Dr. Shrestha is Vice President, Medical Information Technology, University of Pittsburgh Medical Center, Pittsburgh, PA; and Medical Director, Interoperability & Imaging Informatics, Pittsburgh, PA.
Disclosures: Dr. Shrestha is on the Medical Advisory Boards of Nuance, Inc., and Vital Images, Inc., as well as on the Editorial Board of Applied Radiology, and the Advisory Board of KLAS Research.There is no doubt that change is coming to the world of imaging; both in the very way we practice the profession, as well as in the way we contribute value back to health care. The spiraling cost of health care in the United States (U.S.) is unsustainable, and it has perhaps been rightly stated, “advanced imaging is the bellwether for the excesses of fee-for-service medical care.”1
Currently, the United States spends more on health care services than any other country, exceeding $2.6 trillion, or about 18% of our gross domestic product, yearly; yet Americans have a shorter life expectancy than people in almost all of the peer countries.2 What’s worse is that this cost is increasing faster than inflation and the economy as a whole. While there are many reasons for this, one of the key reasons cited is that we tend to pay doctors, hospitals, and other medical providers in ways that reward doing more, rather than being efficient, in the way health care as a whole is delivered. Here’s what is not working: our predominantly fee-for-service system that reimburses for each test, procedure or visit, alongside medical systems that lack integration, propagate unnecessary tests and over diagnosis. The U.S. did 100 magnetic resonance imaging (MRI) tests and 265 computed tomography (CT) tests for every 1,000 people in 2010—more than twice the average in other OECD (Organization for Economic Co-operation and Development) countries.3
There is a definite need to shift from a volume-based practice of imaging to one that emphasizes value across the care continuum.
Health care reform and ACOs
The Health Information Technology for Economic and Clinical Health (HITECH) Act, implemented as part of the American Recovery and Reinvestment Act (ARRA) of 2009, was signed into law on February 17, 2009, to promote the adoption of meaningful use in health information technology. Now, while radiology is no stranger to adopting and using digital technology, the push to use electronic health records (EHR) and care coordination across the full spectrum of health care delivery has wide-reaching implications for radiology—and these implications have not been fully understood or embraced by the radiology community. The Patient Protection and Affordable Care Act (PPACA) of 2010 has provisions for the development of accountable care organizations (ACOs) and happens to represent one of the most significant regulatory overhauls of the U.S. health care system since the passage of Medicare and Medicaid in 1965.
The ACO initiative has the potential to remake health care delivery, incentivizing physicians and health care providers of all types—hospitals, clinics, long-term care facilities, and others—to work together to improve outcomes and generate shared savings. Increasingly, some integrated delivery health systems and large multispecialty groups already consider themselves to be ACOs, or they have adopted many facets of the notion of accountable care. While some of these newer models are rehashing older hospital- and physician-managed care partnerships from the 1990’s, the goal of reducing costs through better care coordination is a noble one and certainly worth another try.
The Centers for Medicare and Medicaid Services (CMS) began entering into agreements with ACOs in January 2012. From late 2011 to early 2013, Medicare contracted with > 250 ACOs nationally with 4 million total Medicare beneficiaries. Another 100 to 200 ACOs are expected to be added in the next 2 years. At the heart of the ACO model is a shared-savings program, which reimburses participating physicians and providers for the quality, efficiency, and appropriateness of the care they deliver. ACOs must meet quality standards to ensure that savings are achieved through improved coordination and provision of appropriate, safe, and timely care. CMS has established 33 quality measures on care coordination and patient safety, the appropriate use of preventive health services, improved care for at-risk populations, and patient and caregiver experience of care. If the ACO surpasses certain performance benchmarks, CMS will effectively share those cost savings with the ACO.
The war against inappropriate overutilization of health care resources is on, and radiology is a prime target.
Understanding the climate to weather the storm
Accountable care may provide a framework to control costs primarily by reducing avoidable, duplicative, variable, and inappropriate use of health care resources. In this era of turbulent financial rumblings, fully comprehending the climate is critical to weathering the storm.
Imaging leaders face many business and operational challenges. While some perceive destabilizing effects of health care reform, the reelection of President Obama ensured one thing for health care, regardless of party lines: Reform is here to stay. It is now time to turn any question marks into periods—perhaps even into exclamation marks. Understanding the challenges affords us the chance to leverage the opportunities at hand. In his most recent State of the Union address,4 the President remarked, “We’ll bring down costs by changing the way our government pays for Medicare, because our medical bills shouldn’t be based on the number of tests ordered or days spent in the hospital—they should be based on the quality of care.”
