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Radiology in ACOs/APMs – Where Do We Fit In?

February 28, 2023
By: Nicole Jones-Gerbino, President

Nicole Jones-Gerbino is the President of PBS Radiology Business Experts and has over two decades of experience in radiology practice management, revenue cycle leadership, and operations across large practices and health systems. As President, she oversees strategic growth, business development, client relationships and performance from coast to coast. Her tenure in radiology leadership includes working with physicians and health systems to grow practices and help them become more profitable. Her health system background includes development of large multi-specialty networks, helping providers navigate regulatory and reimbursement challenges to improve their financial outlook. She has served on various compliance and state regulatory boards and has served as president of the RBMA California Chapter.


The shift from Fee for Service (FFS) to Value Based Care continues….

The alternative payment models to traditional Fee for Service reimbursement are here to stay. Payors are increasingly complex in their quest to reduce provider reimbursement and their bottom-line patient care cost, without noticeably sacrificing quality.

One of the most challenging undertakings of my career was to implement a new Alternative Payment Model (APM) model in the early days of Medicare Shared Savings Program ACOs. Our ACO became the 3rd largest Medicare ACO in the state of California in the first year. This was in an academic health system setting, which allowed further resources and support, yet added challenges in understanding the value to our organization which led to some resistance to the necessary new workflows. The different strategy of managing physician ordering patterns, shifting care to lower cost outpatient environments, and partnership in the community felt like pioneering in a new landscape when everyone didn’t quite understand the rules.

A seat at the table for radiology

Radiologists are often last to the table or uninvited in these models for a variety of reasons – not on the initial cost radar given lower relative cost of procedures compared to surgical specialties, and fewer resources are available for administrative partnership.

Additionally, higher assigned patient volume is key in these scenarios to balance a higher mix of healthy patients with those with higher co-morbidities. Historically, the patient attribution model used by CMS makes primary care providers and those specialties with the most frequent visits more desirable partners to the ACO system.

However, the volume/utilization impact of radiology should not be overlooked. Here are a few ways to understand and engage in this type of model as a radiologist leader or administrator of a group practice.

Leveraging outpatient ancillary service models

Know your market, and your health system partners’ HMO and ACO offerings.

Offering outpatient services has become so important for availability/access to HMO members, and to manage costs for high volume services with a large variance in facility vs. non facility reimbursement. Your area health system’s appetite for Shared Savings/ACO models will dictate how open they are to partnership with a standalone outpatient radiology practice rather than seeing as the historic competition to their outpatient volumes.

Showing value in today’s market

Participation in Alternative Payment Models opens the door to demonstrate more local radiologist engagement, showing value to your health system in cost and quality. Open up conversations with health system ACO leadership, or community partnerships in the area offering APM options.

It is important to have people at the table on behalf of your group who understand this structure and the end goal of APMs/value-based care models, and can carefully evaluate any agreements for impacts such as new HMO or government contract participation requirements.

Showcasing your practice’s existing imaging quality measures and any workflows to reduce waste or unnecessary imaging orders is the best place to begin for hospital practices. Demonstrating quality measures, in addition to turnaround times and access availability for stat and preventative care appointments is important for those groups with imaging center oversight/ownership.

In our era of radiologist shortages and resourcing demands, resulting in increasing use of network radiology and teleradiologist growth, illustrating this value can be a crucial advantage for the independent radiologist group.

The advantage for your group

To address the age-old “what’s in it for me” question:

  • APM incentives with CMS – currently 3.5% for performance year 2023, and exclusion from MIPS reporting/payment adjustments.
  • Bonus and cost savings sharing from select ACO models – understanding the ACO/APM’s attribution models is important here, as radiologists will not qualify for typical patient attribution volumes.
  • Increased profit sharing on Imaging Center JVs if negotiated/executed well.

3 things your radiologists/practice can do:

  • Engage with health system/ACO leadership wherever possible. Who are the largest APM participants/hosts in your market?
  • Create awareness in your group – it’s happening, regardless. Be willing to engage in cost/utilization discussions vs. typical RVU models.
  • Educate physicians, especially those newer to this model. It isn’t sufficient to simply understand traditional RVU compensation in this landscape.

Radiologists have truly experienced “death by a thousand cuts” in the last two decades, from the Deficit Reduction Act, continued bundling of services, RVU reductions, and continued reimbursement hits to the technical component of exams. Opportunities to leverage incentives through APM program participation will continue to reduce and should be evaluated for alignment with your practice’s goals.

 

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