Radiology and the Accountable Care Organization

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1 Radiology and the Accountable Care Organization

2 Very few radiology groups actively participate in an ACO beyond a separate fee-forservice contract with the ACO network Introduction Economic and political conditions have led to significant change and uncertainty in the healthcare environment. In this paper, we explore accountable care organizations (ACOs) and their relation to radiologists. An Accountable Care Organization (ACO) is a healthcare delivery model that is generally understood to involve a group of providers that agree to be accountable for the quality, cost and overall care of a group of patients. This model represents a shift from volume-based to value-based healthcare delivery. Most commonly used in reference to the CMS (Medicare) ACO initiatives, the term also applies to a spectrum of commercial payer and health delivery models. Overview of CMS ACO Program and Commercial ACOs The CMS ACO initiative began with the Pioneer Model that involved participants sharing in savings and losses. Later the Medicare Shared Savings Program (MSSP) was introduced to give participants greater options in their share of upside and downside risk. For radiology groups, it is important to understand that the performance quality measures have changed over time and are likely to change in the future. At present, only one relates directly to radiology; breast cancer screening with mammography. In essence, economic incentives are used to control costs while still allowing flexibility to payment structures and risk allocation between payers and providers. [2] More information on the CMS ACO initiative can be found in Appendix A or on the CMS website. The CMS ACO initiative encourages participants to negotiate outcomesbased contracts with other payers which is one driver of commercial ACO and integrated care formation. Most commercial integrated care systems are similar to Medicare ACOs in that they assume responsibility for a defined number of lives from either a large employer or insurance organization however they generally set their own quality metrics, payment methodologies, risk and length of contracts which vary from payer to payer. Commercial payers involved in ACOs include but are not limited to Aetna, Cigna, United Healthcare, Blue Cross Blue Shield. Beyond payments, commercial payers partner with providers bringing investment money, data, data modeling and benefits to an ACO partnership in order to help manage patients and associated costs. Leadership ACOs emphasize physician leadership in order to lead quality improvements and cost controls or reductions from a clinical standpoint. Radiologists are well positioned to take a leadership role due to their clinical knowledge base and broad connections as a crossroad of care that most patients pass through.

3 Quality standards are designed to eliminate the quality concerns experienced with early HMO attempts Collaboration with other healthcare providers will be a key contributor to reduce patient leakage for radiology Quality Standards Almost all ACO arrangements will have some quality standards component. A portion of bonus payments amongst both the commercial and CMS based ACO programs revolves around meeting these quality standards. In the case of commercial ACOs these quality standards are agreed upon by the provider and the payer. The aim is to improve the quality of care, patient experience (customer service) and identify practices that improve downstream outcomes. Radiologists must develop their own quality standards that are both meaningful and measurable in order to ensure they are eligible for bonus payments in the future. We have identified several areas where quality initiatives exist or are being investigated for radiology including: 1. Retrospective performance review (peer review) 2. Continuing education (CME) 3. Validation and certification (validation testing of radiology skills ) 4. Volume of subspecialty exams read by subspecialists 5. Subjective quality measures aimed at improving service levels such as referrer and patient satisfaction surveys. Preparing quality programs and metrics ahead of time can make negotiations more productive when forming new ACOs. Groups that have metrics in place will have baseline measurements and an understanding of their quality weaknesses, capabilities, and opportunities. Patient Leakage Not all ACO arrangements restrict patients to in-network providers. Patient leakage occurs when a patient receives care outside the ACO network and the network is financially responsible for this out-of-network care. This reduces the ACO s chances of achieving their benchmarks both in quality of care and cost which will affect shared savings programs or other financial incentives provided by payers. Educating providers and patients on who is within network becomes an important step in reducing leakage. Building healthy relationships between referring physicians and radiologists, implementing systems such as computerized physician order entry (CPOE) in conjunction with clinical decision support, and involving radiologists more broadly in the clinical environment will further reduce leakage. Most ACOs have identified controlling leakage as a primary strategy for success. Many commercial ACOs are using narrow network plans to help their ACOs achieve their targets. These are similar to the provider networks that existed with HMOs whereby patients are required to seek care with a discrete group of healthcare providers. If patients choose to go out-of-network, they are either required to pay a significant portion, or all of the out-of-network costs. Narrow networks occur in many of the lower cost plans in the health insurance exchanges under the Affordable Care Act. [3]

