OPINION
Clinician and Radiologist: A Time for Realignment William R. Reinus, MD, MBA Economics and politics have in a very short time completely altered the health care economic playing field. Fee-for-service is disappearing from American medicine. It is being replaced by large-scale capitation with economic risk transference from the insurer to the provider, at least as a partner. This shift has momentous implications. It implies a complete change in the economic incentives that all providers face and to which they will respond. In overview, it means changing from a piecework payment system in which the more care provided, the more revenue generated, regardless of health outcome, to a fixed-payment world where the incentive is to strike a balance between the amount of care delivered and optimal patient health outcomes. In this new world, providing more care doesn’t mean more revenue to providers; in fact, it may mean less. Similarly, failing to provide for the best possible health for each individual patient will mean more care consumption and hence lower margins to providers. Thus, a new paradigm is coming into place, whereby to optimize margins, providers must learn just how much care results in the best health outcomes. For radiologists, this paradigm shift is compounded by 2 decades of rapidly advancing imaging and information technologies. On one
1120
hand, more detailed imaging means that finer and finer anatomic detail is displayed. Thus, increasing anatomic knowledge is required to interpret images. On the other hand, remote accessibility of imaging studies has made image interpretation more accessible to nonradiologists, particularly clinical subspecialists who possess sophisticated understanding of relevant studies. This has created turf battles, particularly in our current economic climate of decreasing reimbursements [1-4]. With the advent of the Patient Protection and Affordable Care Act, new cost reduction initiatives are being superimposed on preexisting ones. These include new bundling of care models [5-8]. The legislation calls for the creation of accountable care organizations (ACOs). These are structured so that groups of health care providers who form ACOs are paid what is essentially a bundled or capitated rate for the lives that each ACO covers [9,10]. With bundled payments, all clinical activities, including laboratory and imaging examinations, are paid for out of the total capitation. As bundling replaces fee-forservice, incentives will change. Clinicians will be inclined to reduce the number of studies they obtain because every dollar spent on diagnostic examinations will come directly out of their ACO’s or other provider organization’s budget and
hence lower their net revenue. Thus, the future economic driver will be to reduce the utilization of medical imaging, but only to the point at which the impact on patient health is not negative, in which case ACO costs would again rise. This system theoretically provides for a built-in optimization of care according to the invisible guiding hand of Adam Smith (ie, finding the efficient frontier of care). One might suspect that the economic cost of radiologists to ensure presumably higher levels of diagnostic accuracy and hence better health care is a value without which our system cannot function. This is not necessarily so. For example, many imaging studies performed on patients in the British National Health Service system are not interpreted by a radiologist unless a clinician makes a specific request for a read (Ian Beggs, National Health Service radiologist, personal communication). In fact, technologists interpret a portion of medical ultrasound imaging in the United Kingdom. Despite this practice, according to the Organisation for Economic Co-operation and Development, there has been little impact on either quantity or quality of life, but a real impact on their health care economics [11,12]. Data from the Organisation for Economic Cooperation and Development suggest that the United Kingdom outranks
1546-1440/15/$36.00
n
ª 2015 American College of Radiology http://dx.doi.org/10.1016/j.jacr.2015.02.017
the United States in many measured areas while spending less than half per capita on health care [11,12]. Should we adopt such a system in the United States, the potential effects to health outcomes, rates of litigation, and the economics of care delivery are currently unknown. Perhaps the greatest value a radiologist provides is in the interpretation of studies on patients sent by clinicians who do not feel competent to render interpretations. At the present time, this represents the majority of interpretations, but this is no reason for complacency. It is likely that these clinicians themselves will become part of ACOs or similar organizations that contain both specialists and generalists. As economic pressures induce reductions in imaging, and if radiology is seen as a cost center without generating value, eventually clinical specialists could assume more and more of radiologists’ current work, perhaps leaving nothing behind or leaving only low-value studies for radiologists. Although the possibility might seem extreme, the economic drivers of ACOs may make this behavior more attractive than one might anticipate. Certainly, this outcome would be unsatisfactory to radiologists from both professional and economic points of view. In a worst-case scenario, one could envision a tipping point beyond which clinicians assume all imaging interpretation, if not voluntarily, then by governmental mandate. The current state of imaging brings a time of humble and honest self-examination as to what value radiologists add to patient care. Unquestionably, medical imaging provides value. What we need to ask ourselves is how much value radiologists add in the current
