ACOs and Radiology Technology: A Conversation With Bibb Allen Jr, MD

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Bibb Allen Jr, MDThe Patient Protection and Affordable Care Act calls for early adopters to launch accountable-care organization (ACO) demonstration projects and shared-savings programs in 2012. The development of these value-added services and the general trend toward formation of ACOs will undoubtedly lead to changes not only in the acquisition of imaging technology by providers, but also in the radiology landscape as a whole. Bibb Allen Jr, MD, of Trinity Medical Center in Birmingham, Alabama, says, “We are on the cusp of some major shifts.” ImagingBiz.com sat down with Allen (who is chair of the ACR Commission on Economics and served as lead author of an article,1 “ACR White Paper: Strategies for Radiologists in the Era of Health Care Reform and Accountable Care Organizations: A Report From the ACR Future Trends Committee,” that recently appeared in Journal of the American College of Radiology: JACR) to discuss these changes. ImagingBiz: Some have said that if ACOs indeed take root, ACO facilities will purchase and use imaging technology according to a new set of standards. Do you agree? Allen: Yes; given that a push for cost savings accounts for much of the intent behind establishing ACOs in the first place, I think the criteria for purchasing imaging technology will definitely change. While they will no doubt support the replacement of equipment at the end of its life cycle, ACO facilities will almost certainly not go along with the idea of replacing a perfectly good piece of imaging equipment with another just because it is new. Whether or not it happens immediately, there absolutely will come a time when ACOs will unfailingly ask, when an equipment purchase is being considered, whether and how that 3T magnet (or what have you) will really benefit them and their patients alike. They will want a true patient-care and business justification for acquiring a 256-slice CT scanner, when the 64-slice scanner they have still functions perfectly well. Newness alone is not going to induce them to write the check. Imaging Biz: What would constitute this kind of true justification? Allen: ACOs, we hope, will see their way clear to using comparative-effectiveness research as a benchmark, not only for justifying imaging-equipment acquisitions in general but for ensuring that the right equipment is purchased. I believe, however, that even if comparative-effectiveness research becomes a standard against which a potential imaging equipment acquisition is evaluated, the documentation will need to be very, very detailed and extensive in order for ACOs to spend the money—especially in instances where there seemingly is no money to spend. ImagingBiz: What other forces might have an impact on imaging-equipment purchases in an ACO environment? Allen: The marketing climate is one. There remains the as-yet-unanswered question of whether ACOs will turn into another form of managed care. The argument that an ACO needs to have the latest scanner for purposes other than improving patient care will not stand up there. ImagingBiz: Beyond challenges posed by a changed process for imaging-equipment purchasing, what additional predictions can you make about how the advent and growth of ACOs would alter the radiology landscape? Allen: There will be a huge cultural shift. We will see a major move from our present focus on productivity tied to the number of exams we have interpreted during a given time period. This might present challenges to radiologists and their practices because it requires fundamental changes in culture from a current focus on productivity based on the number of exams interpreted to productivity based on the ability to provide cost-effective care and outcomes. As we have all seen in recent months, many specialties are attempting to validate cost-effective care by focusing on outcomes studies. Obviously, though, that is more difficult with radiology, because it isn’t imaging itself that determines outcomes. Rather, how the patient fares hinges on all of the other treatments that come after the radiologic study. For this reason, working in an ACO environment will push us—as is the case with imaging equipment purchasing—not just to research quality, but to conduct comparative-effectiveness research. In addition, while the ACO factor might remove from the equation the use of imaging technology as a competitive weapon, ACOs themselves will make the competition more fierce than ever before. The fact that a radiologist or radiology group has a contract at a participating hospital won’t buy admission into an ACO circle. Smarter players, I think, will start to aggregate into larger (or regional) radiology entities so that they can maximize subspecialization and efficiencies in the delivery of imaging care to patients. Then, there is the challenge of capitation. Some ACOs are absolutely going to circle back to it, despite those who insist it has been tried, and has failed, enough times already. It’s true that with capitation, physicians and other providers are given back any savings that exceed the predetermined targets. As such, it offers the highest potential for rewarding those providers. It might also lead to better coordination of care, while minimizing duplication and inappropriate utilization of services. The challenge, though, is this: If imaging services are, in the ACO model, paid under a simplistic capitation arrangement, without risk corridors that control for utilization history, there will be no incentive for referring physicians to limit the utilization of imaging services. ImagingBiz: There has been a lot of talk lately about radiologists being pushed into the background in an ACO environment. What will the consequences be if the situation plays out this way? Allen: If radiologists are put on the back burner, so to speak, as ACOs take root, I believe we will see some severe disconnects with regard to imaging-equipment purchasing. In general, it’s the radiologists who understand what the new technology is about and how it might fit into the patient-care scenario. If they lose their key role in making buying decisions, there will be no guarantee of a great fit. Just as significantly, radiologists can contribute to efficient, effective care—by recommending to referring physicians the appropriate use of imaging studies that, if their results are negative, could limit unnecessary referrals to specialists and cut unnecessary procedures by ensuring that tests are properly conducted the first time. If they lose their voice here, we will probably see more unnecessary utilization—increasing costs and defeating some of the purpose of ACOs. Nothing is yet written in stone—but ACOs and their effect on the radiology community are areas that merit a close watch. Julie Ritzer Ross is a contributing writer for ImagingBiz.com.