Imaging Providers and the Pioneer ACO Model
By Adrienne Dresevic, Esq., and Leslie A. Rojas, Esq., of The Health Law Partners, P.C.
On May 4, the Department of Health and Human Services (HHS) issued a press release (available here) announcing that the initiative known as the Pioneer ACO Model resulted in more than $384 million in Medicare savings over two years.
The Pioneer ACO Model and the Cost-Reduction Report
The Pioneer ACO Model is an initiative of the CMS Innovation Center, which was created to test new healthcare payment and delivery models. This particular model is “designed to support organizations with experience operating as Accountable Care Organizations (ACOs) or in similar arrangements in providing more coordinated care to beneficiaries at a lower cost to Medicare.” (For more information, visit CMS’s website here.) Pioneer ACOs whose providers meet quality performance standards and keep patients healthy share in the cost-reduction generated for Medicare, but are also liable for a share of any losses.
The Pioneer ACO Model report released by HHS (available here) states that the initiative generated more than $384 million in savings when compared to fee-for-service programs, with most of the savings occurring in the first year ($279.7 million). The report also states that the savings were generated while also delivering high-quality patient care to the more than 600,000 participating beneficiaries. In fact, HHS claims that on average, Medicare beneficiaries in Pioneer ACOs:
- Reported more timely care and better communication with their providers;
- Used inpatient hospital services less and have fewer tests and procedures; and
- Had more follow-up visits from their providers after hospital discharge.
The Pioneer ACO Model is part of a larger framework of payment reform under the Patient Protection and Affordable Care Act to move Medicare towards payments for quality care rather than fee-for-service payments. CMS plans to weave the lessons learned from the Pioneer ACO Model into permanent Medicare programs as its focus shifts to quality care. In light of the report’s cost-reduction findings, CMS certified the expansion of the Pioneer ACO Model to allow more Medicare beneficiaries to enroll in ACOs.
What This Means for Imaging Providers
As ACOs and other payment reform models continue to grow both inside and outside of the Medicare realm, imaging providers will be asked to participate in cost-reduction efforts. For example, the Pioneer ACO Model report found a correlation between a decrease in spending and a decrease in utilization of imaging services. Imaging cost-reduction efforts will likely center around:
- how to reduce duplicative and medically unnecessary testing; and
- how to coordinate care between the radiologist and the ordering physician.
For example, radiologists will be increasingly called upon to educate ordering physicians about imaging appropriateness. In addition to cost-reduction efforts, the discussion will also focus on how to measure quality care in the imaging setting.
While the initial focus of many payment reform models was the hospital and primary care settings, it is inevitable that the focus will shift to specialists. Radiologists and other imaging providers must take a seat at the discussion table to help shape the payment reform landscape in which healthcare providers will eventually be expected to work.
Adrienne Dresevic, Esq. graduated Magna Cum Laude from Wayne State University Law School. Practicing healthcare law, she concentrates in Stark and fraud/abuse, representing various diagnostic imaging providers, e.g., IDTFs, mobile leasing entities, and radiology and multi-specialty group practices.
Leslie Rojas, Esq. graduated from Wayne State University Law School and is licensed to practice law in Michigan and Illinois. Practicing healthcare law, she concentrates on fraud/abuse issues, compliance with federal and state healthcare regulations, health information privacy and technology issues, and transactional and corporate aspects of healthcare.
The authors are members of The Health Law Partners, P.C. and may be reached at (248) 996-8510 or (212) 734-0128, or at www.thehlp.com.
For more regulatory news, visit www.ahraonline.org/news.