The Patient Protection and Affordable Care Act (ACA) generated significant media attention since its inception. When the law was approved in 2010, the U.S. health care system began facing multiple changes to adapt and to incorporate measures to meet the new requirements. These mandatory changes will be challenging for academic radiology departments (ARDs) since they will need to promote a shift from a volume-focused to a value-focused practice. This will affect all components of the mission of ARDs, including clinical practice, education, and research. A unique key element to success in this transition is to focus on both quality and safety, thus improving the value of radiology in the post-ACA era. Given the changes ARDs will face during the implementation of ACA, suggestions are provided on how to adapt ARDs to this new environment.
In March 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA). Although appeals were made in several federal and state courts, the law was upheld by the Supreme Court in 2012. Further, the reelection of President Obama in 2012 solidified the eminent implementation of the ACA.
The promulgation of the ACA will create a new fiscal-legal environment that will impose changes to both patients and health care providers. Patient-related changes will include mandated access to health care for certain workers via state-run and small business health care exchanges with commensurate access to imaging services, for those currently without health insurance.
On the other hand, implementation of the ACA will impact health care providers including academic radiology departments (ARDs) to adapt to new incentive payment methods; determine the need, safety, and appropriateness of imaging studies; and encourage data pooling for utilization review . ARDs will have a more prominent role as the gatekeeper in the new environment. To obtain greater performance excellence, efficient patient care management, and improve patient satisfaction, radiologists will have to work with the clinicians to develop much more focused imaging utilization guidelines and care pathways. This review provides a perspective for ARDs on how to adapt to the new changes of ACA emphasizing the impact of the ACA on clinical practice, research, and education.
Impact of ACA on clinical practice
The ACA will attempt to assure affordable insurance coverage for approximately 30 million additional uninsured citizens, through the expansion of state Medicaid programs and the creation of small business and state-run health care exchanges. Additionally, improvements in patient safety and quality of care through delivery of efficient low-cost, high-quality clinical services will be required. To adapt to this new model, ARDs will require a priority rearrangement mainly based on improved service quality and patient safety/satisfaction. They will be required to measure and maintain improved service quality through the implementation of work process standardization.
Appropriate utilization
Imaging utilization and quality management programs will become especially important in reducing imaging costs. The use of imaging studies has increased markedly within the past few decades. A report provided by the US Government Accountability Office (GAO) shows Medicare spending for imaging services paid for under the physician fee schedule more than doubled, increasing to about $14 billion . However, this rapid increase in imaging is slowing for Medicare patients, as demonstrated in a recent report from the Neiman Health Policy Institute . In the US general population, cross-sectional imaging almost doubled from 1997 through 2006, rising from 260 to 478 examinations per 1000 enrollees per year . In 2008, Otero et al reported that while imaging utilization for appendicitis increased rapidly (from 1.85 to 3.07 imaging studies per patient) the average hospital charges increased only by 16.3%, implying that imaging cost has been reduced in proportion to total hospital expenses. In 2012, Ip et al showed that reducing unnecessary imaging studies reduce waste and costs, helping to improve health care quality. On the other hand, imaging when used appropriately can improve the outcome measures including the total admission-related cost and inpatient mortality. A study reviewing 1 million admissions to 102 US hospitals indicated that inpatient diagnostic imaging may be associated with decreased in-hospital mortality, while imposing a statistically insignificant impact on admission related costs. This study included all clinical conditions treated in hospitals; examined the experiences of patients with private, commercial, and government sponsored insurance; and reported the hospitals’ incurred costs . Batlle et al showed that the early use of imaging (computed tomography [CT], magnetic resonance imaging [MRI], and nuclear scintigraphy) mainly on the day before or the day of admission was associated with a shorter length of stay. According to the American College of Radiology (ACR), the most effective ways of using appropriate imaging are removal of incentives for self-referral and education and support of referring physicians for the inappropriate use of imaging.
Radiation exposure control
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Reimbursement changes
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Medical informatics
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Accountable care organizations
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Impact of meaningful use
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Impact of ACA on research
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Impact of ACA on education
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Conclusion
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