Radiology and the ACO: Early Experiences

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.”

In addition to deploying the software, AMI has committed to having its radiologists visit its primary care physicians to discuss clinically challenging issues in imaging, model different patient scenarios, and review guidelines and best practices. “They are going to collaborate with one another in a way that, outside ACOs, has been missing in American medicine for a long time,” Lyons says.

Whitfill explains that his practice decided to take on the risk of the ACO model to avoid commoditization in its market. “Without passing judgment on whether value-based approaches are good or bad, it’s clear that this type of change is happening across all kinds of different payor environments—it’s not just CMS,” he says. “ACOs will be focused to some degree on controlling utilization, and that may result in some lost revenue, but if this is going to happen anyway, radiology groups would be wise to make themselves a part of it, so that some of the savings comes back to them.”

In fact, he notes, some specialties have actually benefited financially from participation in clinically integrated organizations of this kind. “There are great examples in areas like orthopedics and spine where bundled payments or other value-based products have actually increased physician revenue. So it’s not always a losing proposition—as in any risk situation, there are upsides and downsides.”

At the John C. Lincoln ACO, one hospital has brought its employed radiologists to the organization, while another has brought the independent practice with which it partners. Anspach says he sees no difference in the service the ACO receives from the two. “Both groups have been very actively involved in our ACO as well as the development of our EMR strategy, and both have provided a lot of leadership,” he says. “A radiology group certainly doesn’t have to be employed to be involved. For independent radiology groups, my recommendation is to get involved and talk to the ACO about how they can provide value.”

Defining the value proposition

Anspach is witnessing radiology groups coming forward to tell referring physicians which study will provide the most information for specific indications. “They’re available to primary care and other referring physicians to give them advice about precisely the right study to order,” Anspach says. “The challenge is getting the right study the first time. That means the wrong radiologists can become a cost center—but radiologists who are engaged can provide incredible value.”

Whitfill notes that population health management on the scale that ACOs are intended to support will require “a more holistic view of the patient”—and that radiology can help manage that approach. “We need to get people to collaborate so that patients aren’t just shuffled from physician group to physician group,” he says.

“Our organization has a strong care coordination department. When patients are discharged from the hospital, we make sure we follow up.”

“We look for people whose risk of bad outcomes will decrease if we can just get a little more time with them—for instance, a patient with heart disease who could avoid hospitalization with more visits to his or her physicians or even at home,” he explains. “We’re spending more time focused on things like that than just the utilization piece.”

At AtlantiCare, in addition to consultation with and education of referring physicians, the radiologists also participate in strategic planning and leadership. “The commoditization of what we do is a significant threat,” Glassberg notes. “Our mindset is that there is no question about whether we will be at the table. We must. We make a concerted effort to participate in hospital policy and procedures and in hospital and health system strategic planning.”

Mukherji also emphasizes the importance of educating the various ACO constituents about how and where wasteful imaging originates. “We need to communicate to the administration and our participating physician colleagues that we want what is best for the patient when it comes to imaging—the most appropriate study obtained with the highest quality, interpreted by the most qualified physician, and performed at the lowest reasonable cost,” he says. “We need to make sure the health system and its physicians understand that imaging should be performed by radiologists to eliminate any hint of self-referral, which is one of the primary drivers of inappropriate studies.”

Ingrid Lund, practice manager with the Advisory Board Company, suggests a range of additional innovative approaches to adding value. “We’re seeing a lot more interest in and pursuing of JVs to create lower-cost sites of care within the network,” she says. “Imaging experts can help with capital equipment purchasing—they’ve probably learned a thing or two about working with vendors and service contracting that could help the organization with some of those big decisions.”

 She adds that screening exams often act as a gateway that bring patients into the health system, creating another opportunity for radiologists to supply their expertise. “There are a lot of careful steps you need to take to optimize that, from pricing to marketing to downstream needs,” she points out. “A lot of what imaging has learned about that could be much more widely applicable.”

Further, she says, radiology groups can make themselves invaluable by offering to supplement the organization’s informatics infrastructure. “IT is so important to reducing repeat exams,” she says. “If radiology groups are willing to manage the storage and communication around that issue, that will make them very valuable partners to the ACO.”

Importance of informatics

Glassberg says the importance of informatics to accomplishing the goals of ACOs—and, ultimately, to managing population health—cannot be understated. “Everything we’re going to do is going to be directly reliant on our informatics systems and their ability to talk to one another,” he says. Lyons concurs: “Our organization is still growing, but modest, and we are spending a small fortune on interoperability,” he says. “We need to get data from a huge number of EMRs into a stable environment.”

Anspach calls data analysis “one of only a few things that will make or break an ACO.” Pointing out that participants in the Medicare Shared Savings Program are given access to current and historical claims data from CMS, he sees potential for ACOs to break new ground when it comes to business intelligence and analysis of data. “We have a lot of opportunity now to look at cost effectiveness of care and quality outcomes in a way that we never have before,” he says.

