Wo m e n ’s I m a g i n g • C l i n i c a l Pe r s p e c t i ve Parikh and Yang Breast Imaging as a Paradigm for ACOs
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Women’s Imaging Clinical Perspective
Jay R. Parikh1 Wei T. Yang Parikh JR, Yang WT
Breast Imaging: A Paradigm for Accountable Care Organizations OBJECTIVE. Accountable care organizations (ACOs) are being promoted by the Centers of Medicare Services as alternative payment models for radiology reimbursement. Because of its clinical orientation, focus on prevention, standardized reporting, quality orientation through mandatory accreditation, and value demonstration through established outcome metrics, breast imaging offers a unique paradigm for the ACO model in radiology. CONCLUSION. In radiology, breast imaging represents the paradigm for ACOs. he Patient Protection and Affordable Care Act (PPACA) [1] included resources for the Centers for Medicare and Medicaid Services (CMS) to test new payment models for Medicare and Medicaid. These models emphasized evidence-based quality care at the lowest cost. Payment for physician services inherently transitioned from fee-forservice (FFS) volume-based to value-based reimbursement. In light of early successes achieved in Medicare savings, U.S. Department of Health and Human Services Secretary Sylvia Burwell announced that the agency is ambitiously targeting a shift in care reimbursement from FFS to 90% valuebased by 2018, with 30% alternative payment models by 2016 and 50% by 2018 [2]. The four predominant CMS payment models since passage of the PPACA are pay for performance, bundled payments, coordinated care models, and accountable care organizations (ACOs) [3, 4]. In pay for performance, or value-based, purchasing, payment is aimed at improving the quality, efficiency, and overall value of health care. Typically, providers are reimbursed a bonus payment for achieving a predetermined set of quality measures [4, 5]. In bundled payment arrangements, payers provide a group of providers a single payment for an episode of care, defined as a set of services delivered to a patient over a specific period of time [4, 5]. Providers often share in savings from maintaining expenses below the predetermined bundled payment. Coordinated care models of payment are complex
T
Keywords: accountable care organizations, alternative payment models, breast imaging, paradigm DOI:10.2214/AJR.15.15398 Received August 2, 2015; accepted after revision September 24, 2015. 1 Both authors: Department of Radiology, University of Texas M. D. Anderson Cancer Center, 1155 Pressler St, Houston, TX 77030. Address c orrespondence to J. R. Parikh ([email protected]).
AJR 2016; 206:270–275 0361–803X/16/2062–270 © American Roentgen Ray Society
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investments used for patients with chronic conditions. A team-based approach is emphasized with typical coordination of care through a primary physician [4, 5]. ACOs have been defined as a group of providers that are collectively held accountable for the total cost and quality of care for a defined population [6]. This definition does not emphasize the inherent capitation and shared risk affecting physicians and radiologists practicing at multiple locations. Therefore, another definition has been proposed that designates an ACO as a type of organization providing managed care that is characterized by the accountability of a group of networked providers (e.g., joint ventures, group practices, practice networks, hospitals, or hospitalprovider partnerships) for the health care of a defined patient group [7]. ACOs follow two fundamental payment tracks [8]. In the onesided shared savings track, the ACO bears no financial risk but is eligible to share any savings with the Medicare program. In the twosided shared savings and losses track, the ACO shares in both the savings and losses but is rewarded for risk with a higher percentage of shared savings. A radiology group may therefore belong to multiple ACOs, receive simultaneous reimbursement from multiple CMS payment models, or both. Radiology practices will need to increasingly strategize how to prepare for and cope with the ACO transition. ACOs have overcome early concerns [9–12], having increased in number in the United States from 64 in 2011 to 744 in 2015 [13]. The ACO movement is strongly associated with the
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Breast Imaging as a Paradigm for ACOs Medicare program [5]. Historically, radiologists have been reimbursed using the FFS model, but concern is growing about eventual capitation [8, 14]. The need to engage and show quality-driven value to physician peers, patients, and relevant organizations is therefore paramount. Breast imaging has been a testing ground and represents a model for connecting radiology with ACOs [15]. Breast imaging is a paradigm because of its inherent and longstanding connection with primary care, focus on population health, standardized metrics, federally mandated quality standards, evaluation of physician performance, clinical integration, potential cost savings, digital image innovation, and physician leadership. Connection With Primary Care Provision of effective primary care is a core premise of any ACO model because it reduces cost, facilitates coordination, and reduces miscommunication that can result from patients seeing multiple specialists [14]. The breast radiologist acts not only as a consultant but in many practices also as an extender of the primary caregiver to help evaluate and assist in the management of clinical concerns such as a palpable breast mass [14]. Diagnostic breast imaging and ultrasound are performed in accordance with the appropriateness criteria of the American College of Radiology (ACR) [12]. These criteria include pertinent history, tailored clinical examination to the area of concern, and direct communication with the patient regarding imaging outcomes and management recommendations (e.g., additional imaging studies, surveillance, or biopsy). Increased interaction with patients is consistent with the Imaging 3.0 platform advocated by the ACR [16]. In addition, the breast imager takes on tasks traditionally performed by referring clinicians, such as effectively communicating before image-guided interventions to reduce patient anxiety [17], managing anticoagulation around procedures [18], communicating biopsy results directly to patients [19], and managing complications, such as breast hematomas [18, 20], abscess formation [20], and false-negative biopsies [19], from image-guided procedures. Some breast imaging practices are now communicating formal risk of breast cancer assessment to patients [21, 22], with the risk calculations based on data entry during patient history taken before a mammogram is performed.
