1. Society of Vascular Ultrasound Annual Meeting 1 08/07/2014 UF Health Shands Tim Goldfarb

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11. 11 The Environment Public payor rate erosion Private payor cost shift to employees and perhaps exchanges Utilization rates will fall

12. 12 Targets: FFS Payment Utilization Rates

13. 13 Public Payors Continue Shift To Risk And Utilization Controls Medicare MS DRG Medicare Advantage Two Midnight Rule Bundling P4P ACO IME reduction or elimination Medicaid MCO Community Care Organizations MS DRG Discounted FFS Shared Savings

14. 14 Private Payor Consolidation Most states have 4 to 5 National Payors and a few Regional Payors Exchanges Bundling P4P PPO MCO Discounted FFS ACO Narrow Networks Shared Savings

15. 15 Physician Consolidation Hospital employment Broad multispecialty Disease/Condition specific multispecialty Continued Expansion into ancillary services as long as FFS holds and utilization controls are lax

16. 16 Hospital Consolidation Vertical Integration—retail, PCP, Urgent Care, Satellite ED, ASC, Acute Care, Rehab, LTAC, Home Care, Hospice, Physician Alignment Mergers or Affiliation Not-for-Profit/For-Profit blending

17. 17 Blending of Roles Community Care Organizations PSN’s Direct Contracting Blue Zones ACO’s

18. 18 Patient/Customer Engagement Driven by high deductibles and co-payments Transparency of pricing and medical information Consumerism Medical Tourism

19. 19 Where is this going?

20. 20 Certainties Less $ on an inflation adjusted basis Lower overall utilization

21. 21 How Will This Affect Vascular Sonography One Model: Kaiser Consolidated Imaging from administrative perspective Radiologists for General Ultrasound Vascular Surgeons for venous and arterial MFMs for perinatal Cardiologists for cardiac related Dedicated training and certification for Sonographers in sub- specialty areas Additional pay for dedicated training and certification Not a radical change in a model that we appear to be moving towards