DOTmed.com – Muroff predicts radiology’s future in an era of reform

Lawrence Muroff

Muroff predicts radiology’s future in an era of reform

by Lauren Dubinsky, Staff Writer
Just like every other area of medicine, radiology is feeling the pressure of health care reform. Continuing reimbursement cuts and the shift from the traditional fee-for-service payment model to a performance and value-based model is transforming the profession.

While there will always be a need for imaging, the role of radiologists is far less certain. Lawrence Muroff, CEO and president of Imaging Consultant Inc., explains what radiologists must do to survive in this new era.

Imaging is here to stay 
Two major goals under health care reform aim to prevent unnecessary readmission and shorten necessary admissions. Imaging may be able to help with that.

“Nobody knows for sure what’s going to happen with imaging under health care reform, but there is at least a strong feeling among some radiology leaders that appropriate imaging will actually increase,” says Muroff.

Certain studies can help emergency room physicians avoid unnecessary readmissions. Additionally, if a patient is admitted, early imaging with CT or MR can hasten getting an appropriate diagnosis and result in a shorter hospital stay, says Muroff.

Imaging can run into problems if it’s not done appropriately — meaning if it results in costly and unnecessary follow-up studies. But there may be a way to solve that.

More specialized training 
Muroff believes that as the degree of specialized training goes up, the degree of diagnostic uncertainty goes down. For example, if a radiologist is not well-trained in neuroimaging and they spot something on a CT but are not sure what it is, they are more likely to ask for another study.

But if a radiologist is well-trained then they are more likely to have encountered that finding before and can at least offer educated speculation as to what it is rather than order another study.

“If we are going to change the way we reimburse for medical care then I think we need to also change the way we train those who provide medical care,” says Muroff. “That means training for accountability for speed, accuracy and cost and we don’t do that.”

He believes that if you ask most academic chairs what their institutions are charged for a variety of different procedures, they would have no idea. “So it’s not surprising that residents and fellows have no idea what things cost,” he says.

Health care reform is going to demand subspecialization and it starts with the way trainees are educated.

Become more significant 
“Radiologists will have to show significance because if we don’t provide services that others can’t then others will basically take over our turf,” says Muroff.

Radiologists are going to have to be available to consult, be visible to the patients and integrate themselves into the medical, social and political fabrics of their hospitals and communities. If they fail to do that, they’re at risk of becoming insignificant in the new health care dynamic.

Most patients think that it’s their doctor who is reading the studies and they’re confused when they get a bill from an “unknown and unseen entity,” says Muroff. “We’ve got to be visible, we’ve got to provide a level of service that others can’t emulate unless they have the same intensive training that we have,” he says.

Muroff is hopeful that radiologists will do this. “I think, if it embraces the need to provide significance, to provide value, then I think radiology is going to thrive,” he says.

10 Choosing Wisely Recommendations by Specialists for Hospitalists :: Article – The Hospitalist

From: The Hospitalist, June 2014

Medical societies list safe, cost-effective tests physicians should perform—and ones to avoid—when diagnosing patients

by Karen Appold

When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.

In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.

1 American Gastroenterological Association (AGA)

Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.

When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.

“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”

An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.1

“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.

According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”

2 American College of Rheumatology (ACR)

Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.

“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”

Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.

“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.

Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”

LISTEN NOW to Daniel Wolfson, MHSA, executive vice president and CEO of the ABIM Foundation, discuss how the Choosing Wisely campaign got started and its significance in U.S. healthcare.

3 American College of Physicians (ACP)

Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.

VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.

Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.

Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.

Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.

Moises Auron, MD, FAAP, FACP, SFHM“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan.”

—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic

4 American Geriatrics Society (AGS)

Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.2 In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).

The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.

“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”

If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.

“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”

LISTEN NOW to Linda Cox, MD, owner of Allergy and Asthma Center in Ft. Lauderdale, Fla., and president of American Academy of Allergy, Asthma & Immunology, discuss why it’s important for hospitalists to not diagnose or manage asthma without spirometry.