4 ACO contract terms beyond the straightforward compensation numbers can affect the profitability of the practice. Radiologists should understand all aspects of their operations and how the new agreement may impact them Impact of Data and Technology Managing claims data enables ACOs to identify and monitor key populations, especially individuals with chronic disease in order to meet quality and efficiency goals. Payers have much of the data providers need to manage care and the healthcare services being used. Radiologists should be prepared to discuss their data needs including timeliness of data transmissions when facing ACO formation to improve outcomes. Historical claims data can be used to provide predictive modeling in order to target services and establish performance targets. Radiologists should also utilize their own data to understand their current benchmarks before agreeing to specific terms and conditions. For radiology, technology will create meaningful change in the areas of collaboration and care coordination, cost control through appropriate utilization and identifying high-use patients to develop improved utilization and treatment algorithms. Five information systems that may be used in a successful ACO. [4] [5] 1. An Electronic Medical Record (EMR) used in a consistent and meaningful way across the accountable care enterprise to document patients healthcare status and treatment as well as support safe, evidence based care. 2. A Health Information Exchange (HIE) to enable sharing of patients clinical data across disparate EMRs in the accountable care enterprise. 3. A Time Driven Activity Based Costing (TDABC) system to enable detailed, patient-specific collection of cost data from various hospital systems to allow ACOs to precisely understand cost of production and revenue margins in capitated payment models. 4. An Electronic Patient Reported Outcomes (epro) system allows patients to provide clinical outcomes information which is combined with other health data to enable the complete understanding of clinical outcomes and quality, from the patient s perspective. 5. A Data Warehouse (DW), which is central to enabling the analysis of data collected in the other information systems. This enables detailed analysis to identify downstream outcomes, dashboard reporting and trending. Of all components in the IT network, the DW is the most critical as it aggregates all other systems and allows integration and analysis of clinical, financial and patient reported data in a single repository. Radiologists do not need to be experts in ACO technology, however a basic understanding of system IT requirements arms radiologists for success and can lead to more meaningful negotiations.

5 Reimbursement Under an ACO The spectrum of reimbursement options available to radiologists under an ACO will continue to evolve, however currently most systems participating in ACOs have negotiated FFS payments to their radiologist groups. Radiologists may be exposed to bundled payments whereby they are paid a single payment for a single episode of care for an individual patient. Under this arrangement, the patient may receive several imaging exams during their single episode of care and the radiology group accepts the associated risk and cost. It is possible that radiologists will be included in shared savings programs whereby they receive a portion of savings as part of the ACO s ability to reduce expenditure in one-sided shared savings programs or are exposed to both the savings but also the risk of costs in two-sided shared savings programs. Non-Exclusive ACOs Related to geographic coverage requirements, a single ACO may desire more than one radiology group. In such circumstances it is incumbent upon the disparate groups to develop an alignment enabling them to function as a cohesive group within the ACO. Being proactive in this regard in anticipation of an ACO will be advantageous. Unquantified value is unmarketable value Determining Radiology s Value Appropriate alignment in an ACO allows radiologists to better demonstrate their true value to the healthcare enterprise. Historically many radiologists have defined their value by good enough quality based on the number of misses combined with their RVU volume. As reimbursements continue to decline, ACOs may be an opportunity for radiologists to mitigate these changes. ACOs however are not a free ride for radiology. In order to receive satisfactory compensation, radiologists will need to prove their value beyond RVUs and a written report. Some of this proof will be provided through improved tracking and reporting of outcomes. Some will be through the development of quality programs. The majority however, will be through changes in the culture of the radiology group and the role of the radiologist in the healthcare enterprise. Radiologists need to be visible, they need to market themselves, they need to consult as often as possible with both referrers and patients and spend time making administration familiar with their skills and value proposition through metrics wherever possible. Unquantified value is unmarketable value. Radiologists Evolving Role In the past, radiologists held unique relationships with their referrers that involved in-depth consultations. Over time, market conditions led us to a productivity focus, enabled by technology. Radiologists now may be perceived more as a commodity, as fungible report generators.

6 The radiologist s focus needs to change from volume to value. [6] The interpretation of the image, the report, is only a piece of the radiologist s contribution and responsibility. The radiologist may play an important role as triager for primary care providers as well as specialists. A role in clinical decision support and appropriate utilization will certainly be of value. Rapid, accurate diagnosis and actionable reports drives efficiency of the entire enterprise. In the ACO environment, the radiologist will have improved access to patient information and can bring a much deeper level of connection between clinical and radiological findings. Radiologists must also become co-managers of the entire imaging enterprise, working with the ACO and hospital system to strategize, be accountable for operational and quality outcomes, educate referrers, and manage department resources. Importantly, radiologists need to emphasize their consulting role to truly maximize their value to patients and referrers. [2] ACOs can be led by hospitals, insurers or physicians. We believe the most successful ACOs will be led by physicians as they are in the best position to be the central integrators in the ACO alignment model. They understand best the risks and opportunities in healthcare and they can develop the toolkits to manage them real-time. Acute care delivery will still center around hospitals however, much of the cost saving will occur in the outpatient setting under the guidance of primary care physicians working with radiologists and other physician colleagues and extenders. As part of the shift from reactive to proactive medicine, an increase in screening exams will likely occur under an ACO model of which radiology will be an integral component. Summary: Preparing Radiologists for an ACO 1. Understand the billing and collections data for your practice. a. Being familiar with volume and revenue data by payer group will be helpful in future contracting discussions. b. Segmenting your data will help you identify groups of patients where the practice may benefit from some form of risk/ capitation arrangement. 2. Understand your outpatient reach. a. In order to achieve the required geographic footprint, ACOs are often not exclusive to a single radiology group. b. Building relationships with other groups in your area that can help you achieve both the culture and reach, will reduce the risk that the ACO will choose your radiology partners for you. 3. Have access to decision support tools. a. Insurance providers supply algorithms that can be loaded into Computerized Physician Order Entry (CPOE) systems. b. Providing access to CPOE for outpatient providers can help reduce leakage and improve convenience for those providers.