According to a recent study that retrospectively analyzed a large group of CT and MRI examinations for appropriateness using evidence-based guidelines, approximately 26% to 30% of the imaging tests ordered were deemed either unnecessary or inappropriate.5 The American College of Physicians (ACP), the largest U.S. medical specialty group, found that excessive testing costs a staggering $200 billion to $250 billion per year.6
Another reality facing imaging leaders is that of softening volumes amidst a climate of continued reimbursement erosion. Despite an exceptional run in the late 1990’s and early 2000’s, with Medicare outpatient imaging volumes experiencing growth rates from 10% to 15% annually, the growth of discretionary noninvasive diagnostic imaging in the Medicare fee-for-service population has distinctly been slowing since 2005, with the slowdown being most pronounced in MRI and nuclear medicine.7 Current trends also point to declines in hospital-based imaging in almost all modalities. The previous ‘age of growth’ in imaging has given way to an ‘age of accountable care,’ with increased scrutiny, greater price sensitivity, and greater focus on the full cost-of-care that rewards imaging appropriateness.
CMS has also finalized the expansion of Multiple Procedure Payment Reduction (MPPR), and this clearly will have an impact on reimbursement. CMS will apply MPPR to the professional payments of certain advanced imaging services, such as CT, MRI, and ultrasound, primarily in situations when multiple imaging services are furnished to the same patient, in the same session, on the same day, by the same practitioner. The imaging procedure that carries the highest professional payment will be paid in full, while professional payments for other services will be reduced by 25%.8
However, the reimbursement battle rages on, led by organizations such as the American College of Radiology (ACR). Expressing strong opposition to further cuts in imaging reimbursement, the ACR recently argued that imaging reimbursement has been cut 12 times since 2006,9 and warned of adverse effects on patient care resulting from these reductions, including a significant regulatory cut to (noncontrast) lower- and upper-extremity MRI reimbursement in the 2013 Medicare Physician Fee Schedule. The ACR correctly argues for the adoption of quality-based imaging utilization and management policies that would mandate the use of appropriateness criteria in ordering advanced imaging studies.
Imaging utilization, defensive medicine, and decision support
A massive cultural revolution, incentivizing a move away from blind defensive medicine, is needed to address a number of cascading key trigger points in support of appropriate imaging. It is not just the swell of patient demand for more imaging, triggered by consumer-directed marketing of the availability and benefits of various procedures, such as full body CT scans. Nor is it just the disturbing and proven relationship between physician self-referrals and higher imaging utilization,10 perhaps to offset costs associated with acquiring expensive imaging equipment. Many physicians choose, and are taught, to practice ‘rule-out medicine’ as opposed to actual ‘diagnostic medicine’ in fear of liability and expensive litigation resulting from missed findings. According to a recent survey,11 the cost of defensive medicine is estimated to be in the $650 billion to $850 billion range, or between 26% and 34% of annual U.S. health care costs.
What prompted a New England Journal of Medicine paper, “The Uncritical Use of High-Tech Medical Imaging,”12 was an interesting observation the author makes: Imaging tests are most valuable when the probability of disease is neither very high nor very low but in the moderate range. Various imaging utilization management systems have been enforced in various forms by insurance companies and radiology benefit management (RBM) companies. Prior authorization, prenotification, and various network strategies that focus on examination costs, total quality, and practice guidelines have also had varying levels of success. Beyond more tailored tort reform, and an evolution in medical education and training, perhaps the most effective antidote to this trend is data—intelligent, personalized data based on solid, evidence-based medicine, tightly integrated into the decision support and physician-order entry workflow. Ordering physicians want to do what is best for their patients, and presenting them with intelligent, personalized data around image-order entry appropriateness, alongside easy access to relevant priors, will work wonders. This is difficult, but not impossible—and is a critical step toward meaningful, value-based imaging.
Continuous quality improvement
A key enabler of value-based imaging is also to embrace a culture of continuous quality improvement (CQI) that ensures both qualitative and quantitative methods to assess quality. Value-based imaging needs a core culture of continuous improvement in safety, performance, appropriateness, and outcomes to stay competitive in today’s rapidly changing health care environment. We need to thoroughly embrace the ACR accreditation programs, which are based on the ACR Practice Guidelines and Technical Standards13 and created through a thorough consensus process with collaborative efforts with other medical specialty societies.