5 American Society of Echocardiography (ASE)

Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.

Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.

“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”

If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.

“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.

6 American Society of Nephrology (ASN)

Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.

Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.

PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.

Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.3 In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.4 The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).7

A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.

James J. O’Callaghan, MD, FAAP, FHMHospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses, such as bronchiolitis and croup, remain a leading cause of admission.

—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member

7 The Society of Thoracic Surgeons (STS)

Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.

By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.

“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”

Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.

8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)

Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.

Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.

“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology atNorthwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”

Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.

“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.

Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.

“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.

LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children’s National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.

9 American Academy of Pediatrics (AAP)

Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).

Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.8,9

“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.

Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.

This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.

James D. Thomas, MD, FASE, FACC, FAHA, FESC“Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside. These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt. Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”

—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.

10 American College of Obstetricians and Gynecologists (ACOB)

Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.

Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.

This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.

“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.

Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”


Karen Appold is a freelance writer in Pennsylvania.

References

  1. U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
  2. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
  3. Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
  4. Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
  5. Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
  6. Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
  7. El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
  8. Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
  9. Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.

Neurosurgeons Unveil Choosing Wisely® List, Identifying Five Unnecessary Tests or Procedures

Neurosurgeons Unveil Choosing Wisely® List, Identifying Five Unnecessary Tests or Procedures

Encourage physician and patient conversations about their treatment options

Released: 6/24/2014 10:30 AM EDT
Source Newsroom: American Association of Neurological Surgeons (AANS)

Contact Information

Available for logged-in reporters only

Newswise — Washington, DC – The American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) today released a list of specific tests or procedures that are commonly ordered, but not always necessary, in neurosurgery. As part ofChoosing Wisely®, an initiative of the ABIM Foundation, the list identifies five targeted, evidence-based recommendations that can support physicians in working with their patients to make wise choices about their care.

Neurosurgery’s list includes the following five recommendations:

1. Don’t administer steroids after severe traumatic brain injury.
2. Don’t obtain imaging (plain radiographs, magnetic resonance imaging, computed tomography [CT], or other advanced imaging) of the spine in patients with non-specific acute low back pain and without red flags.
3. Don’t routinely obtain CT scanning of children with mild head injuries.
4. Don’t routinely screen for brain aneurysms in asymptomatic patients without a family or personal history of brain aneurysms, subarachnoid hemorrhage (SAH) or genetic disorders that may predispose to aneurysm formation.
5. Don’t routinely use seizure prophylaxis in patients following ischemic stroke.

“Neurosurgeons are committed to identifying the right treatment, for the right patient, at the right time to help eliminate unnecessary procedures, optimize outcomes, and reduce healthcare costs,” said AANS president, Robert E. Harbaugh, MD. “Participating in the Choosing Wisely initiative is a key step in this process.”

The AANS and CNS Choosing Wisely list was developed after months of careful consideration and review by the organizations’ Joint Guidelines Committee, Quality Improvement Workgroup and seven clinical subspecialty sections. The recommendations reflect the most current evidence about management and treatment options for patients facing disorders of the brain and spine.

CNS president, Daniel K. Resnick, MD, noted, “A broad range of neurosurgeons, from across the spectrum of our specialty, reviewed the evidence and contributed to these recommendations. We anticipate that these will help neurosurgeons and their patients make informed decisions by promoting conversations about the most appropriate tests and treatments, and avoiding care whose potential harm may outweigh the benefits.”

Today, the AANS and CNS are joining more than 100 national and state medical specialty societies, regional health collaboratives and consumer partners in promoting conversations about appropriate care. With the release of these new lists, the Choosing Wisely campaign will have covered more than 300 tests and procedures that the specialty society partners say are overused and inappropriate, and that physicians and patients should discuss.

The campaign also continues to reach millions of consumers nationwide through a stable of consumer and advocacy partners, led by Consumer Reports—the world’s largest independent product-testing organization—which has worked with the ABIM Foundation to distribute patient-friendly resources for consumers and physicians to engage in these important conversations. To learn more about Choosing Wisely and to view the complete lists and additional detail about the recommendations and evidence supporting them, visit www.ChoosingWisely.org.

