AHRA: Healthcare reform squeezes radiology

DALLAS—AHRA took a deep dive into healthcare reform and its impacts on the practice of radiology during an educational session Aug. 15 at its annual meeting.

“We’ve been working on the healthcare issue and taking care of Baby Boomers for more than 50 years,” acknowledged Robert T. Sill, practice manager at Lancaster Radiology Associates in Auburn, Pa. The decades-long task may be reaching an apex (or nadir).

Reform by the numbers
The data that Sill offered as a context for understanding the impetus for reform point to a stark and unsustainable reality.

The U.S. spends $2 trillion annually on healthcare, and demand will increase as Baby Boomers age.

• Nearly 20 percent of the population will be more than 65 years old in 2030.
• The number of Medicare beneficiaries will swell from 46.6 million in 2010 to 77.2 million by 2030.

In addition, the Patient Protection and Affordable Care Act of 2010 (PPACA) will increase the ranks of insured. Currently, approximately 50 million Americans are uninsured. PPACA will require nearly all of them to become insured and also mandates that states create health insurance exchanges.

Sill shared one caveat: If legislation contending the unconstitutionality of the insurance mandate succeeds, the whole law may be voided. He predicted that the battle will reach the Supreme Court by 2012.

Reform and hospitals
Other provisions of the law trim Disproportionate Share Hospital payments, which subsidize hospitals that serve a high number of low-income patients, by $14 billion.

On the flip side, $1.1 billion has been allocated to bundled payments demonstration projects. Hospitals participating in a project, explained Sill, receive a single payment to cover hospital and physician services for a particular diagnosis related group.

The goal is lofty, as the projects aim to align physician and hospital payments and encourage coordination of care, improve quality of care and contain costs by eliminating unnecessary readmissions, stated Sill. These themes recur and are likely to become major drivers of reform and reimbursement.

The bundled payments model has major implications for hospital administration and physicians, emphasized Sill, and will force them to find ways to distribute payments among providers.

Another element of reform, the accountable care organization (ACO), also remains highly contested. According to Medicare, “An ACO provides an opportunity for Medicare beneficiaries to receive high quality, evidence-based healthcare that eliminates waste and reduces excessive costs through improved care delivery.”

But specific ACO mechanisms remain undefined. Organizations will be assessed by quality and spending measures, with members sharing in savings. Multiple leading providers including Mayo Clinic, Cleveland Clinic and Geisinger Health System have criticized the concept, claiming it is unworkable, shared Sill.

Shared savings will be based on a quality performance score based on five domains, explained Sill. These are: the patient/caregiver experience domain, care coordination domain, patient safety domain, preventive health domain and at-risk population/frail elderly domain. Radiology needs to determine how it fits into each domain, he said.

The overarching theme is “get it right the first time,” stated Sill. Medicare may no longer pay hospitals for preventable readmissions.

Reform and radiology
Other targets for future cuts include unrestricted reimbursement based on volume and intensity, i.e. radiology, he said.

Radiology practices need to start asking new questions, such as:

• Is that the right study?
• Is the study needed now?
• Is there another study that will prevent future downstream tests?
• Should the physician cancel the study and listen to the chest with a stethoscope?

Sill reiterated, “The goal of higher quality and lower costs will drive change in how the radiology department is managed.”

Sill closed with a brief look at related issues.

He predicted that radiology benefits managers may play a larger role in decision-making, as Medicare cost-savings data, which are likely to inform the debt ceiling discussions, are based on radiology benefit manager data.

Advanced imaging equipment utilization also may be targeted. Current Medicare data assume a utilization rate of 75 percent for advanced imaging equipment. In reality, that figure may be closer to 55 percent. The rate may factor into decisions going forward.

Finally, Sill confirmed that meaningful use, and the prospect of a $44,000 incentive, does apply to radiology. The hitch, however, is the lack of a clear path for radiologists to comply with meaningful use measures.

Sill closed with several reminders for the audience, including:

• Imaging will be driven back to the hospital setting.
• Quality, service and productivity will become critically important.
• Do it right the first time.
• New measurement metrics will be developed by all providers.
• Perform the right study at the right time.
• Prove value in imaging.
• Build bridges with primary care physicians.
• Understand the implications of the pre-authorization process.
• Know thy EHR.