Patients can then be referred to a formal risk assessment clinic for genetic testing or for MRI screening [23] directly by the radiologist or the breast center team. This practice pattern is consistent with ACR recommendations that radiologists make every effort to align with primary care providers, who are typically heavily involved in the governance of the ACO [24]. Population Health Breast imaging has the potential to be a future model for radiology in ACOs because of population screening with mammography, with its inherent benefits of reduced patient mortality and morbidity [25–31]. The goal of cost-effective population health focuses on prevention, early diagnosis of disease, and chronic disease management [14]. Though not currently preventable, breast cancer can be detected in women 40 years old or older at an earlier stage with screening mammography. Randomized control trials and secondary screening have been shown to reduce mortality from breast cancer screening [25–29]. The Society of Breast Imaging and the ACR [32] recommend annual screening mammograms for women in this age group. In addition to reducing mortality, population screening with mammography has been shown to downstage breast cancer at the time of diagnosis [30, 31, 33]. In two prospective cohort studies [30, 31], mammographydetected breast cancer was associated with lower rates of mastectomy and chemotherapy than breast cancer diagnosed by breast self-examination or by clinical examination. Relapse-free survival rates, disease-specific survival rates, and overall survival rates after treatment were higher in both cohort studies when mammography detected the breast cancer. Retrospective studies have also shown reduced rates of chemotherapy and increased rates of breast-conserving surgery in patients who underwent screening mammography [33]. Standardization Breast imaging is the first imaging modality with standardized reporting, that was achieved using the BI-RADS lexicon. The reporting system was first introduced to standardize lesion descriptors on mammography, to create standardized final assessment categories indicating level of suspicion from a particular finding, and to provide final recommendations for patient management [34].
The standardized descriptors enabled more robust communication between radiologists and other colleagues. The standardized reporting lexicon has now been expanded to include breast ultrasound and MRI [35]. The development and implementation of standardized breast imaging protocols for lesion workup and management is best done by breast imagers. Radiologists can best define the quality of a breast center by determining which patients should undergo breast imaging, what type of imaging examination to use, how the imaging studies should be interpreted relative to clinical context, and how the results of the imaging studies should influence clinical care [36]. Redundant imaging studies, incentivized under traditional FFS, will be problematic for an ACO accountable for total cost of care [3]. Quality Mammography providers are specifically required by the federal Mammography Quality Standards Act to undergo annual formal accreditation [37]. No other imaging modality in radiology is legally bound to maintain standards of acceptable quality. In an ACO model, this requirement represents an opportunity for breast radiology to build bridges with hospital administration and ACO governance, because incentives for maintaining quality align among these entities. Accurate, rapid diagnosis is a critical aspect of patient safety and quality, as well as a major factor in reducing costs [38]. In ACOs, breast imagers must continue to promote safety, quality, and best practices by actively supervising mammographic positioning by technologists [39]. Review of data from randomized control trials studying screening mammography indicate improved image quality resulted in higher cancer detection rates, detection of breast cancer at earlier stages, and lower interval cancer rates [40]. In one study, suboptimal mammography positioning was 2.57 times more likely to be associated with interval diagnosis of cancer than adequate positioning [41]. In practice, however, quality can be a code word for lack of service or behavioral issues that hospital administration finds objectionable [42], which emphasizes the importance of objective metrics to monitor and demonstrate quality. Metrics Metrics are indicators selected to manage practice performance [43]. Many cur-
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Parikh and Yang rent metrics in radiology are process metrics, which monitor the performance of a step or series of steps in a healthcare process. Examples of process metrics include patient access times, appointment times, and report turnaround time [44]. Focused process improvement is generally successful in improving practice performance, but continued process evaluation and ongoing workflow modifications are warranted as changing environments influence sustainability [45]. Value-driven care can be defined as patient care provided under systems of accountability that prioritize and reward contributions to the value equation, defined as outcomes divided by cost [44, 46]. In ACOs, with focus now on value, attention shifts from process metrics to outcome metrics. Metrics assessing radiology’s contribution to cost, quality, or outcomes are generally lacking [47] and will likely take years of research to develop [48]. In contrast to most fields in radiology and medicine, breast imaging has well established outcome metrics. Desirable goals published in 1994 [49] by the Agency for Healthcare Policy and Research were referenced in the basic clinical relevant