environment. Will radiologists’ interpretive services eventually become superfluous in an age of increasing constraints on health care expenditures, bundled payments, and highly accurate and detailed imaging, when clinicians have increasing confidence in their own interpretive skills, particularly as they have more intimate knowledge of patient histories and laboratory data? Traditionally, articles such as this call for radiologists to network with their clinical colleagues and assume administrative roles in hospitals and clinics. This is an impotent response to increasing pressure. Radiologists are now in a position to rethink proactively their role in medical care and how they interact with their clinical colleagues. In this fashion, they can, at least to some degree, control the future of the specialty. Radiologists may consider how to better align their interests with those of clinical colleagues to achieve a higher degree of complementarity under new economic realities. Indeed, many turf issues faced by the specialty have arisen from the fact that radiologists have seen themselves as a separate specialty and have billed accordingly. Although this model is long standing, it is under pressure from factors that are affecting the behavior of clinical colleagues and insurance companies. Instead of acting as independent consultants, the time might be right to consider more integration of care, with radiologists working alongside their clinical colleagues as part of a single economic entity. This would mean that radiologists should work to integrate not only into provider organizations but directly into the practices of their clinical colleagues. Integrating radiologists into the same economic and clinical entities
Journal of the American College of Radiology Reinus n Opinion
as clinicians will align incentives. Under these circumstances, the same economic drivers will motivate clinicians and radiologists to work together to ensure that studies are indicated, will answer the clinical question at hand, and affect patient management. In this collegial fashion, because of overarching economic drivers, radiologists will have an incentive to act as ombudsmen to direct appropriate imaging services, and likely clinicians will now welcome this role if not demand it as an essential function of an imaging specialist. Clinical integration would support the role of radiologists as providers of unbiased opinions, individuals to set standards for imaging, and, of course, their traditional role as the experts in imaging interpretation. Such alignment may lead to overall better clinical care at lower costs. Beyond integrating into provider organizations, radiologists may consider an entirely new way of practicing. Instead of concentrating imaging services in 1 centralized radiology department, better care and better integration of services might be achieved if radiologists work side by side with their clinical colleagues. This may mean that various radiology subspecialties will need to physically locate into the same space as their clinical colleagues. Thus, one might see body, musculoskeletal, cardiothoracic, and neurologic imagers practicing in the same space as relevant specialties. Already, interventional radiology is becoming increasingly integrated with corresponding surgical services. Fortunately, technology no longer necessitates that radiologists work near where medical images are obtained. Radiologists, not imaging, are facing uncertain times. Although 1121
there is danger in the air, there also may be opportunity. First and foremost radiologists must seek to align both their clinical and economic interests with those of their clinical colleagues. Although the former have always been aligned to a large degree, the latter have not. To accomplish the alignment of economic interests, radiologists need to integrate themselves into ACOs and other bundled payment systems in a fashion whereby imaging can be optimized to provide care at the efficient economic frontier (ie, promote the highest level of health at the lowest cost). This may mean that radiologists need not only to integrate into these larger provider structures but also to consider decentralizing their practices and assuming the role of ombudsmen to ensure that imaging dollars are spent most effectively. Seizing this opportunity may require some deep self-examination, radical thinking, and a willingness to transform how radiology is practiced in the United States.
REFERENCES 1. Johnson SR. Outlook 2014: public hospitals. Modern Healthcare. January 4, 2014. Available at: http://www.modernhealth care.com/article/20140104/MAGAZINE/ 301049945/outlook-2014-public-hospitals. Accessed February 26, 2015. 2. Lee DW, Duszak R Jr, Hughes DR. Comparative analysis of Medicare spending for medical imaging: sustained dramatic slowdown compared with other services. AJR Am J Roentgenol 2013;201:1277-82. 3. Nordt JC, Connair MP, Gregorian JA. As Medicare costs rise, reimbursements drop. AAOS Now. December 2012. Available at: http://www.aaos.org/news/aaosnow/dec12/ cover1.asp. Accessed February 26, 2015. 4. Salmen A. 2014 Medicare payment cuts for radiology services. HealthWorks Collective. July 29, 2014. Available at: http://healthworks collective.com/andy-salmen/179336/2014medicare-payment-cuts-radiology-services. Accessed February 26, 2015. 5. Centers for Medicare and Medicaid Services. Bundled Payments for Care Improvement (BPCI) initiative: general information. Available at: http://innovation.cms.gov/initiatives/ bundled-payments/. Accessed November 10, 2014. 6. Thorpe J. Reforming how we pay for health care: the role of bundled payments. Health Affairs Blog. December 12, 2013. Available at: http://healthaffairs.org/blog/2012/ 12/13/reforming-how-we-pay-for-health-carethe-role-of-bundled-payments/. Accessed November 10, 2014. 7. Evans M. Interest surges in Medicare bundled-payment initiative. Modern Healthcare. July 13, 2014. Available at:
8.
