JACR: ACOs require rads to focus on value and service

On top of the shifting climate of healthcare delivery, radiologists have remained some of the least involved providers in the transition to accountable care organizations (ACOs), a move that could pose important risks to radiologists and the specialty as a whole, argued the authors of a May 2 article in the Journal of the American College of Radiology.

“Accountable care organizations are intended to be local, flexible provider groups that are accountable for both the cost and quality of care for defined populations of patients,” wrote Bibb Allen Jr., MD, of Trinity Medical Center in Birmingham, Ala., and co-authors.

With primary care at the center of the ACO movement, radiologists have remained largely inactive in hospitals’ preparations to become epicenters of healthcare value. But whether radiologists are in academic departments or outpatient imaging centers, ACOs will have far-reaching effects on all physicians, and private practice as much as academic radiologists should begin to take leadership roles in these shifts, the authors recommended.

“Radiologists are well positioned to assume leadership roles in the informational, triage and decision support infrastructure of an ACO … radiologists should strive to align themselves with any integrated healthcare provider organization that either becomes or joins an ACO. If radiologists are unwilling to assume this role, imaging could become a marginalized commodity within the ACO,” Allen and colleagues maintained.

In the clinical setting, such leadership roles are essential, Allen and co-authors stated. Often underutilized, radiologists need to take the lead as consultants. As the ACO focuses on primary care at a time when the supply of primary care physicians dwindles, radiologists’ expertise will be especially important to the growing volume and duties of physician assistants.

As the payment structure of healthcare transforms—to a yet-to-be defined model, aside from the well-publicized emphasis on savings—one of the most critical contributions of radiologists will be the reduction of inappropriate imaging. But without a definite understanding of how fee-for-service, pay-for-performance and capitation models will all fit into ACO structures, how much radiologists stand to gain from more appropriate utilization remains uncertain.

“The overarching message…is that radiologists must be willing to provide the best possible care to patients in the most cost-effective way. This will most likely entail changing their focus from interpretive productivity, in the traditional sense of number of examinations interpreted, to becoming recognized as experts in noninterpretive areas that add additional value to the ACO,” Allen and colleagues stated.

The authors provided the example of a patient who presents to the primary care physician with chest pain. The primary care physician might suspect coronary artery disease but may also be worried about such problems as a pulmonary embolism, aortic dissection, penetrating ulcer of the aorta or pericarditis.

Allen and co-authors asserted that, rather than referring the patient to a cardiologist for a lengthy and expensive workup, the radiologist could perform a triple-rule-out CT angiography, which would most likely establish the diagnosis or clear the patient of any serious issue. Referral changes such as these offer the potential to provide improved value and efficiency for the ACO while maintaining high-quality care for the patient, the authors argued.

Moreover, these individual-level initiatives on the parts of radiologists would diminish the commoditization of the specialty. Radiologists have already taken leading roles in integrating care via IT projects, Allen and colleagues said, so that expanding the breadth of their contributions and the judiciousness of exam ordering would make radiologists highly valuable and important members of the ACO ethos.

“The challenges to providing optimal healthcare in the U.S. are enormous and include controlling the rapidly growing costs of care, better integrating the currently fragmented delivery system, overcoming disparities in patient access to care and regional variations in utilization, and eliminating inefficiency and waste,” Allen and colleagues wrote.

Meeting these challenges and adapting to the structure of the ACO will require “fundamental changes” on the part of radiologists, most notably a shift away from productivity and toward value-added services, Allen and colleagues concluded. “Because radiologists are critical to effective and efficient diagnosis and treatment of a large majority of patients with serious or chronic illnesses, radiologists should have an integral role in the success of an ACO.”