Advancing quality tracking should be a core goal. Physician Quality Reporting System (PQRS) certification and maintenance needs to be considered a serious opportunity to embrace quality. The Affordable Care Act also required CMS to provide physicians with the option to report data on quality measures through a Maintenance of Certification (MOC) program operated by a specialty body of the American Board of Medical Specialties. An incentive payment of 0.5%, additional to the PQRS bonus, is authorized for years 2011-2014 if certain requirements are met.
Accountable care entails a keen focus on quality, outcomes, and costs—and continuous quality improvement is the linchpin that will enable better clinical outcomes at lower costs.
Transparency and visibility
Accountable care will require radiology to function in an environment of increased transparency, while it requires radiologists to become more visible across the care delivery continuum.
Data transparency between the payer and the provider in terms of utilization data, appropriateness, and costs will foster an environment of informed decision making. A recent study14 that looked at price transparency and its impact on imaging-order appropriateness found that cost alone was not a determining factor in deterring high-cost imaging procedures. However, with a focus on bundled payment models and outcomes-driven treatment, ACOs will need to seriously enable transparency of data available to radiology services. Successful strategies that aim to reduce costs and increase collaboration across clinical lines call for both insurers and providers to develop more transparent policies and procedures for business, and to use clinical data analytics so that these metrics are clearer and more visible as the new models of care.
At the same time, however, visibility is key for the often-lonesome radiologists. Radiology as a group is facing increasing threats of commoditization. The inordinate level of focus on metrics, such as report turn-around time (TAT) and fee-for-service, has made the radiologist an invisible commodity ready to be traded freely on price. This is directly contradictory, however, to the notion of value-based imaging, where quality and care coordination are just as important as costs. Radiologist-outreach programs must be put in place, and radiologists should be incentivized to forge meaningful relationships with referring physicians.
Visibility should also be fostered through improved intradepartmental and cross-specialty collaborations that highlight the value that radiologists bring to the care continuum. Improving communication with referring clinicians in both a synchronous and asynchronous manner is critical to sustaining the value of the full radiology service to the health care organization. The era of accountable care calls for radiologists to be fully engaged with emergency physicians, hospitalists, and primary care physicians (PCPs) as part of a collaborative solution toward appropriate image utilization and improved outcomes. Radiologists have always served as strong, albeit silent, patient advocates around imaging appropriateness. But as health care organizations move from fee-for-service to fee-for-value models, the value needs to be quantifiable and measurable to really matter. In guiding and defining the future of radiology, the ACR continues to seek to affirm the role of radiologists as physician consultants.15 The ACR’s “Face of Radiology” campaign conveys to patients that the “radiologist is the physician expert in diagnosis, patient care, and treatment through medical imaging.”
Without a doubt, there is a steady march away from the practice of volume-based imaging to that of value-based imaging. In anticipation of these newer care models that bring with them payment changes and a redefinition of the measures of ‘outcomes’ associated with the very practice of our profession, it is critical for radiologists and all associated with the industry to better comprehend the rationale and intricate workings of accountable care. The challenges ahead also call for developing innovative information technology investments or strategies to support key priorities and well-thought-through informatics solutions that intelligently enable the realization of value-based imaging from the core.
Becoming accountable for the total quality, cost, and care of patients while embracing evidence-based medicine, coordinated care, and shared savings can be a tall order. But these are exactly what we, as an industry, now need to focus on so we can weather the storm of payment reform, redefine service excellence in radiology, and explore new models of hospital-radiologist partnerships.
The Boy Scouts have it right: “Be prepared.”
Accountable care and value-based imaging: Challenges and opportunities. Appl Radiol.
Dr. Shrestha is the Chief Innovation Officer at University of Pittsburgh Medical Center, Pittsburgh, PA, and Executive Vice President of UPMC Enterprises. He is also Chair of the RSNA Informatics Scientific Program Committee; a Founding Member of the Executive Advisory Program, GE Healthcare; a member of the advisory boards of KLAS Research and Peer60; a member of the Board of Directors of the Society for Imaging Informatics in Medicine; a member of the boards of Pittsburgh Dataworks and Omnyx Inc., and a member of the Applied Radiology editorial board.