Radiology's Changing Dynamics: Health Care Reform

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It's a cold, sunny morning here in Chicago, and I'm sitting in on the first of two sessions entitled "Where is the Radiologist?: Radiology's Changing Dynamics." The second of the two will kick off at 10:30 a.m. in room E350 of the Lakeside Learning Center, so if you're missing out on this morning's session, you can still stop in for the latter session. Valerie Cronin kicked off the discussion. "I think we all know how changing times with PACS and teleradiology have meant that the radiologist is not always right down the hall when he's needed," she said. Attorney Bill Sarraille began the presentation by discussing health care reform and its potential impact on radiology. "By DC standards, things are moving very quickly," he said. "We are as close as you can be at this point to having a major health care reform package passed." He reminded attendees that today the Senate will take up their first deliberations on the health care bill, though whether they reach a conclusion by the end of the year remains to be seen. In broad terms, Sarraille said, health care reform will encompass initiatives toward health care affordability, expansion of coverage, and quality, prevention and wellness. Politically speaking, the notion of extending coverage to the uninsured didn't go over very well, so the focus of the discussion has shifted to affordability. The upside for health care providers is that more people will have insurance; the downside is that there will be more pricing pressure on health care services, a "necessary and core element," according to Sarraille. And, of course, we really don't know how many people are uninsured in the US; estimates range from 8 million (the Republican figure) to 67 million (according to the study Democrats are fond of citing, which includes illegal immigrants). "I'm going to offend everyone in this talk," Sarraille warned. "Having gone to law school with the President, I will apologize in advance for my criticism of him, though I voted for him. The White House has used the figure 47 million, and that includes individuals who are not lawfully present in the US. When that became an issue, they shifted very quickly to 34 million, which represents the number of individuals in the US lawfully without health insurance." An additional 34 million folks with coverage opens up a big opportunity for more volume. And it's important to note that the bill speaks not just to the ends, but to the means: in order to achieve affordability, the bill mandates addressing issues of quality, prevention, wellness and health care disparities. "Those health care providers who can make these themes a more significant part of their practice are going to do better," he said. "How do you fit within these themes?" Bottom line: we're in Year One of a decade-long fight that will ultimately shape health care in the future. Expanded coverage and new coverage mechanisms won't kick in for four years or so, according to Sarraille. Building the regulatory infrastructure will take time; on a cynical note, Sarraille adds, "If this is your major domestic issue, you might want to run for reelection before implementation." The implication, therefore, is that we won't know the actual costs of reform for another four or five years. "What that means is that at some point in Year Five, Congress will be confronted with the actual costs of this, and they'll blame you, the health care provider. They'll say it's a function of fraud and abuse. That is the way of the world." Well. Happy holidays! According to Sarraille, the discussion about the public option is a red herring, in large part because the legislation mandates Medicaid expansion no matter what. Reform will expand the program to individuals who live at up to 150% of the federal poverty level, meaning a household earning up to $60,000 a year would be able to be insured via Medicaid. "This means that much of the expansion of health care coverage doesn't come through the private market," he said. "It comes from Medicaid. Can the states continue to handle Medicaid the same way when essentially middle-class people are insured through it?" Plenty of freestanding imaging centers don't accept Medicaid patients. Continuing that policy could mean eliminating the upside of reform, but what will centers have to do in order to take these patients? The federalization of the private insurance market is another key issue. The federal exchange would provide subsidies to help those not eligible for Medicaid pay for their health insurance, and would define health care insurance packages and corresponding premiums, deductibles and co-pays. "The government will essentially divide the marketplace into four packages, offered through an exchange operating on a state or regional basis," he said. "The concept here is that we're going to incentivize people to get insurance where perhaps they're uncertain about the benefit to them -- the 'young invincibles.' We have to force healthy people to participate." Payors are going to be looking for reimbursement cuts. "Somehow, the fees the government wants them to pay will find their way into premiums," Sarraille predicted. "You can bet that they're going to be a lot more cost-conscious on imaging services going forward. You're also going to see tougher negotation." Congress, in an attempt to isolate itself from having to make Medicare cuts, is going to make a separate commission like MedPAC to propose cuts, and if Congress doesn't act within a certain period, those cuts will be automatically implemented. Sarraille says this allows them to pass the buck -- kind of like what happened to imaging back in 2005 with the DRA fiasco. "I think this is the single biggest fear to have about health care reform going forward."