What is Imaging Appropriateness and Utilization Management?

Transcription

1 Economic Update AMCLC 2014 Christopher G. Ullrich MD FACR Chair, ACR Utilization Management Committee Imaging Appropriateness and Utilization Management Accountable Care Organizations Economic and Political Advocacy No disclosures

2 Definitions Imaging Appropriateness Performing the right procedure to ensure an appropriate diagnostic outcome related to a given set of clinical indications Clinical Decision Support (CDS) An interactive decision support system (DSS) Computer Software, which is designed to assist physicians and other health professionals with decision making tasks. Utilization Management The use of a CDS system and analytics to ensure that Imaging Appropriateness is achieved, Care Quality is improved, & Macroeconomic Targets are met. 2

3 Imaging Appropriateness The American College of Radiology s Appropriateness Criteria (AC) represent the combined knowledge of hundreds of physicians, diverse medical societies, and cover 90% of the known clinical scenarios in imaging The AC represent a National Standard for Imaging Appropriateness The AC are ACR intellectual property. ACR is responsible for maintaining the integrity and future development of this blend of evidence based & professional experience medicine 3

4 Decision Support System The ACR Appropriateness Criteria have become a digitally consumable software platform that can be used as part of an Imaging Clinical Decision Support System The ACR has formed a commercial entity so that the AC can be used to integrate this knowledge base into CDS systems using the ACR-Select branding 4

5 National Decision Support Company NDSC is the commercial entity created to manage the delivery and integration of ACR Select into imaging computer decision support and order entry systems NDSC is the exclusive agent of the ACR for delivery of the content into the market The ACR manages the actual content of the knowledge base 5

6 Business Model Non EMR vendors who have licensed ACR Select to include in a 3 rd party solution Rule Set EMR vendors where NDSC has a direct integration of ACR Select NDSC s mission is to ensure broad adoption of ACR Select for use in CPOE platforms, payer portals or as a reference tool. NDSC has developed a portal to access the Rule Set for use as a reference guide or integration component 6 Every decision driven by ACR Select is assigned a unique Decision Support Number to provide traceability

7 Example use cases Integration of ACR Select in EMR order entry workflow Web window / portal Outpt, ED, Inpt uses Radiologist consultation and approval Payer authorization Reference Tool Patient Engagement 7

8 UTILIZATION MANAGEMENT (UM) Will be needed to achieve the Volume to Value & Quality Goals of Imaging 3.0 Computer Physician Order Entry (CPOE) and ACR Select imaging decision support (ICDS) improve test selection at the point of care Analytics provide both actual performance data and the opportunity to improve patient care in a data documented continuous quality improvement environment. Standardized data will facilitate benchmarking and improve Big Data analysis of patient care models and predictive modeling 8

9 Utilization Management 1.0 Reimbursement cuts to reduce utilization 12 times since 2005 Decreased imaging utilization No focus on quality Introduction of Radiology Benefits Managers Overhead Penalties Higher Costs 9

10 Utilization Management 3.0 Drives toward appropriate utilization of imaging Ensures that the role of the Radiologist and imaging is defined and documented as valuable Creates a platform and tools to promote the value of imaging For each patient: the right test, done at the right time, properly performed and interpreted, diagnosis delivered, and the proper treatment determined 10

11 Example Use case: EHR order entry Order Entry in EHR Assess appropriateness of ordering Order Entry in EHR with appropriateness guidance Expose Scores and criteria, automatically suggest higher scoring alternatives Direct consults occur with the Radiologist when needed, guided by ACR Select Access to relevant medical literature All configurable by physician, care setting, modality, etc. 11

12 Integrating with the EHR Avoid duplication of screens, clicks and data entry at all levels of the workflow Perform most, if not all of the Decision Support workflow within existing CPOE No HL-7 interfaces Zero penalty experience for all users of the system Embed Decision Support data within Patient Record 12

13 ACR Select is now embedded within Cerner and Epic EHR CPOE systems. Other EHR systems will follow. The use of a web window link in an EHR can reduce the software integration burden. Outside referrals can use the web portal to generate a unique decision support number that can be entered into your EHR system similar to a pre-authorization number from an RBM. These integrations will continue to improve over the next 5 years or more. So will the ACR Select decision data. 13

14 Radiologist as Consultant Appropriateness Scoring during order entry helps drive consultation and real time learning and interaction between Radiologist and ordering physician Implement workflow where Radiologist assumes function of consultant for exams of questionable utility 14

