by Jill Rathbun

In coming back from the August recess, Congress got to work addressing an area that has become a hot topic in the health care community — consolidation. Even before the mergers between Anthem/ Cigna and Aetna/Humana were announced, there was concern regarding the number of hospital and hospital systems, and physician practices that had merged or been acquired. Hospital acquisition physician practices have already prompted studies by the congressional advisory body, MedPAC. Their testimony regarding this phenomenon and its potential impact on the health care system and patients has been given to several Congressional committees.
 
A series of hearings in the U.S. House of Representatives was kicked off on Sept. 10, 2015, by the Subcommittee on Regulatory Reform, Commercial and Antitrust Law of the House of Representatives Judiciary Committee. This first hearing entitled, “The State of Competition in the Health Care Marketplace: The Patient Protection and Affordable Care Act’s Impact on Competition,” served to set the stage on a variety of topics. These included the impact of these various types of mergers on competition, and what the effect is on providers and patients; and what, if any, new regulations are necessary to ensure choice and value for all in the U.S. health care system, given these types of mergers. Future hearings will serve to go into more depth on these discussions.
 
For imaging services, there were two themes at the hearing that are important to be aware of as these hearings continue this fall. One is the concept of providers needing to “get bigger,” to be able to take on risk. The second is the issue of site-of-service for the provision of imaging services and the concept of site-neutral payment, which is a source of concern.
 
Regarding the concept of needing to take on risk, most of the alternative payment models such as Accountable Care Organizations or shared savings demonstrations require the provider to take on some level of risk, usually in the form of bonuses and penalties, for the overall cost of the patient’s care. To handle this type of risk, many providers have felt the need to increase in size as a way to better coordinate care and save money for the health care system. However, just increasing in size with no additional tools to help with the rendering of more appropriate care may not be producing the intended cost-savings results.
 
The types of tools needed to do well in a value or risk-based payment system is something that imaging service providers know well: appropriate use criteria and patient safety protocols. Appropriate Use Criteria that are evidence- based and developed by physician-led organizations, such as the American College of Radiology and the American College of Cardiology, can help clinicians to order the right scan at the right time, and lower the need for additional imaging services or for expensive imaging tests to be ordered, when an ultrasound or X-ray test is just as, or more, appropriate.
 
With Medicare moving forward to adopt Appropriate Use Criteria for the ordering and rendering of imaging services reimbursed under Medicare’s fee for service payment system, it seems only natural that the Centers for Medicare and Medicaid Services (CMS) would encourage its use in all of its risk-based demonstration projects, such as Accountable Care Organizations, and provide access to these tools to those providers.
 
Similarly, patient safety protocols where central venous access or the placement of a tap or a needle is done under ultrasound guidance have been studied and shown to prevent several costly complications. Uniform adherence to such protocols would save the health care system and the patient money, but more importantly ensure higher quality patient care.
 
Another theme in this hearing revolved around competition. Members of Congress expressed concerns at the hearing about hospitals buying physician practices to then being able to charge the higher facility payment rates for services under the hospital outpatient department payment system. As discussed previously in this column, such a practice has led policy makers to the topic of “site neutral” payments for certain services, including some imaging services. In fact, it would primarily be the least expensive imaging services, such as ultrasound and X-ray, which would be negatively impacted by these types of site neutral policies.
 
This is because in some instances these services are “conditionally packaged,” which means that hospitals do not always get the cost of the service on the patient’s claim because the service is not, in that circumstance, paid separately. This incomplete data submission means that the overall payment by Medicare for the hospital outpatient department can go down, as hospital outpatient payment rates are set based on the charges submitted to Medicare by the hospital, if the charges do not get reported on the claim.
 
As mentioned at the start of this article, this was the first in a series of hearings Congress will have on the topic this fall. They are something that everyone should be aware of as the hearings could lead to policy changes
that could potentially impact imaging services in the future. To see a video of the hearing and read the testimony of the witnesses, please visit http://judiciary.house.gov/index.cfm/hearings?ID=417B9E62-CB8D-4FC7-905D-40F39B91E5E7.
 
About the author: Jill Rathbun is managing partner at Galileo Consulting Group in Arlington, Virginia.
She will be commenting for HealthCare Business News on issues of interest to health care professionals.