Mukherji adds that radiology can enhance its standing in the healthcare community by being an active participant in these kinds of analyses. “A big shortcoming of ours in the past twenty years has been that we have never tried to quantify how much money imaging saves and how much morbidity it prevents,” he says. “Instead, we’ve let people do it for us, and all they have focused on is the costs associated with those studies instead of how imaging improves outcomes. We need to be focusing on demonstrating the tangible benefits of imaging—how we improve treatment, accurately assess treatment outcomes and avoid costly surgeries. 

“One never hears about an acceptable ‘negative rate for exploratory laparotomies performed for trauma or children with suspected appendicitis,’” he continues by way of example. “Rates on the order of 10 percent to 20 percent were acceptable twenty years ago, but are now considered unacceptable because of imaging’s ability to avoid unnecessary surgery and eliminate the associated morbidity.  This has resulted in improved patient care and reduced costs to the patient.”

From an administrator standpoint, Anspach says he also sees an opportunity for radiology groups to bring data on cost reduction. “If radiology can analyze its own costs to the ACO on a per-member per-month basis, it can play a significant role in reducing that expense,” he observes.

Obstacles to involvement

The issue of cost is one of the most daunting barriers to radiology participation in the ACO model, Mukherji observes. “ACOs are looking at their overall costs and comparing them to benchmarks in their local regional communities,” he says. “Those costs are global—for instance, in the case of knee injuries, they include everything from nursing care to MRI scans to what the anesthesiologist and surgeons are paid. But if your organization doesn’t fare well on cost, there could be a knee-jerk reaction of looking too closely at imaging. Therefore, radiologists must be knowledgeable about the process and be willing to invest the time to participate in the process at the local/regional level.”

Lund and Lazerow express similar concerns. “What we don’t want is for ACOs to be focused on cost first and foremost, without thinking about quality,” Lund says. “They need to be considering both levers.” Lazerow adds that any imaging that happens outside the network will contribute to the appearance that radiology is a cost center.

“Even if the appropriateness question is resolved, there is still the question of where the study should be done,” he says. “If ACOs are going to have that cost on their scorecards anyway, they want the revenue coming into the organization as well.”

Lyons adds that there are still pockets of hesitation on the specialty practice side as well. “I’ve had multiple conversations with specialists who have had great success in the past and don’t entirely like the look of the future,” he notes. “If they are going to work with an ACO, they’re going to do it somewhat reluctantly, and in part because they feel pressure—there’s a lot of that old culture to work through. And that makes it all the more refreshing when progressive organizations like AMI embrace the future.”

Looking forward

Though approaches to and models for radiology participation in fledgling ACOs can vary widely, everyone agrees that practices need to “lean in,” as Anspach puts it. “This is a new area of healthcare finance and delivery, and there’s a lot of learning taking place among everyone involved,” he says. “The engagement of the radiology physician is critical to the success of the radiology group. Having them actively involved in developing clinical protocols will be invaluable.”

Of course, the commonly proffered advice—be at the table or on the menu—doesn’t explain exactly how groups should get invited to dinner in the first place. For AMI and AtlantiCare, the relationship was the result of the radiology practice’s prior involvement with the health system’s leadership.

“I’ve had a relationship with the hospital’s executive leadership for years,” Glassberg says. “I have partners who serve in leadership roles as chairmen of committees, creating more direct links. When we learned AtlantiCare was branching out into having an ACO, it was a natural and easy step for us to get involved and be at the table.”

Lyons and Glassberg had never met, but Glassberg knew AtlantiCare’s CFO, who connected the two. “AMI is also a very large local employer, so as we were developing this clinical relationship, we started talking about whether we could migrate AMI’s employees onto an ACO benefits platform,” Lyons recalls. “I wasn’t shy, and Rob was very positive and proactive about the possibility. That’s where the relationship really started.”

Once those relationships are established, radiology groups can begin the process of adapting to the value-based paradigm with optimism instead of wariness, Whitfill says. Because ACOs represent a new approach to payment and delivery, experimentation will be the hallmark of the next few years, he predicts.

“There aren’t any playbooks that tell you how to do this,” he says. “A lot of it is just taking guesses at what will improve quality and decrease costs, then putting those ideas into production to see what works. It’s not a simple proposition, and many attempts will likely go awry.”

He adds, however, that for radiology, that experience could prove invaluable to laying the foundation for the future. “We’re all trying different things and comparing data to see what’s working and what isn’t,” he concludes. “It’s both uncertain and exciting.”

Reference

• Mukherji SK. The potential impact of accountable care organizations with respect to cost and quality with special attention to imaging.  J Am Coll Radiolo. 2014;11:391-396.