mammography audit section of the 4th edition of BI-RADS [34]. The recently published 5th edition of BI-RADS has expanded its outcome monitoring section, listing metrics for screening and diagnostic mammography, breast ultrasound, and breast MRI [50]. Managing Physician Performance Breast imaging was the first imaging modality to use a formal medical audit to help monitor and improve physician performance [51]. This pioneer work was the basis for some of the language of the Mammography Quality Standards Act, which requires lead interpreting physicians for a facility to provide annual feedback regarding physician outcomes [37, 52]. Radiologists are receptive to feedback from these medical audits to improve performance, with a preference for receiving performance feedback graphically with clear benchmarks [53, 54]. Because multiple factors can affect outcomes, including geographic variation in cancer detection rate, recent approaches have been developed to combine metrics to better assess overall performance. Using the Breast Cancer Surveillance Consortium database, updated combined criteria for identifying physicians with acceptable performance were recently published [55] (Table 1).
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TABLE 1: Updated Combined Criteria for Acceptable Cancer Detection Rate, Recall Rate, and Positive Predictive Value of Recall Updated Criteria
Cancer Detection Rate (%)
Recall Rate (%)
Positive Predictive Value of Recall (%)
1
≥ 6/1000
3–20
2
4–< 6/1000
3–15
≥3
3
2.5–< 4/1000
5–12
3–8
Note—Criteria are based on data from the Breast Cancer Surveillance Consortium database.
Integration Multidisciplinary breast care conferences increase communication across specialties. The breast imager participates in these conferences, presents a synthesized history, and helps guide clinicians to additional appropriate imaging studies, based on ACR Appropriateness Criteria [55] and ACR Practice Parameters [31]. These patient-centered decisions build relationships and trust with the other members of the multidisciplinary breast care team and recognize the radiologist as a valued consultant and care provider. Integration should be both horizontal and vertical. The mutual goal of increasing appropriate use of breast studies, such as screening average-risk women 40 years old or older, and decreasing inappropriate use of imaging studies is an opportunity to generate a win-win relationship with other provider leaders during utilization management and resource allocation committees in the hospital or network. This integration opportunity with network leadership may support greater involvement with strategic planning and capital acquisition. Cost Savings One of the primary drivers behind the ACO model is selective cost cutting [4]. On the basis of evidence showing that higher quality leads to reduced cost, Berwick et al. [56] coined the term “triple aim” of health care: improving the individual experience of care, improving the health of populations, and reducing the per capita cost for populations [56]. The ACO model is essentially a capitation model with shared risk among all providers [57]. Early data suggest successful cost savings in some ACO models, but some ACOs have not reduced cost, and some have exited the program. For the cost reduction to be done in a way that optimizes patient care, organizations will need to be led by providers [58]. Reduced rates of surgery, radiation therapy, and chemotherapy in patients who undergo screening mammography, coupled with
reduced recurrences requiring treatment, lead to reduced treatment expenses for the ACO. The cost savings from reduced treatment must be balanced against the costs of screening and potential costs of overdiagnosis and overtreatment in ACOs. In the absence of a universal formula for reducing oncology costs in ACO models [59], support for breast screening will likely continue. ACOs will probably pass on incentives along to member physicians, who will be responsible for most utilization decisions [60]. One opportunity to help reduce unnecessary utilization in ACOs is incorporating clinical decision support (CDS) in electronic records to help referring clinicians order appropriate imaging tests for appropriate indications. Starting in 2017, the Protecting Access to Medicare Act of 2014 [61] will mandate the use of CDS systems when ordering advanced diagnostic imaging for patients receiving Medicare. Radiologists can be powerful advocates for implementing appropriate indications in breast imaging studies in CDS systems. Digital Imaging Innovation Breast imagers have a long history of incorporating technologic innovation and will need to do so in ACOs. Breast radiologists were champions for the transition from filmscreen to full-field digital mammography over the past decade [62, 63]. In ACOs, their expertise will lead to evaluation of cost-effectiveness, deployment, and indications for digital tomosynthesis [64], synthetic digital tomosynthesis [65], and contrast-enhanced digital mammography [66]. Communication of testing results to patients is increasingly sought by patients and organizations. Though only recently incorporated into technology platforms, this communication has long been routinely performed by breast imagers. Immediate assessment of breast imagers is possible because of established metrics in breast radiology. ACOs are thirsty for disease
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Breast Imaging as a Paradigm for ACOs
