Risk and Responsibility: Radiology and the ACO
The passage of the Patient Protection and Affordable Care Act made accountable-care organization (ACO) one of the most feared buzzwords since capitation, but if the concept of ACOs is framed within its larger context, which is a nationwide collaborative-care initiative with federal support, participation begins to seem less onerous. After all, the ACO is simply the government’s attempt to duplicate the success of leading health systems like the Mayo Clinic (Rochester, Minnesota) and Geisinger Health Systems (Danville, Pennsylvania). These health systems have coordinated care paths, better outcomes, and lower costs that are the envy of organizations nationwide. Further, some of the most central goals of the collaborative-care initiative are those that radiology has been pursuing on its own for years, which means that ACOs represent both a threat to and an opportunity for the specialty. By giving organizations incentives to handle the patient’s care correctly the first time (eliminating, among other things, the need for duplicative tests), collaborative care offers radiologists a unique platform for their expertise. If radiologists do not insert themselves into the planning process early, however, they might face being treated as vendors and, ultimately, might see their services commoditized. Flexible and Local At the Accountable Care Summit to be held on June 6–8, 2012, in Washington, DC, experts on the model (including Mark McClellan, MD, PhD, MPA, former CMS administrator, and Elliott Fisher, MD, MPH, of the Dartmouth Institute for Health Policy and Clinical Practice) will indicate that the cost savings being sought on the federal level from ACOs are the low-hanging fruit—including duplicative, costly imaging exams, as well as other services offered by specialists. Although many people believe that hospitals will be at the center of the majority of new ACOs, the legislation is flexible, leaving room for multispecialty groups or other entities to take center stage, if interested. One criticism garnered by CMS during the comment period on the first round of proposed legislation, however, is that specialists are likely to need to function within multiple ACOs to survive, assuming that they are to continue operating according to a business model similar to that of the past. As a result, specialists are at risk of being treated like vendors, rather than as collaborative partners who help guide patients’ care paths. What is clear is that the formation of ACOs will probably be driven by geography more than by any other factor. The legislation is sufficiently flexible to allow local market dynamics to determine what is at the center of the ACO—a hospital, a large multispecialty group, or another entity. Whether radiologists should head off the commoditization issue at the pass by taking an ownership interest in their local ACOs will have to be determined by groups on a case-by-case basis. It cannot be ignored that ACOs are largely about risk assumption, and groups must be forward thinking if they are planning to take on this kind of risk for the first time. More Risk, More Responsibility Federally subsidized ACOs offer several models, from an incentive system riding on a fee-for-service chassis—offering a financial bonus in return for lower overall costs—to a fully capitated model where a fixed sum of money is paid per episode of care. It is the responsibility of the ACO to use only the money required to attain the best possible patient outcome. The ACR® and other influential bodies are urging radiologists to take a seat at the table in the formation of ACOs—in effect, to step up and indicate a willingness to assume risk. This assumption comes with responsibilities: the responsibility to act not as a profit-seeking vendor, but as a vital, collaborative consultant, and the more abstract responsibility to change the image of the profession. Imaging has been targeted, in recent years, for contributing to the high cost of medical care. As ACOs take root, radiologists who want to hold leadership roles will have to understand that ensuring the future of their specialty might mean a sacrifice, in terms of compensation. The other option is to continue with the business model of the past, which will necessitate being treated as vendors—sellers offering necessary commodities. Looking Forward The capitated model failed in the 1990s, but there is little reason to fear that the mistakes of that decade will be repeated in coming years. As economists often point out, incentives drive change; in the 1990s, the health-care industry still had one eye on maximizing profit, whereas today, every constituent is aware that costs are increasing at an unsustainable rate. In the 1990s, we could still afford to make mistakes; today, we know that if we do not find a way to drive down costs on our own, the government will not hesitate to step in and enforce change. Economics, as opposed to politics, is the discipline in the driver’s seat now. Ultimately, radiologists (like their fellow health-care providers) are trying to make patients healthier: in part, through the preventive care made possible by imaging, and in part, through an increased emphasis on appropriateness. Though the ACO does represent a federal effort to institutionalize that at which health care in the United States has so far failed—lowering costs while improving outcomes—change can be difficult without a strong impetus. The framework for collaborative care that the government is attempting to provide can be a very positive development for radiologists and their colleagues across the care continuum. If radiology steps up to the plate now and establishes its role as a critical contributor to smarter care, the profession will thrive as a steward of lower costs and better outcomes. If radiologists wish to continue as they were before, however, the specialty might find itself rapidly commoditized. Randal Roat, CHBME, is vice president of radiology services for Medical Management Professionals, Inc (MMP), Atlanta, Georgia.