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.

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