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registries. Breast imagers are already leading efforts to establish such registries, exemplified by their support of the National Mammography Database of the ACR [67]. Physician Leadership Physicians played a strong leadership role in the first wave of ACOs. According to an early survey [6], 51% of ACOs were physician-led, 78% of governance board members were physicians, and 40% of ACOs had physicians owning equipment, employing staff, or both. In today’s environment, radiologists need to step up their leadership role. Historically, radiologists have had a history of apathy and entitlement [68] and have been perceived as lacking leadership skills [42]. ACO models will have major impact on many aspects of physicians’ lives, including degree of autonomy, clinical practice protocols, work environments, and income [6, 69]. To preserve their specific long-term interests, radiologists will need to be at the table quickly. Authors have argued that whoever dominates the formation of ACOs at the start will likely continue to do so (i.e., establish path dependence) [69]. Future decisions will be based on and constrained by past decisions. In addition, radiologists who do not participate in ACOs may be penalized by their peers for not being resourceconscious and ultimately may be viewed as less desirable ACO participants [70]. Breast imagers have historically participated in and led nonclinical activities such as quality control [71], maintenance of facility accreditation [72], radiation safety, technologist supervision and education [39], equipment selection and optimization, imaging flow model design [73], and managing physician performance [39, 51]. These activities, which are not reimbursed, are seen as added value to ACOs [24] and can help build bridges to enterprise leadership. Ideally, this process will serve as a conduit for radiologists to become involved with enterprise administration, strategic planning, and resource utilization. Breast Imagers: ACO Radiologists Radiologists in ACOs need to be able, available, affable, affordable, aligned, and accountable—the so-called “six As” [74]. Breast imagers, because of the inherent characteristics of their subspecialty, represent the four dimensions of a doctor needed to accomplish the six As.
Patient’s Doctor Radiologists in ACOs will need to have more direct contact with patients. Imaging 3.0 encourages radiologists to move away from the viewbox and spend time with patients [16]. This practice combats potential commoditization of radiology, in which radiology services are outsourced to the lowest bidder. Breast radiologists already represent the face of radiology, interacting with patients during diagnostic mammography, ultrasound, and interventional procedures. By developing relationships with patients and providing positive customer experiences [47], radiologists encourage patients and their primary care physicians to become advocates for radiology. Doctor’s Doctor Radiologists will provide the most value in ACOs if they are effective, affable consultants to primary clinicians and specialists. Teamwork across specialties will be fundamental, including skills such as listening, developing trust, and collaboratively managing complex conditions with effective communication across specialties and disciplines [75]. A culture shift in radiology to breast imaging’s service-first mentality will be the expectation [42]. Breast imagers crystallize physician relationships through their described roles as physician extenders and nonclinical leadership roles. System’s Doctor Breast radiologists are in a position to show their ability through established metrics and to be accountable for their performance to ACO leadership based on their annual medical audits. Higher quality should lead to lower cost, especially when coupled with reduced treatment cost and morbidity, aligning breast imaging with ACOs. Society’s Doctor Breast imagers show their ability to serve society by being champions for quality. Breast imaging is the only imaging modality that by law [37] needs to be accredited annually. The mission of breast imaging—namely, to reduce mortality from breast cancer—is aligned with society’s expectation of radiology to perform the right study for the right patient at the right time. Conclusion ACOs represent an alternative payment model introduced by Medicare over the past
5 years. CMS is now projecting further expansion of ACO models with increasing coverage of Medicare beneficiaries. Other insurers are interested in following this payment model. Radiology practices will need to increasingly strategize how to cope with the ACO transition. Because of its clinical orientation, focus on prevention, standardized reporting, quality orientation with mandated accreditation, and value demonstration through established metrics, breast imaging is the paradigm for radiology in ACOs. References
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Women’s Imaging Clinical Perspective
Jay R. Parikh1 Wei T. Yang Parikh JR, Yang WT
Breast Imaging: A Paradigm for Accountable Care Organizations OBJECTIVE. Accountable care organizations (ACOs) are being promoted by the Centers of Medicare Services as alternative payment models for radiology reimbursement. Because of its clinical orientation, focus on prevention, standardized reporting, quality orientation through mandatory accreditation, and value demonstration through established outcome metrics, breast imaging offers a unique paradigm for the ACO model in radiology. CONCLUSION. In radiology, breast imaging represents the paradigm for ACOs. he Patient Protection and Affordable Care Act (PPACA) [1] included resources for the Centers for Medicare and Medicaid Services (CMS) to test new payment models for Medicare and Medicaid. These models emphasized evidence-based quality care at the lowest cost. Payment for physician services