U.S. healthcare payment policy is finally shifting towards rewarding value not volume and radiologists are a critical part of the transformation.
The healthcare delivery system in the United States has been notoriously expensive with marked variability in quality. The Affordable Care Act, “Obamacare” has led to more Americans being insured, but has not yet meaningfully reshaped care delivery and cost. Existing quality programmes either predate the ACA or they have failed to shift the needle of cost, although there have been real gains in reporting on quality metrics. The passage of two subsequent pieces of signature healthcare legislation promises to accelerate the transition to a payment system that rewards value over volume and both have significant implications for radiologists.
The Protecting Access to Medicare (PAMA) legislation passed in 2014 mandates the use of clinical decision support for providers who order advanced imaging studies for Medicare beneficiaries. Medicare is the Federal health insurance programme that covers the elderly and those with chronic disease. This was a policy for which the American College of Radiology advocated strongly as it uses evidence-based guidelines to support the ordering provider at the point of care and has been proven to reduce inappropriate imaging and improve quality of care. Many “commercial” or private insurance companies use companies called Radiology Benefit Managers to manage imaging utilisation. These companies claim to use evidence-based guidelines, but are not transparent and impose significant costs on the ordering physician who has to submit requests for authorisation that can take days to adjudicate. This type of programme has not been implemented for Medicare but was proposed several times. The PAMA legislation was originally scheduled to go into effect in 2017, but has been delayed until 2018 as the Federal Agency that oversees Medicare struggles to implement the programme, but many health systems have already adopted clinical decision support so the benefits are already accruing.
The Medicare Access and Chip Reauthorization (MACRA) legislation passed in 2015 not only fixes a flawed payment update formula for Medicare but also accelerates the transition towards value-based payment policy. By 2025 9% of the payments a provider receives for seeing Medicare patients will be at risk for meeting metrics on quality, cost, patient experience and electronic record adoption. Those physicians willing to accept significant financial risk can potentially benefit even more. The legislation specifically solicits metrics and payment models that are specific and meaningful to specialists. There are incentives for reporting through registries, a particular strength of radiology. Organised radiology is working diligently to ensure that radiologists can measure their performance in a meaningful way and not only succeed in garnering bonuses but more importantly improve the quality of their practice.
Radiologists have been targeted in the past as part of the problem of high cost care. Although the rapid growth of imaging utilisation seen in the early part of this century has slowed recently fingers continue to point towards imaging as a significant cost driver. Radiologists are rebranding themselves as the stewards of appropriate imaging through the implementation of clinical decision support and, as such, a critical part of the solution. It’s important to state that appropriate imaging doesn’t always mean less imaging. Our focus must be on doing the right imaging at the right time and we have an opportunity to add more value through increasing participation in life saving screening programs for breast, colon and lung cancer.
New payment models that reward those radiologists who benchmark themselves against peers, engage with their referring colleagues and provide a patient-centred high quality episode of imaging care offer exciting opportunities to not only reduce costs of care but more importantly improve outcomes.
What is your top management tip?
Be generous. I like this quote from legendary University of Alabama football coach Paul "Bear" Bryant: "If anything goes bad, I did it. If anything goes semi-good, we did it. If anything goes really good, then you did it"
What would you single out as a career highlight?
Being selected as the Vice Chair of the Board of Chancellors of the American College of Radiology, the first woman to achieve this honour.
If you had not chosen this career path you would have become a…?
I've wanted to be a doctor since I can remember but I really enjoy the business aspect of my job so maybe a role in a large healthcare company. That said I love that I still get to be a clinical radiologist in addition to my business role!
What are your personal interests outside of work?
I love travel and am fortunate to combine my professional career with lots of travel. Like many New Yorkers, I am obsessed with food, I am always thinking about my next meal! I am an avid reader. I think it's important to give back and am engaged with a local organisation, the Lower East Side Girls Club that provides opportunities for young women to expand their horizons.