9.
10.
11.
12.
http://www.modernhealthcare.com/article/ 20140731/NEWS/307319832/interest-surgesin-medicare-bundled-payment-initiative. Accessed November 10, 2014. Centers for Medicare and Medicaid Services. Bundled Payments for Care Improvement initiative. August 23, 2011. Available at: http://innovation. cms.gov/Files/fact-sheet/Bundled-PaymentsFact-Sheet.pdf. Accessed November 10, 2014. Centers for Medicare and Medicaid Services. ACO investment model. Available at: http://innovation.cms.gov/initiatives/ACOInvestment-Model/. Accessed November 10, 2014. US Department of Health and Human Services. New Affordable Care Act tools and payment models deliver $372 million in savings, improve care. September 16, 2014. Available at: http://www.hhs.gov/ news/press/2014pres/09/20140916a.html. Accessed November 10, 2014. Davis K, Stremikis K, Schoen C, Squires D. Mirror, mirror on the wall, 2014 update: how the U.S. health care system compares internationally. The Commonwealth Fund. June 2014. Available at: http://www. commonwealthfund.org/publications/fundreports/2014/jun/mirror-mirror. Accessed February 26, 2015. Squires D. Multinational comparisons of health systems data, 2013. The Commonwealth Fund. November 2013. Available at: http://www.commonwealthfund.org/w/ media/files/publications/in-the-literature/2013/ nov/pdf_oecd_multinational_comparisons_ hlt_sys_data_2013.pdf. Accessed February 26, 2015.
The author has no conflicts of interest related to the material discussed in this article. William R. Reinus, MD, MBA: Department of Radiology, Temple University, Philadelphia, PA 19140; e-mail: [email protected].
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Journal of the American College of Radiology Volume 12 n Number 10 n October 2015
Clinician and Radiologist: A Time for Realignment William R. Reinus, MD, MBA Economics and politics have in a very short time completely altered the health care economic playing field. Fee-for-service is disappearing from American medicine. It is being replaced by large-scale capitation with economic risk transference from the insurer to the provider, at least as a partner. This shift has momentous implications. It implies a complete change in the economic incentives that all providers face and to which they will respond. In overview, it means changing from a piecework payment system in which the more care provided, the more revenue generated, regardless of health outcome, to a fixed-payment world where the incentive is to strike a balance between the amount of care delivered and optimal patient health outcomes. In this new world, providing more care doesn’t mean more revenue to providers; in fact, it may mean less. Similarly, failing to provide for the best possible health for each individual patient will mean more care consumption and hence lower margins to providers. Thus, a new paradigm is coming into place, whereby to optimize margins, providers must learn just how much care results in the best health outcomes. For radiologists, this paradigm shift is compounded by 2 decades of rapidly advancing imaging and information technologies. On one
1120
hand, more detailed imaging means that finer and finer anatomic detail is displayed. Thus, increasing anatomic knowledge is required to interpret images. On the other hand, remote accessibility of imaging studies has made image interpretation more accessible to nonradiologists, particularly clinical subspecialists who possess sophisticated understanding of relevant studies. This has created turf battles, particularly in our current economic climate of decreasing reimbursements [1-4]. With the advent of the Patient Protection and Affordable Care Act, new cost reduction initiatives are being superimposed on preexisting ones. These include new bundling of care models [5-8]. The legislation calls for the creation of accountable care organizations (ACOs). These are structured so that groups of health care providers who form ACOs are paid what is essentially a bundled or capitated rate for the lives that each ACO covers [9,10]. With bundled payments, all clinical activities, including laboratory and imaging examinations, are paid for out of the total capitation. As bundling replaces fee-forservice, incentives will change. Clinicians will be inclined to reduce the number of studies they obtain because every dollar spent on diagnostic examinations will come directly out of their ACO’s or other provider organization’s budget and
hence lower their net revenue. Thus, the future economic driver will be to reduce the utilization of medical imaging, but only to the point at which the impact on patient health is not negative, in which case ACO costs would again rise. This system theoretically provides for a built-in optimization of care according to the invisible guiding hand of Adam Smith (ie, finding the efficient frontier of care). One might suspect that the economic cost of radiologists to ensure presumably higher levels of diagnostic accuracy and hence better health care is a value without which our system cannot function. This is not necessarily so. For example, many imaging studies performed on patients in the British National Health Service system are not interpreted by a radiologist unless a clinician makes a specific request for a read (Ian Beggs, National Health Service radiologist, personal communication). In fact, technologists interpret a portion of medical ultrasound imaging in the United Kingdom. Despite this practice, according to the Organisation for Economic Co-operation and Development, there has been little impact on either quantity or quality of life, but a real impact on their health care economics [11,12]. Data from the Organisation for Economic Cooperation and Development suggest that the United Kingdom outranks
1546-1440/15/$36.00
n
ª 2015 American College of Radiology http://dx.doi.org/10.1016/j.jacr.2015.02.017