7 4. Provide referrer education. a. Aimed at appropriate utilization. b. May include outlining benefits of screening programs that lead to reduced downstream costs. 5. Have access to a Health Information Exchange (HIE). a. Having access to prior studies improves report outcomes and reduces repeat imaging. 6. Provide improved consult access. a. Establish a direct line of communication to radiologists to improve peer-to-peer relationships, assist with appropriate utilization and prevent leakage. b. Radiologist participation in a system-wide patient portal. 7. Develop quality program. a. Radiologists will be required to demonstrate meaningful and measurable quality initiatives to payers and referring physicians. b. Objective quality measures should be supplemented with subjective quality measures such as satisfaction surveys. 8. Begin process to standardize best practices between facilities within the ACO network. 9. Consider utilizing physician extenders. a. Nurse practitioners and physician assistants can allow radiologists the time to provide more value-added services. 10. Be proactive. 11. Assume a leadership role.

8 References [1] M. Gamble and H. Punke, ACO Manifesto: 50 Things to Know About Accountable Care Organizations, 03 September [Online]. Available: [2] R. Abramson, P. Berger and M. Brant-Zawadski, Accountable Care Organizations and Radiology: Threat or Opportunity?, Journal of the American College of Radiology, vol. 9, no. 12, pp , 2012 [3] N. Bauman, M. Chopra, J. Cordina, J. Meyer and S. Sutaria, Winning Strategies for Participation in Narrow-Network Exchange Offerings, May [Online]. Available: MCK_Hosp_ExchangeStrategy.pdf. [4] T. O Brien, Making the Most of Electronic Medical Records Through Time-Driven, Activity-Based Costing, 14 October [Online]. Available: [5] D. Sanders, Accountable Care Organization Software: 5 Critical Information Systems, 26 July [Online]. Available healthcatalyst.com/information-systems-for-accountable-careorganizations. [6] American College of Radiology, Imaging 3.0 Overview, [Online]. Available: Economics/Imaging3/Imaging3.pdf.

9 Appendix A: CMS ACO Program For CMS driven ACO programs, there are two program types. [1] 1. Pioneer ACO Model a. Participants share in the savings and losses b. This program has a higher risk level than Medicare Shared Savings Program (MSSP) and can achieve shared savings in the first two years under the shared savings and losses model. There is no option for a shared savings only arrangement for the pioneer program. c. Pioneer ACOs can move from fee-for-service to populationbased payment in year three, which is a per-member-permonth payment designed to replace most or all of the ACOs FFS payment. They must also negotiate outcomes-based contracts with other payers by the end of the second performance year (which is most likely driving the commercial ACOs). 2. Medicare Shared Savings Program (MSSP); which has two tracks a. Track 1: ACOs that achieve a specified minimum amount of savings can share in up to 50 percent of the savings with CMS. Track 1 ACOs do not take on downside risk for the three-year period. b. Track 2: ACOs that achieve a specified minimum savings can share in up to 60 percent of the savings. If Track 2 ACOs do not meet the specified savings benchmark, they are liable for up to 60 percent of the difference between the benchmark and the actual expenditures for the performance year c. For the first performance year in the MSSP, ACOs are paid for reporting on 33 quality measures. Known as pay-for-reporting d. In year two, more reimbursement is tied to the ACOs performance. Pay-for-performance applies to 25 of the quality measures, and pay-for-reporting applies to eight (7, 8, 19, 20, 21, 31, 32, 33) e. In year three, 32 quality measures are pay-for-performance, and #7 is the only pay-for-reporting measure f. The advanced payment model falls under the MSSP and is meant to help small organizations that have less access to capital participate in the shared savings program. Recipients of the advanced payment model receive three types of payments: Upfront, fixed payment; upfront variable payment based on the number of historically assigned beneficiaries; or a monthly payment based on the number of beneficiaries. The quality measures can be accessed through the CMS website, however only one relates directly to radiology; breast cancer screening with mammography. In essence, economic incentives are used to control costs while still allowing flexibility to payment structures and risk allocation between payers and providers. [2]

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