###

The American Association of Neurological Surgeons(AANS), founded in 1931, and the Congress of Neurological Surgeons (CNS), founded in 1951, are the two largest scientific and educational associations for neurosurgical professionals in the world. These groups represent over 8,000 neurosurgeons worldwide. Neurological surgery is the medical specialty concerned with the prevention, diagnosis, treatment and rehabilitation of disorders that affect the entire nervous system, including the spinal column, spinal cord, brain and peripheral nerves. For more information, please visitwww.aans.org or www.cns.org, read our blogwww.neurosurgeryblog.org, follow us on Twitter or connect with us on Facebook.

About Choosing Wisely®
First announced in December 2011, Choosing Wisely® is part of a multi-year effort led by the ABIM Foundation to support and engage physicians in being better stewards of finite health care resources. Participating specialty societies are working with the ABIM Foundation and Consumer Reports to share the lists widely with their members and convene discussions about the physician’s role in helping patients make wise choices. Learn more atwww.ChoosingWisely.org.

Accountable Care Organizations: What You Need to Know – Journal of the American College of Radiology

According to CMS, US health care expenditures have more than doubled every decade since 1960, with annual spending reaching $2.793 trillion in 2012. That number represents almost one-fifth of our nation’s gross domestic product. But in a system designed to compensate providers on the basis of the number of tests run and procedures done, should an alternative outcome be expected? Providers have been incentivized to provide more, but not necessarily better, care.

Accountable care organizations (ACOs) were designed to address the problems inherent in a cost-based and volume-based reimbursement model of health care. With an emphasis on preventive care and keeping participants healthy, the goal is to provide health care to participants across a continuum of care and, ultimately, to provide the right care at the right time while reducing unnecessary expenditures and duplication of services.

Jump to SectionWhat are ACOs?Implications for RadiologistsThe Role of Radiologists in ACOs

What are ACOs?

An ACO can be defined as an integrated health care delivery system that contracts to provide a full continuum of services to a defined patient population with specific reimbursement incentives established for meeting both quality and expense cost targets. The driving force of the ACO model is the provision of tangible, financial benefits to providers who can consistently provide better quality of care at reduced costs.

Since the inception of the Patient Protection and Affordable Care Act, more than 360 ACOs have been created, serving 5.3 million Medicare beneficiaries. Each ACO serves a population of at least 5,000 traditional fee-for-service beneficiaries who are assigned to that ACO on the basis of the primary care services the beneficiaries receive from ACO providers. ACOs must agree to participate in the shared savings program for at least 3 years (the agreement period), with any early termination potentially resulting in exclusion from future participation in the program.

Each year of the agreement period, an ACO is entitled to share in any savings (or losses) it generates, as long as the ACO satisfies its savings and quality performance requirements. CMS develops a cost benchmark, which is adjusted annually, for each ACO by determining the fee-for-service expenditures for the ACO’s beneficiaries assigned to the ACO. Participation in shared savings or losses will depend not only on the operation of the ACO, but also on the track model the ACO decides to participate in. Track 1 allows an ACO to receive 50% of any shared savings generated in connection with the operation of the ACO while insulating the ACO from sharing in any losses for the first 2 years of the agreement period. ACOs participating in Track 2 are given an increased upside (60% of shared savings), but also are liable for shared losses throughout the entire agreement period.

Before receiving any potential shared savings, an ACO must achieve its minimum savings rate (MSR) each year. This means that an ACO must generate savings of at least the MSR as measured against the benchmark established by CMS for the particular ACO. For ACOs on Track 1, CMS uses a sliding scale to establish the MSR, which ranges from 3.9% to 2.0% on the basis of the number of beneficiaries assigned to the ACO. Track 2 ACOs have a flat 2% MSR. If an ACO generates savings in excess of the MSR, it may receive a portion of those savings, provided the ACO has met its quality performance score.