inherently transitioned from fee-forservice (FFS) volume-based to value-based reimbursement. In light of early successes achieved in Medicare savings, U.S. Department of Health and Human Services Secretary Sylvia Burwell announced that the agency is ambitiously targeting a shift in care reimbursement from FFS to 90% valuebased by 2018, with 30% alternative payment models by 2016 and 50% by 2018 [2]. The four predominant CMS payment models since passage of the PPACA are pay for performance, bundled payments, coordinated care models, and accountable care organizations (ACOs) [3, 4]. In pay for performance, or value-based, purchasing, payment is aimed at improving the quality, efficiency, and overall value of health care. Typically, providers are reimbursed a bonus payment for achieving a predetermined set of quality measures [4, 5]. In bundled payment arrangements, payers provide a group of providers a single payment for an episode of care, defined as a set of services delivered to a patient over a specific period of time [4, 5]. Providers often share in savings from maintaining expenses below the predetermined bundled payment. Coordinated care models of payment are complex
T
Keywords: accountable care organizations, alternative payment models, breast imaging, paradigm DOI:10.2214/AJR.15.15398 Received August 2, 2015; accepted after revision September 24, 2015. 1 Both authors: Department of Radiology, University of Texas M. D. Anderson Cancer Center, 1155 Pressler St, Houston, TX 77030. Address c orrespondence to J. R. Parikh ([email protected]).
AJR 2016; 206:270–275 0361–803X/16/2062–270 © American Roentgen Ray Society
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investments used for patients with chronic conditions. A team-based approach is emphasized with typical coordination of care through a primary physician [4, 5]. ACOs have been defined as a group of providers that are collectively held accountable for the total cost and quality of care for a defined population [6]. This definition does not emphasize the inherent capitation and shared risk affecting physicians and radiologists practicing at multiple locations. Therefore, another definition has been proposed that designates an ACO as a type of organization providing managed care that is characterized by the accountability of a group of networked providers (e.g., joint ventures, group practices, practice networks, hospitals, or hospitalprovider partnerships) for the health care of a defined patient group [7]. ACOs follow two fundamental payment tracks [8]. In the onesided shared savings track, the ACO bears no financial risk but is eligible to share any savings with the Medicare program. In the twosided shared savings and losses track, the ACO shares in both the savings and losses but is rewarded for risk with a higher percentage of shared savings. A radiology group may therefore belong to multiple ACOs, receive simultaneous reimbursement from multiple CMS payment models, or both. Radiology practices will need to increasingly strategize how to prepare for and cope with the ACO transition. ACOs have overcome early concerns [9–12], having increased in number in the United States from 64 in 2011 to 744 in 2015 [13]. The ACO movement is strongly associated with the
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Breast Imaging as a Paradigm for ACOs Medicare program [5]. Historically, radiologists have been reimbursed using the FFS model, but concern is growing about eventual capitation [8, 14]. The need to engage and show quality-driven value to physician peers, patients, and relevant organizations is therefore paramount. Breast imaging has been a testing ground and represents a model for connecting radiology with ACOs [15]. Breast imaging is a paradigm because of its inherent and longstanding connection with primary care, focus on population health, standardized metrics, federally mandated quality standards, evaluation of physician performance, clinical integration, potential cost savings, digital image innovation, and physician leadership. Connection With Primary Care Provision of effective primary care is a core premise of any ACO model because it reduces cost, facilitates coordination, and reduces miscommunication that can result from patients seeing multiple specialists [14]. The breast radiologist acts not only as a consultant but in many practices also as an extender of the primary caregiver to help evaluate and assist in the management of clinical concerns such as a palpable breast mass [14]. Diagnostic breast imaging and ultrasound are performed in accordance with the appropriateness criteria of the American College of Radiology (ACR) [12]. These criteria include pertinent history, tailored clinical examination to the area of concern, and direct communication with the patient regarding imaging outcomes and management recommendations (e.g., additional imaging studies, surveillance, or biopsy). Increased interaction with patients is consistent with the Imaging 3.0 platform advocated by the ACR [16]. In addition, the breast imager takes on tasks traditionally performed by referring clinicians, such as effectively communicating before image-guided interventions to reduce patient anxiety [17], managing anticoagulation around procedures [18], communicating biopsy results directly to patients [19], and managing complications, such as breast hematomas [18, 20], abscess formation [20], and false-negative biopsies [19], from image-guided procedures. Some breast imaging practices are now communicating formal risk of breast cancer assessment to patients [21, 22], with the risk calculations based on data entry during patient history taken before a mammogram is performed.