15 Value Based Radiology Appropriate Imaging improves patient care and saves costs Proper consultation and the resulting appropriate exam and properly communicated result reduces length of stay and readmission rate. Utilization Management by the experts - Focused on appropriate use. ACR Select creates simplicity and transparency. Allowing physicians to focus on patient care vs. navigating medically irrelevant workflows. ACR Select creates a transparent platform for all stakeholders in the process to share data and align on outcomes. 15

16 Radiology Enterprise UM Opportunities Continuous Improvement Real-time automated guidance for ordering Doc s, PA s,np s Opportunity for better collaboration with Radiologists Analytics Utilization profiles of staff, care units and service lines Impact on overall care cycle when integrated with EHR Data documented quality / cost improvements Data standardization for benchmarking and Big Data Expected impact on care cycle Better diagnosis -> Better care Reduced length of stay Efficiency Reduces overhead in pre-authorization process Reduced resource consumption / expenditures Appropriateness criteria at the point of care across the health system enterprise, not only outpatients as with RBMs Gain sharing??? Management payments??? 16

17 Summary ACR Select is a National Standard Decision Support System, published by the imaging experts Opportunity for Radiology to transition the dialog with its customers towards value based care Creates Transparent, Actionable metrics Appropriate Imaging, not less imaging Enterprise UM role for Radiologists? Gain sharing? 17

18 Accountable Care Organizations - ACO s Many flavors of ACO s: the details really matter. Withholds, shared savings, risk corridors, population definitions, etc Radiologists have the opportunity to belong to more than one ACO, but few do today. In the CMS Pioneer ACO s and other CMS ACO s, Radiologists are being paid fee for service, usually at Medicare rates. Imaging UM is variable. Specialists in the Medicare Shared Savings Plan ACO s have seen virtually no shared savings yet. 18

19 ACO s: Financial challenges are very daunting The existing 360 ACOs achieved a CMS payment savings of 1%. Provider costs for managing a CMS ACO are high, and CMS rules are raising costs even higher. Pioneer ACO s were selected from the highest performing healthcare systems, not average performing systems. Of 114 P-ACO s, only 54 reached spending targets, and only 29 made it to shared savings. Most of these programs lost money when operating costs are considered. Nobody made much money. 19

20 ACO s: Providers are not insurance companies Hospitals and physician groups : Do not have risk actuaries and risk managers Cannot appropriately price their risk: CMS dictates rates without actually considering risk, retrospectively assigns population members, etc Do not have appropriate reserve funds or access to mezzanine financing to buffer a bad year(s). Re-insurance for ACO s is virtually non-existent today. Warren Buffett: Only when the tide goes out do you discover who s been swimming naked. 20

21 Effective Economics Advocacy requires Effective Political Advocacy (Public and Private) 21

22 Realities Government actions are increasingly defining Radiology s future Government policy = Private Payer policy Public policy is a political process Relationships and money fuel politics Economic advocacy requires political advocacy High Quality Professional Survival is ACR s goal High Quality Professional Survival is not mandatory or assured 22

23 Some ACR Survival Activities Imaging 3.0 RADPAC - Federal only State specific PACS ACR Federal GR team ACR State GR Committee Radiology Advocacy Network Advocacy Action enewsletter The Radiology Leadership Institute Commission activities 23

24 Political Advocacy Suggestions Build political coalitions with your: State Medical Society o Promote Radiologists for committees Hospital government relations team Med. Sp. Societies: Anes, EM, Path, FP Appoint Radiologists to state government committees Engage and support RBMA / MGMA 24

25 Political Advocacy Suggestions Educate your groups and state chapters RADPAC: do payroll deduction $42/member/month = $504/year State PAC: creates identity and credibility With 20 PAC members, $10,000/year Show up at political events - designate people Your local politician may be your future senator, governor, etc. 25

26 Political Action Suggestions State PAC efforts should always be bipartisan Local PAC governance/decisions work best NC has 8 separate state PACS Find a good political mentor at the state level Develop dedicated state networks for practice leaders and political advocates Try to learn who knows who 26

27 Political Advocacy Suggestions Pay certain organization dues as business expenses ACR and state ACR chapter dues State and county medical society dues American Medical Association Allow individual opt out, but they can t take the money for themselves Engage your group leadership and business manager in an ACR call to action response plan and have a government relations plan. 27

28 Economic Update AMCLC 2014 Christopher G. Ullrich MD FACR Chair, ACR Utilization Management Committee Imaging Appropriateness and Utilization Management Accountable Care Organizations Economic and Political Advocacy

29 Be there or Be eaten! 29

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