By Jef Williams, MBA, PMP and Shawn McKenzie, MPA, CRA, RT, CRT
June 2011–It is no secret that much ambiguity remains around the structure, reimbursement model, and reporting requirements of Accountable Care Organizations (ACOs). That ambiguity, however, has not slowed the momentum we see with most organizations moving to become certified. While many questions remain unanswered, there are several things we are sure of. ACOs will include and affect the following:
- Primary care providers (PCPs) who provide service aggregately to at least 5000 Medicare beneficiaries
- Contracted specialists and hospitals (affiliated or otherwise)
- Reporting requirements that measure quality of care and cost at patient and episode level
- Commitment to operate for a minimum of 3 years
- The ability to receive and distribute CMS payments (and potentially shared savings returns) to all participants of the ACO
Diagnostic imaging (DI), as a service provider along the entire continuum of care, stands to be impacted most significantly by the potentially drastic changes that will accompany participation in an ACO. The current operation, technical, and administrative (business) model adopted by nearly all DI departments will undergo major shifts. The challenge for directors and managers in this time of uncertainty is to prepare for the future in an environment where the specifics for that future are unclear. While this may prohibit your ability to establish a detailed imaging strategy for the next 5 years related to ACO participation, there are steps you can take to poise your organization for success.
One of the foundational elements of the ACO model is shared risk. In the current fee-for-service model, your department and the radiology staff are rewarded for volume and operational efficiency. Within an ACO, the payment structure, whether it be capitation or bundled payments, will drive the fiscal rewards directly tied to better outcomes, fewer studies, and collaborative decision making regarding most appropriate exam types.
In order to prepare your staff and radiology group for these changes, it is important that you begin discussions now to build trust and discuss the potential changes to workflow, the definition of efficiency, and roles and responsibilities both within the department as well as to the entire ACO organization.
ACOs will be joined together by way of information technology (IT). Without the technological functions provided with well built and implemented clinical information systems, the ability to share, as well as report and track patient data, will be overwhelming to the point of impossible. Your service line systems, along with other business or clinical applications integrated or interfaced to your department, will need to provide the following minimal functionality:
- Image sharing across care providers (including those captured by disparate PACS)
- Patient reporting across entire ACO
- Decision support for CPOE
- Cost reporting at patient/episode level
The challenges of technical interoperability within an ACO developed within affiliated providers or an integrated delivery network (IDN) will be difficult. For those pursuing an ACO model with providers and organizations that are non-affiliated and using disparate systems, it is critical that technical discussions be ongoing from the beginning. While technical in nature, this discussion must include IT staff, but steadfastly be driven by clinical stakeholders and leadership. Outcomes, workflow, patient information, and interoperability are under the purview of clinicians. The dangers of relinquishing leadership to IT in this area will create significant department operational challenges later.
Preparing your business, department, or organization for participation in an ACO is perhaps the most difficult to address. Without a clear path to reimbursement models, community benchmarks, shared savings allocations, or even the potential change in relationship with your radiology group makes business and strategic planning difficult. One important thing to do in lieu of specific business planning is to prepare your organization for change. Change management, often overlooked, can be the ingredient that either makes or breaks your transition to an ACO. Preparing your staff for eventual workflow changes and fostering your relationship with radiologists may be one of the most important things you do while you move toward ACO certification. Eventually you will have to incorporate budgeting, cost analysis, informatics reporting, and other structural efforts, but until you know what those look like, they will be difficult to codify.
Serve by Leading
The ACO model is coming in one form or another. Perhaps the greatest risk to imaging will be the commoditization of services, which will drive down the value, revenue, and likely morale of your business. The best way you can ensure medical imaging remains an important, valuable component of the patient care continuum is providing leadership to those who are developing the specifics for your ACO. Including your chief radiologist in those discussions can be beneficial in helping tell the story of the value you bring to patient outcomes and the benefit of consultative services to their PCPs.
Whether the ACO model is viable and ultimately sustainable is yet to be determined. Most organizations, however, are moving toward certification. Whether you are poised for success in a new model will be largely determined by your leadership. Engage now and begin preparing your organization. Those who don’t will be left at a significant disadvantage.
Learn more about ACOs during the 2011 Annual Meeting! Click here for related session information.
Shawn McKenzie serves as president and CEO of Ascendian Healthcare Consulting in Sacramento, CA and is a co-presenter at the 2011 AHRA Annual Meeting & Exposition. He can be reached at firstname.lastname@example.org.
Jeff Williams serves as vice president of Ascendian Healthcare Consulting in Sacramento, CA and is a co-presenter at the 2011 AHRA Annual Meeting & Exposition. He can be reached at email@example.com.