Patients can then be referred to a formal risk assessment clinic for genetic testing or for MRI screening [23] directly by the radiologist or the breast center team. This practice pattern is consistent with ACR recommendations that radiologists make every effort to align with primary care providers, who are typically heavily involved in the governance of the ACO [24]. Population Health Breast imaging has the potential to be a future model for radiology in ACOs because of population screening with mammography, with its inherent benefits of reduced patient mortality and morbidity [25–31]. The goal of cost-effective population health focuses on prevention, early diagnosis of disease, and chronic disease management [14]. Though not currently preventable, breast cancer can be detected in women 40 years old or older at an earlier stage with screening mammography. Randomized control trials and secondary screening have been shown to reduce mortality from breast cancer screening [25–29]. The Society of Breast Imaging and the ACR [32] recommend annual screening mammograms for women in this age group. In addition to reducing mortality, population screening with mammography has been shown to downstage breast cancer at the time of diagnosis [30, 31, 33]. In two prospective cohort studies [30, 31], mammographydetected breast cancer was associated with lower rates of mastectomy and chemotherapy than breast cancer diagnosed by breast self-examination or by clinical examination. Relapse-free survival rates, disease-specific survival rates, and overall survival rates after treatment were higher in both cohort studies when mammography detected the breast cancer. Retrospective studies have also shown reduced rates of chemotherapy and increased rates of breast-conserving surgery in patients who underwent screening mammography [33]. Standardization Breast imaging is the first imaging modality with standardized reporting, that was achieved using the BI-RADS lexicon. The reporting system was first introduced to standardize lesion descriptors on mammography, to create standardized final assessment categories indicating level of suspicion from a particular finding, and to provide final recommendations for patient management [34].
The standardized descriptors enabled more robust communication between radiologists and other colleagues. The standardized reporting lexicon has now been expanded to include breast ultrasound and MRI [35]. The development and implementation of standardized breast imaging protocols for lesion workup and management is best done by breast imagers. Radiologists can best define the quality of a breast center by determining which patients should undergo breast imaging, what type of imaging examination to use, how the imaging studies should be interpreted relative to clinical context, and how the results of the imaging studies should influence clinical care [36]. Redundant imaging studies, incentivized under traditional FFS, will be problematic for an ACO accountable for total cost of care [3]. Quality Mammography providers are specifically required by the federal Mammography Quality Standards Act to undergo annual formal accreditation [37]. No other imaging modality in radiology is legally bound to maintain standards of acceptable quality. In an ACO model, this requirement represents an opportunity for breast radiology to build bridges with hospital administration and ACO governance, because incentives for maintaining quality align among these entities. Accurate, rapid diagnosis is a critical aspect of patient safety and quality, as well as a major factor in reducing costs [38]. In ACOs, breast imagers must continue to promote safety, quality, and best practices by actively supervising mammographic positioning by technologists [39]. Review of data from randomized control trials studying screening mammography indicate improved image quality resulted in higher cancer detection rates, detection of breast cancer at earlier stages, and lower interval cancer rates [40]. In one study, suboptimal mammography positioning was 2.57 times more likely to be associated with interval diagnosis of cancer than adequate positioning [41]. In practice, however, quality can be a code word for lack of service or behavioral issues that hospital administration finds objectionable [42], which emphasizes the importance of objective metrics to monitor and demonstrate quality. Metrics Metrics are indicators selected to manage practice performance [43]. Many cur-
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Parikh and Yang rent metrics in radiology are process metrics, which monitor the performance of a step or series of steps in a healthcare process. Examples of process metrics include patient access times, appointment times, and report turnaround time [44]. Focused process improvement is generally successful in improving practice performance, but continued process evaluation and ongoing workflow modifications are warranted as changing environments influence sustainability [45]. Value-driven care can be defined as patient care provided under systems of accountability that prioritize and reward contributions to the value equation, defined as outcomes divided by cost [44, 46]. In ACOs, with focus now on value, attention shifts from process metrics to outcome metrics. Metrics assessing radiology’s contribution to