Value-based Purchasing: From Theory to Practice

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Richard Duszak Jr, MDIn the May 2011 issue of Journal of the American College of Radiology: JACR, the ACR® Future Trends Committee¹ published a paper focused on helping radiologists manage the transition to value-based purchasing. The paper outlines roles for radiologists that might be helpful in successfully participating in accountable-care organizations (ACOs). Richard Duszak Jr, MD, says, “The earlier radiologists get on board with ACOs and the more energy they exert, the likelier they are to be successful.” Duszak, a diagnostic radiologist with Mid-South Imaging & Therapeutics (Memphis, Tennessee) is a coauthor of the paper. “ACOs may not be exactly the model we’ll ultimately go to, but they are a predictor of the fact that we are transforming from a fee-for-service system to value-based purchasing,” he adds. Centering the ACO Although how future ACOs will be structured remains ambiguous, Duszak predicts that hospitals and/or health systems will make natural stewards of the process. “In theory, there is absolutely an opportunity for practices to be at the center of an ACO,” he says. “Moving to practice, however, becomes more challenging.” At issue, he explains, is the fact that any practice-centered ACO would require the participation of multiple physician groups—and “coordinating and organizing physicians is like herding cats,” he says. “What it would entail would be developing a core group of representative physicians to have a collective vision and work out a governance structure that doesn’t disenfranchise competitors. In a perfect world, perhaps it would be best if this was physician driven—after all, nobody can speak better to the interests of patients—but the challenge is the structure.” Instead, Duszak predicts that ACOs will form around health systems, where some degree of structural alignment with physician groups already exists, in many cases. “The health systems are, to some extent, already proceeding along some structural arrangement along the lines of an ACO—in a vacuum, sometimes,” he says. “My crystal ball would say this is probably going to be health-system driven, and that the most successful ones will already have strong relationships with their physicians, rather than a bunch of administrators creating this in a conference room, with the physicians on the outside.” Recommendations for Radiologists With that prediction in mind, Duszak joins the white paper’s coauthors in urging radiologists to get to the ACO table early. “We’re at a crossroads in the specialty,” he says. “Are we going to go with the path of least resistance, where our only work product is an interpretation or a report, or will we change the direction? The ACO model creates a real opportunity for radiologists to stop the commoditization of the specialty in their communities, if they understand that we are moving from fee-for-service to value-based purchasing.” Another issue in this transition is, of course, the concept of value: the value that radiologists create and the value that they add to the care cycle. “If we continue for too long doing business as usual, we may be doomed to commoditization,” Duszak says. “We’re not just interpretation. We need to participate in appropriateness, quality, and safety.” Duszak recommends that radiology groups embrace the shift to value-based purchasing before it’s too late. “Keeping your head in the sand is no longer an option,” he says. “Culturally and mentally, radiology practices need to prepare themselves for this transformation.” Duszak also stresses that groups should begin to make concepts integral to the ACO model (including quality and safety) operational, in preparation for being effective contributors to the organizations. “Quality, turnaround time, and safety will all, to some extent, be components of the way we—as radiologists—get measured (and, therefore, paid) in a value-based purchasing model,” he says. He recommends that groups prepare to assimilate as effectively as possible into ACOs or other value-based purchasing models by engaging in dialogue with the health systems with which they are interested in working. “There’s an opportunity for radiologists to be leaders in this area,” he says. “The practice can become a stakeholder at the earliest stage, so that the issues that are important to radiology are important to the system as a whole.” With imaging remaining a key driver of health-care costs, Duszak says, the risk for radiology groups is that if they fail to get involved, they could see their work commoditized—and their financial health fall by the wayside. “The cuts we’re anticipating may well be mitigated if radiologists are stakeholders from the get-go,” he says. “If they get in on the front end and become participants, that pushes back strongly against commoditization, but if they just want to read studies and let this be imposed upon them, it creates much more of a commoditization risk.”