One of the most talked about new trends in health care, accountable care organizations promise to contain exploding health care costs and improve patient care. But imaging industry experts worry that unless properly worked out, the ACO model could dry up already parched capital equipment budgets and unfairly burden radiologists.

Further, some critics say we've seen this movie before, and it ends badly.

While still largely lumps of unmolded clay on the bureaucratic workbench, ACOs are starting, slowly, to take shape. Pilot projects are beginning to emerge in the run-up to January 2012, when the Centers for Medicare and Medicaid Services will start awarding contract bids for ACOs voluntarily started by providers.

But a lot has to be ironed out before then. Proposed rules from CMS likely aren't arriving for a few months, and exact reimbursement schemes are still mostly a matter for conjecture. Plus, experts still have to ensure ACOs are completely legal and don't run afoul of antitrust laws.

Nonetheless, the gist of the ACO model is to embody the "Triple Aim" concept promoted by the Institute for Healthcare Improvement, founded by current CMS head Donald Berwick: improving patient experience and the health of a defined population, while controlling per capita costs.

Or as the IHI's website puts it, "the best care, for the whole population, at the lowest cost." Simple, right?

In essence, ACOs treat a network of providers around a hospital as a virtual organization managing a set patient population. The idea is to reward the providers for coordinating care and controlling costs, and hitting certain outcomes, such as keeping chronically ill patients healthy and out of the emergency room.

One method is capitation, in which ACO-associated providers get a fixed budget to treat a patient population, and only qualify for yearly increases if they stay under budget. Or, in other models, providers aren't penalized if they go over budget, but if they stay under, they get to pocket some of the savings.

But aggressive cost-curbing measures like capitation are what make some in the imaging industry nervous, as it's not clear exactly how this will press upon imaging utilization or capital equipment purchases.

Jeff Goldsmith, president of health care forecasting firm Health Futures Inc. and an ACO critic, summed up the uncertainty succinctly.

"Radiology and imaging will be disproportionately contributing to savings," he told DOTmed News in an interview, "and it's not clear if they will be disproportionate receivers of savings."

Tried in the 90s

For one, capitation plans were tried in the 1990s and left a bad taste in doctors' mouths, Goldsmith said.

"Some [health plans] assumed capitated risk per member, per month payment in exchange for taking care of health plans' members in their service areas," he explained. "This was pretty much a disaster because there wasn't a lot of good data on basis of which to manage risk, and people did things like pay for services to populations on a fee-for-service basis with withholds. Withholds never made enough to make up for losses."

Throughout the decade, many of these organizations were formed and cratered, he said, leaving an abiding distrust among the provider community.

While it might be different this time around, imaging's place is still cloudy.

Radiologists need fair share of risk

For the American College of Radiology, one of its biggest concerns is how risk gets spread around in the coming ACOs between referring doctors and radiologists. The group worries that it will fall mainly on the radiologist, who has little control of his incoming volume, and not on the referring physician who actually orders the studies.

"The fear of straight capitation without utilization management is that ordering physicians will just continue to order exams on everybody and the overall volume will increase and the only people who will be at risk will be the radiologists, because they're not in a position to manage utilization," Dr. Bibb Allen, chair of the ACR's Economics Commission, told DOTmed News.

The ACR is also insistent that the new models take into account the greater amount of non-interpretive work that radiologists might have to do, such as coordinating with referring physicians about the appropriateness of imaging studies. Currently, there's no mechanism in place to really reimburse them for that time, Allen noted.

One suggestion offered off-the-cuff by Allen would be capitation up to a certain volume, after which it would revert to fee-for-service. When that kicks in, ordering physicians could be at risk for having increased ordering.

Sales pressure

Manufacturers of imaging equipment are also looking closely at ACO plans. They worry that with pressure from cost-controlling measures, capital equipment funding could be a casualty.

"If your entire system is designed to reduce costs, it is a natural thing that capital equipment is going to suffer," Dave Fisher, executive director of the Medical Imaging & Technology Alliance, an industry trade group, told DOTmed News.

"You have to replace needles, you have to replace rubber gloves and you have to do certain test procedures. But some people may not view spending money or setting aside money every year for capital equipment as a necessary part of business," Fisher said.

MITA is working on a set of proposals, but Fisher said it was too early to share them yet. He did say the main concern was that ACOs focus on quality of care and not just cost, and that getting new equipment is critical for patient health.

"Nobody would argue that imaging technologies aren't quickly advancing," he said. "For example, with CT, [we can now get the] same quality of image with less radiation. They are all important and necessary for continuing to improve our health care system."

Appropriateness Criteria

One suggestion separately brought up by the manufacturers and radiologists is to somehow incorporate the ACR Appropriateness Criteria for imaging into an ACO model, as a way to bring an evidence-based quality-control measure.

"Capitation without utilization based on appropriateness criteria - that's bad," Allen said.

"The wrong way to do it is to decide, the CT scan cost too much, or we spent our budget on MRI this month, so we can't do it," Fisher observed.

ACO pilot

But it's still the early days, and it's not clear how it's going to work out, even among groups already starting similar programs.

Performance improvement group and group purchasing organization Premier Healthcare Alliance is currently working with its member hospitals to set up ACOs. Launched in May, the group has two programs, one for hospitals ready to start implementing an ACO model, and the other for hospitals that need to develop the infrastructure first. A Premier spokeswoman told DOTmed News around 24 hospitals joined the implementation collaborative and close to 60 are enrolling in the readiness one.

The group said hospitals are still working out the specifics, but Premier is optimistic that many radiologists have nothing to fear, as this won't be a replay of the 1990s.

"By and large, if you're a high-value radiology provider, then there shouldn't be a significant change in volume or reimbursement," Brent Hardaway, a principal with Premier Consulting Solutions, told DOTmed News.

"In the 90s it was only cost-based, but today we have the offsetting quality and outcomes and patient satisfaction components," he added.

"We're going to want people to be happy with the care they receive. If people are feeling like they're being imaged on a 30-year-old piece of equipment, they're not going to be very happy. I think I understand the concern that there will be less money for capital equipment purchases. But I would say we have to be very careful about limiting capital equipment purchases."

"We're going to be making more rational decisions about how to provide care," he noted, "as opposed to how much care we can provide."

In any case, as with the rest of health care eager to ensure its share of the cut, the imaging industry will be watching the proceedings closely.

"Imaging is clearly central to health care," MITA's Fisher said, "and we want to make sure that payment treats it that way.”

Heather Mayer contributed to this report