the United States in many measured areas while spending less than half per capita on health care [11,12]. Should we adopt such a system in the United States, the potential effects to health outcomes, rates of litigation, and the economics of care delivery are currently unknown. Perhaps the greatest value a radiologist provides is in the interpretation of studies on patients sent by clinicians who do not feel competent to render interpretations. At the present time, this represents the majority of interpretations, but this is no reason for complacency. It is likely that these clinicians themselves will become part of ACOs or similar organizations that contain both specialists and generalists. As economic pressures induce reductions in imaging, and if radiology is seen as a cost center without generating value, eventually clinical specialists could assume more and more of radiologists’ current work, perhaps leaving nothing behind or leaving only low-value studies for radiologists. Although the possibility might seem extreme, the economic drivers of ACOs may make this behavior more attractive than one might anticipate. Certainly, this outcome would be unsatisfactory to radiologists from both professional and economic points of view. In a worst-case scenario, one could envision a tipping point beyond which clinicians assume all imaging interpretation, if not voluntarily, then by governmental mandate. The current state of imaging brings a time of humble and honest self-examination as to what value radiologists add to patient care. Unquestionably, medical imaging provides value. What we need to ask ourselves is how much value radiologists add in the current
environment. Will radiologists’ interpretive services eventually become superfluous in an age of increasing constraints on health care expenditures, bundled payments, and highly accurate and detailed imaging, when clinicians have increasing confidence in their own interpretive skills, particularly as they have more intimate knowledge of patient histories and laboratory data? Traditionally, articles such as this call for radiologists to network with their clinical colleagues and assume administrative roles in hospitals and clinics. This is an impotent response to increasing pressure. Radiologists are now in a position to rethink proactively their role in medical care and how they interact with their clinical colleagues. In this fashion, they can, at least to some degree, control the future of the specialty. Radiologists may consider how to better align their interests with those of clinical colleagues to achieve a higher degree of complementarity under new economic realities. Indeed, many turf issues faced by the specialty have arisen from the fact that radiologists have seen themselves as a separate specialty and have billed accordingly. Although this model is long standing, it is under pressure from factors that are affecting the behavior of clinical colleagues and insurance companies. Instead of acting as independent consultants, the time might be right to consider more integration of care, with radiologists working alongside their clinical colleagues as part of a single economic entity. This would mean that radiologists should work to integrate not only into provider organizations but directly into the practices of their clinical colleagues. Integrating radiologists into the same economic and clinical entities
Journal of the American College of Radiology Reinus n Opinion
as clinicians will align incentives. Under these circumstances, the same economic drivers will motivate clinicians and radiologists to work together to ensure that studies are indicated, will answer the clinical question at hand, and affect patient management. In this collegial fashion, because of overarching economic drivers, radiologists will have an incentive to act as ombudsmen to direct appropriate imaging services, and likely clinicians will now welcome this role if not demand it as an essential function of an imaging specialist. Clinical integration would support the role of radiologists as providers of unbiased opinions, individuals to set standards for imaging, and, of course, their traditional role as the experts in imaging interpretation. Such alignment may lead to overall better clinical care at lower costs. Beyond integrating into provider organizations, radiologists may consider an entirely new way of practicing. Instead of concentrating imaging services in 1 centralized radiology department, better care and better integration of services might be achieved if radiologists work side by side with their clinical colleagues. This may mean that various radiology subspecialties will need to physically locate into the same space as their clinical colleagues. Thus, one might see body, musculoskeletal, cardiothoracic, and neurologic imagers practicing in the same space as relevant specialties. Already, interventional radiology is becoming increasingly integrated with corresponding surgical services. Fortunately, technology no longer necessitates that radiologists work near where medical images are obtained. Radiologists, not imaging, are facing uncertain times. Although 1121
there is danger in the air, there also may be opportunity. First and foremost radiologists must seek to align both their clinical and economic interests with those of their clinical colleagues. Although the former have always been aligned to a large degree, the latter have not. To accomplish the alignment of economic interests, radiologists need to integrate themselves into ACOs and other bundled payment systems in a fashion whereby imaging can be optimized to provide care at the efficient economic frontier (ie, promote the highest level of health at the lowest cost). This may mean that radiologists need not only to integrate into these larger provider structures but also to consider decentralizing their practices and assuming the role of ombudsmen to ensure that imaging dollars are spent most effectively. Seizing this opportunity may require some deep self-examination, radical thinking, and a willingness to transform how radiology is practiced in the United States.
