June 06, 2019

Part Two of ACR Economics Forum Debates Issues at the Center of Health Care Policy

Part two of the Economics Forum at ACR 2019 featured a debate-style format consisting of five rounds on hot topics in radiology during which two experts presented opposing positions on their assigned topic. The debaters included Lauren Golding, MD; C. Matthew Hawkins, MD; Richard Heller, MD; Joshua Hirsch, MD; Anne Hubbard, Ryan Lee, MD; Andrew Moriarity, MD; Greg Nicola, MD; Kurt Schoppe, MD; and Raymond Tu, MD.

Ezequiel Silva, III, MD, FACR, chair of the ACR Commission on Economics moderated the debates and began by reminding the audience that the views espoused by each participant may or may not have been congruent with their personal and professional beliefs and actions. Notably, the presenters’ views do not reflect ACR endorsement of either position in these debates. The purpose, therefore, of this academic exercise was to force presenters and the audience to consider alternative views — highlighting the importance of hearing, understanding and even taking both sides of an argument.

After each debate, the “winner” of the round was chosen based on audience applause — indicating which of the two arguments was the more compelling.

MACRA was the topic at hand for the first round. The argument in favor of the program — described as “the right program at the right time” — lauded its emphasis on data collection, which can be used for the political process and to improve health care. Additional merits of the system included taking a hard look at rising costs of care and increased accountability for providing patients with the highest value care.

The anti-MACRA argument noted the lack of evidence for any tangible improvement in patient outcomes based on the Merit-Based Incentive Payment System’s quality measures — as well as the unreliability of self-reported scoring systems in general. The program, rather than leading to increases in quality, has actually just led to increases in people learning to “game the system.” Vendors and consultants are the only real winners in the game, it was argued, since practices need to hire them to help navigate the idiosyncrasies of the system. Because of this, administrative costs have skyrocketed — which “may be the straw that breaks the backs of many small practices” since they don’t have the resources to play the game. Everyone else is “drowning in paperwork and arbitrary adjustments” with “very little impact on patient care.” The audience determined the latter argument to be the winner of round one.

Next, experts debated the merits of the Affordable Care Act (ACA) and which direction the program should go — to let it implode or to try to save it. The first argument cited the widening gap, caused in part by the ACA, between those who have education and money and those who do not, because “in this country coverage does not equal access.” Essentially, it doesn’t help patients to have cheap screening if they can’t afford the treatment.

The argument in defense of the ACA pointed to the 12 million Americans and 3 million of their children who have health insurance as a direct result— as well as the 133 million Americans with pre-existing conditions who are now covered thanks to the program. While the program is not perfect, leaving 4 million people on unsubsidized exchanges, “we dare not forget the 15 million adults and children that now have coverage.” The program is at real risk of repeal, and “it’s a lot harder to replace than repeal.” Again, the latter argument was chosen by the audience as the more compelling.

The third round of debate featured the topic of the relationship between interventional radiology (IR) and diagnostic radiology (DR) — better together or better apart? Ultimately IR, it was argued, does not have the respect for DR that is needed for the two to successfully work together. What’s more, it’s unrealistic to expect the dynamic to change much based on historical differences in cultures, decision-making and general animosity. Rather, it’s easier and more likely to expect things to remain as they always have, and so the two should go their separate ways because “IRs deserve a choice.”

The argument for keeping the two specialties together acknowledged the historical tension between the two specialties, but noted the reality that while some IRs do 100 percent IR work, some practice a majority of DR work. “The critical point here is that IRs are DRs and DRs are IRs; there’s actually no separation involved.” Therefore, from the lens of IRs, DRs, hospitals and, most importantly, patients, separating the two does not promote increased access to critical diagnostic and therapeutic services for patients. The latter argument won this round.

The next debate centered on whether Alternative Payment Models (APMs) are achieving the desired outcome or not. Americans are spending more on health care than ever before, with health care expenditures topping out at almost 20 percent of gross domestic product. Two-thirds of people who file for bankruptcy cite health care expenditures as the reason for their financial downfall, and many find themselves struggling between paying for health care and paying for groceries. This grim reality has led to efforts at health reform — APMs — that encourage a shift from fee-for-service to value-based payment, which prioritizes efficient and high-quality care over volume growth. This is a transformation that is happening whether radiology likes it or not, it was argued, and though it may not yet be perfect — “Rome wasn’t built in a day and health care transformation isn’t going to happen overnight either” — it’s in radiologists’ interests to engage and participate in the reform rather than let it happen and remain uninvolved, which could lead to commoditization of the field.

The argument against APMs called for CMS, third-party payers, patients and physicians to “wake up” to the reality that APMs are a sinking ship. APMs have cost CMS 70 million dollars since inception — for a program that was designed to save, not lose, money, it was argued. Seven percent of participants have indicated they will be exiting the program, which is not indicative of something that’s working. Three main reasons for this failure were presented: reimbursement deficiencies, the fact that the system is inherently unfair and benchmark deficiencies. This round garnered a ‘tie.’

The final debate posed the question, “Price transparency: now or ever?” The argument for more transparency pointed out the ‘moving train’ nature of the issue; it’s already happening because patients are demanding it and legislators are noticing, so radiologists can either become involved and advocate for the field, or let others do it for them, at their own peril: “If you’re not at the table, you’re on the menu.”

The opposing argument against increased transparency noted that according to CMS, we already have it — “they’ve hung the ‘Mission accomplished!’ banner on the issue.” Not only has transparency failed to provide any real understanding by the public of the costs associated with health care, but also it has muddied the waters even more due to the confusing and very individualized costs associated with health care. Our focus should be on finding actual meaningful quality measures that reflect patient outcomes and experiences, it was argued, rather than on simply providing opaque lists of costs that are meaningless to the consumer and actually promote a “race to the bottom on price.” Audience response deemed this last round another tie.

The new format was a lively, humorous and informative approach to taking the temperature of the room (and thus ACR’s membership) on some contentious topics in radiology.