To assess the quality of care, CMS requires ACOs to track and report patient outcomes and experiences on the basis of specific quality measures in 4 domains:

(1) patient and caregiver experience, (2) care coordination and patient safety, (3) preventive health, and (4) at-risk population.

For the first year of the agreement period, an ACO is required to completely and accurately report on all quality measures to be eligible to participate in shared savings. Thereafter, CMS sets a minimum attainment level for each domain, and for ACOs to participate in shared savings, they must meet or exceed that level on their reported scores per domain.

Jump to SectionWhat are ACOs?Implications for RadiologistsThe Role of Radiologists in ACOs

Implications for Radiologists

One of the stated purposes of ACOs is to reduce the overall cost of health care for the Medicare program. The easiest way to accomplish that objective is for ACO providers to simply run fewer tests and perform fewer procedures. For radiologists, this approach likely translates into being called on less frequently by primary care physicians (PCPs) and specialists to provide imaging services, thereby becoming a commodity within the ACO model. If reduced to such a role, radiologists run the risk of being put in a position in which they are unable to significantly contribute to an ACO.

A heavy-handed cost-cutting approach is an inherently flawed one; improving the quality of care and patient outcomes is the linchpin of the ACO model. Potential overrestriction of patient care is a short-sighted strategy that will likely undermine any potential long-term success. Therefore, it is incumbent on radiologists to refocus the directives of ACOs away from simply cutting costs and to demonstrate their ability to provide value by collaborating with PCPs and specialists in the initial stages of a consultation.

Radiologists are in the best position to determine which tests are clinically appropriate for patients. For example, a study published in JACR in 2010 analyzed the appropriateness of 459 elective outpatient CT and MRI examinations that were ordered by PCPs. The results indicated that roughly 1 in 4 examinations ordered was unnecessary or inappropriate. If such results were replicated in an ACO setting, they could pose a significant threat to the ACO’s ability to participate in shared savings. PCPs and specialists will need tools and guidance to improve the quality of their imaging decision requests, and that is where radiologists can provide tremendous value.

Effective use of imaging in connection with consultations may lead to more accurate diagnoses, and reduce the number of unnecessary referrals to specialists. Correct and efficient imaging also assists PCPs and specialists in initiating appropriate treatment earlier. Better quality of care should translate into a healthier patient population. As a result, this healthier population will likely require fewer medical services in the future, and the dual aim of ACOs (ie, increased quality of care and decreased costs) will be achieved, resulting in further increases in shared savings to ACOs.

Jump to SectionWhat are ACOs?Implications for RadiologistsThe Role of Radiologists in ACOs

The Role of Radiologists in ACOs

Serving a utilization management role seems to be a key to success for radiologists, especially as ACOs become more technologically advanced. Radiologists can be integral in the implementation and use of systems such as decision support systems, which integrate an ACO’s electronic medical records and provide reliable clinical guidance for physicians to order the most appropriate tests on the basis of criteria and protocols published by various medical societies, as well as evidence-based data sets. ACO radiologists could establish the standards for appropriate ordering of imaging services for the entire ACO, which would curtail the frequency of unnecessary imaging. They could also use decision support systems to monitor the actual tests ordered by ACO physicians to determine which orders were noncompliant with ACO standards and report back to the ACO managing staff on a periodic basis. Such oversight provides the ACO with an opportunity to address and correct inefficient ordering and spending before it becomes a larger problem.

Radiologists have the skills necessary to become driving forces in the ACO community. Their knowledge of the clinically appropriate use of imaging services can generate significant savings for ACOs. The determining factor, however, will be how proactive radiologists are in having their voices heard by ACO leadership. If they fail to demonstrate the value they can add in an ACO model, they may be relegated simply to a commoditized role, which would work to the disadvantage of radiologists particularly, and ACO participants at large.

Jacqueline Finnegan, Esq, Garfunkel, Wild, PC, 111 Great Neck Road, Great Neck, NY 11021; e-mail:jfinnegan@garfunkelwild.com.