REFERENCES 1. Johnson SR. Outlook 2014: public hospitals. Modern Healthcare. January 4, 2014. Available at: http://www.modernhealth care.com/article/20140104/MAGAZINE/ 301049945/outlook-2014-public-hospitals. Accessed February 26, 2015. 2. Lee DW, Duszak R Jr, Hughes DR. Comparative analysis of Medicare spending for medical imaging: sustained dramatic slowdown compared with other services. AJR Am J Roentgenol 2013;201:1277-82. 3. Nordt JC, Connair MP, Gregorian JA. As Medicare costs rise, reimbursements drop. AAOS Now. December 2012. Available at: http://www.aaos.org/news/aaosnow/dec12/ cover1.asp. Accessed February 26, 2015. 4. Salmen A. 2014 Medicare payment cuts for radiology services. HealthWorks Collective. July 29, 2014. Available at: http://healthworks collective.com/andy-salmen/179336/2014medicare-payment-cuts-radiology-services. Accessed February 26, 2015. 5. Centers for Medicare and Medicaid Services. Bundled Payments for Care Improvement (BPCI) initiative: general information. Available at: http://innovation.cms.gov/initiatives/ bundled-payments/. Accessed November 10, 2014. 6. Thorpe J. Reforming how we pay for health care: the role of bundled payments. Health Affairs Blog. December 12, 2013. Available at: http://healthaffairs.org/blog/2012/ 12/13/reforming-how-we-pay-for-health-carethe-role-of-bundled-payments/. Accessed November 10, 2014. 7. Evans M. Interest surges in Medicare bundled-payment initiative. Modern Healthcare. July 13, 2014. Available at:
8.
9.
10.
11.
12.
http://www.modernhealthcare.com/article/ 20140731/NEWS/307319832/interest-surgesin-medicare-bundled-payment-initiative. Accessed November 10, 2014. Centers for Medicare and Medicaid Services. Bundled Payments for Care Improvement initiative. August 23, 2011. Available at: http://innovation. cms.gov/Files/fact-sheet/Bundled-PaymentsFact-Sheet.pdf. Accessed November 10, 2014. Centers for Medicare and Medicaid Services. ACO investment model. Available at: http://innovation.cms.gov/initiatives/ACOInvestment-Model/. Accessed November 10, 2014. US Department of Health and Human Services. New Affordable Care Act tools and payment models deliver $372 million in savings, improve care. September 16, 2014. Available at: http://www.hhs.gov/ news/press/2014pres/09/20140916a.html. Accessed November 10, 2014. Davis K, Stremikis K, Schoen C, Squires D. Mirror, mirror on the wall, 2014 update: how the U.S. health care system compares internationally. The Commonwealth Fund. June 2014. Available at: http://www. commonwealthfund.org/publications/fundreports/2014/jun/mirror-mirror. Accessed February 26, 2015. Squires D. Multinational comparisons of health systems data, 2013. The Commonwealth Fund. November 2013. Available at: http://www.commonwealthfund.org/w/ media/files/publications/in-the-literature/2013/ nov/pdf_oecd_multinational_comparisons_ hlt_sys_data_2013.pdf. Accessed February 26, 2015.
The author has no conflicts of interest related to the material discussed in this article. William R. Reinus, MD, MBA: Department of Radiology, Temple University, Philadelphia, PA 19140; e-mail: [email protected].
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Journal of the American College of Radiology Volume 12 n Number 10 n October 2015