cost, quality, or outcomes are generally lacking [47] and will likely take years of research to develop [48]. In contrast to most fields in radiology and medicine, breast imaging has well established outcome metrics. Desirable goals published in 1994 [49] by the Agency for Healthcare Policy and Research were referenced in the basic clinical relevant mammography audit section of the 4th edition of BI-RADS [34]. The recently published 5th edition of BI-RADS has expanded its outcome monitoring section, listing metrics for screening and diagnostic mammography, breast ultrasound, and breast MRI [50]. Managing Physician Performance Breast imaging was the first imaging modality to use a formal medical audit to help monitor and improve physician performance [51]. This pioneer work was the basis for some of the language of the Mammography Quality Standards Act, which requires lead interpreting physicians for a facility to provide annual feedback regarding physician outcomes [37, 52]. Radiologists are receptive to feedback from these medical audits to improve performance, with a preference for receiving performance feedback graphically with clear benchmarks [53, 54]. Because multiple factors can affect outcomes, including geographic variation in cancer detection rate, recent approaches have been developed to combine metrics to better assess overall performance. Using the Breast Cancer Surveillance Consortium database, updated combined criteria for identifying physicians with acceptable performance were recently published [55] (Table 1).
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TABLE 1: Updated Combined Criteria for Acceptable Cancer Detection Rate, Recall Rate, and Positive Predictive Value of Recall Updated Criteria
Cancer Detection Rate (%)
Recall Rate (%)
Positive Predictive Value of Recall (%)
1
≥ 6/1000
3–20
2
4–< 6/1000
3–15
≥3
3
2.5–< 4/1000
5–12
3–8
Note—Criteria are based on data from the Breast Cancer Surveillance Consortium database.
Integration Multidisciplinary breast care conferences increase communication across specialties. The breast imager participates in these conferences, presents a synthesized history, and helps guide clinicians to additional appropriate imaging studies, based on ACR Appropriateness Criteria [55] and ACR Practice Parameters [31]. These patient-centered decisions build relationships and trust with the other members of the multidisciplinary breast care team and recognize the radiologist as a valued consultant and care provider. Integration should be both horizontal and vertical. The mutual goal of increasing appropriate use of breast studies, such as screening average-risk women 40 years old or older, and decreasing inappropriate use of imaging studies is an opportunity to generate a win-win relationship with other provider leaders during utilization management and resource allocation committees in the hospital or network. This integration opportunity with network leadership may support greater involvement with strategic planning and capital acquisition. Cost Savings One of the primary drivers behind the ACO model is selective cost cutting [4]. On the basis of evidence showing that higher quality leads to reduced cost, Berwick et al. [56] coined the term “triple aim” of health care: improving the individual experience of care, improving the health of populations, and reducing the per capita cost for populations [56]. The ACO model is essentially a capitation model with shared risk among all providers [57]. Early data suggest successful cost savings in some ACO models, but some ACOs have not reduced cost, and some have exited the program. For the cost reduction to be done in a way that optimizes patient care, organizations will need to be led by providers [58]. Reduced rates of surgery, radiation therapy, and chemotherapy in patients who undergo screening mammography, coupled with
reduced recurrences requiring treatment, lead to reduced treatment expenses for the ACO. The cost savings from reduced treatment must be balanced against the costs of screening and potential costs of overdiagnosis and overtreatment in ACOs. In the absence of a universal formula for reducing oncology costs in ACO models [59], support for breast screening will likely continue. ACOs will probably pass on incentives along to member physicians, who will be responsible for most utilization decisions [60]. One opportunity to help reduce unnecessary utilization in ACOs is incorporating clinical decision support (CDS) in electronic records to help referring clinicians order appropriate imaging tests for appropriate indications. Starting in 2017, the Protecting Access to Medicare Act of 2014 [61] will mandate the use of CDS systems when ordering advanced diagnostic imaging for patients receiving Medicare. Radiologists can be powerful advocates for implementing appropriate indications in breast imaging studies in CDS systems. Digital Imaging Innovation Breast imagers have a long history of incorporating technologic innovation and will need to do so in ACOs. Breast radiologists were champions for the transition from filmscreen to full-field digital mammography over the past decade [62, 63]. In ACOs, their expertise will lead to evaluation of cost-effectiveness, deployment, and indications for digital tomosynthesis [64], synthetic digital tomosynthesis [65], and contrast-enhanced digital mammography [66]. Communication of testing results to patients is increasingly sought by patients and organizations. Though only recently incorporated into technology platforms, this communication has long been routinely performed by breast imagers. Immediate assessment of breast imagers is possible because of established metrics in breast radiology. ACOs are thirsty for disease
