If the Massachusetts effort to attain universal health coverage is any indication, then national health reform will certainly face roadblocks. Presenting at the 2011 RSNA conference, Alexander Norbash, M.D., highlighted some of the unexpected outcomes and barriers faced in his home state, which passed a health reform law in 2006 under Gov. Mitt Romney.

Norbash, a radiologist at the University of Boston Medical Center, noted how the state faced some similar problems in 2004 that the nation does now, most notably rising health care premiums. Under "RomneyCare" the state mandated insurance coverage, and today nearly 98 percent of residents have health insurance. But due to a severe shortage of primary care and internal medicine physicians, the wait times for appointments have worsened, Norbash said. Wait times to see a general internist are typically 48 days, which is "not acceptable," he said, noting that the long wait continues to drive patients to emergency departments, where the cost of care is higher. Overall, care costs in the state have continued to rise.

Norbash participated on a panel of physicians who discussed various aspects of health reform, including the push to outcomes-based payments. Marta Heilbrun, M.D., assistant professor of radiology at the University of Utah, noted that incorporating clinical-based treatment guidelines into the radiology practice is difficult at best. She cited the multitude of guidelines in place--noting that 36 radiology-related ones can be found online in an HHS Web site--as one hurdle. "Information overload is a barrier," Norbash said. But even more challenging is the need to identify what outcome is expected: Is it lower morbidity, better diagnostic capability, or reduction in lost productivity on the part of employees?

The University of Utah has embedded some practice guidelines in its electronic ordering system, offering recommendations for treatments of certain lesions, based on the size of the lesion and other factors.

Panelist James Rawson, M.D., a radiologist affiliated with the Georgia Health Sciences University, noted that increasingly Medicare will reimburse based on quality metrics, including patient satisfaction scores. He cited a looming national shortage of radiologists and technicians, which will undermine the nation's ability to offer mammography screenings in the years ahead.

Panelists gave a mixed report on the accountable care organization model, which CMS introduced earlier this year. According to Norbash, the success of an ACO model would depend heavily on the mix of patients enrolled in it. The sicker patients were, the less likely his organization could meet quality scores.  Radiology will move to a high through-put model under the ACO set-up he predicted, meaning they must be at the table negotiating with other specialists as to how the pie will be divided. "The ACO is shared risk between providers, but the patient doesn't have the same degree of skin in the game," Rawson added.


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