your expertise and with your wish to provide the best care to the patient.”

“I am not naïve,” she adds. “Yes, there are still areas where there are misaligned incentives and self-referrals and all those things. But as radiologists, we have to aspire to be the best we can be. And that means demonstrating the quality of the care that we deliver, making sure everybody knows that quality care is [our priority]. That’s something you want to do whether you are a practice that is still fee for service or a practice that is in an ACO.”

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References:

¹Paul Keckley On Accountable Care Organizations: What’s Their Future? March 2017. http://www.hhnmag.com/articles/8103-accountable-care-organizations-whats-their-future. Accessed April 2, 2017

²Hassan A. Imaging 3.0 Case Study: The Payment Pendulum. https://www.acr.org/Advocacy/Economics-Health-Policy/Imaging-3/Case-Studies/Payment-Models/The-Payment-Pendulum. Accessed April 4, 2017.

³Hassan A. Imaging 3.0 Case Study: Rewarding the Radiologist. https://www.acr.org/Advocacy/Economics-Health-Policy/Imaging-3/Case-Studies/Payment-Models/Rewarding-the-Radiologist. Accessed April 4, 2017.