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registries. Breast imagers are already leading efforts to establish such registries, exemplified by their support of the National Mammography Database of the ACR [67]. Physician Leadership Physicians played a strong leadership role in the first wave of ACOs. According to an early survey [6], 51% of ACOs were physician-led, 78% of governance board members were physicians, and 40% of ACOs had physicians owning equipment, employing staff, or both. In today’s environment, radiologists need to step up their leadership role. Historically, radiologists have had a history of apathy and entitlement [68] and have been perceived as lacking leadership skills [42]. ACO models will have major impact on many aspects of physicians’ lives, including degree of autonomy, clinical practice protocols, work environments, and income [6, 69]. To preserve their specific long-term interests, radiologists will need to be at the table quickly. Authors have argued that whoever dominates the formation of ACOs at the start will likely continue to do so (i.e., establish path dependence) [69]. Future decisions will be based on and constrained by past decisions. In addition, radiologists who do not participate in ACOs may be penalized by their peers for not being resourceconscious and ultimately may be viewed as less desirable ACO participants [70]. Breast imagers have historically participated in and led nonclinical activities such as quality control [71], maintenance of facility accreditation [72], radiation safety, technologist supervision and education [39], equipment selection and optimization, imaging flow model design [73], and managing physician performance [39, 51]. These activities, which are not reimbursed, are seen as added value to ACOs [24] and can help build bridges to enterprise leadership. Ideally, this process will serve as a conduit for radiologists to become involved with enterprise administration, strategic planning, and resource utilization. Breast Imagers: ACO Radiologists Radiologists in ACOs need to be able, available, affable, affordable, aligned, and accountable—the so-called “six As” [74]. Breast imagers, because of the inherent characteristics of their subspecialty, represent the four dimensions of a doctor needed to accomplish the six As.
Patient’s Doctor Radiologists in ACOs will need to have more direct contact with patients. Imaging 3.0 encourages radiologists to move away from the viewbox and spend time with patients [16]. This practice combats potential commoditization of radiology, in which radiology services are outsourced to the lowest bidder. Breast radiologists already represent the face of radiology, interacting with patients during diagnostic mammography, ultrasound, and interventional procedures. By developing relationships with patients and providing positive customer experiences [47], radiologists encourage patients and their primary care physicians to become advocates for radiology. Doctor’s Doctor Radiologists will provide the most value in ACOs if they are effective, affable consultants to primary clinicians and specialists. Teamwork across specialties will be fundamental, including skills such as listening, developing trust, and collaboratively managing complex conditions with effective communication across specialties and disciplines [75]. A culture shift in radiology to breast imaging’s service-first mentality will be the expectation [42]. Breast imagers crystallize physician relationships through their described roles as physician extenders and nonclinical leadership roles. System’s Doctor Breast radiologists are in a position to show their ability through established metrics and to be accountable for their performance to ACO leadership based on their annual medical audits. Higher quality should lead to lower cost, especially when coupled with reduced treatment cost and morbidity, aligning breast imaging with ACOs. Society’s Doctor Breast imagers show their ability to serve society by being champions for quality. Breast imaging is the only imaging modality that by law [37] needs to be accredited annually. The mission of breast imaging—namely, to reduce mortality from breast cancer—is aligned with society’s expectation of radiology to perform the right study for the right patient at the right time. Conclusion ACOs represent an alternative payment model introduced by Medicare over the past
5 years. CMS is now projecting further expansion of ACO models with increasing coverage of Medicare beneficiaries. Other insurers are interested in following this payment model. Radiology practices will need to increasingly strategize how to cope with the ACO transition. Because of its clinical orientation, focus on prevention, standardized reporting, quality orientation with mandated accreditation, and value demonstration through established metrics, breast imaging is the paradigm for radiology in ACOs. References
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