Reimbursement Revolution

Value-based payments are coming. How is the ACR positioning radiology for success in this new system?

Reimbursement Revolution clip art calculator on orange backgroundOn April 16, 2015, President Obama signed into law a potentially game-changing piece of legislation related to radiology payment policy.

Before receiving Obama’s signature, the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 overwhelmingly passed in the House (392 votes to 37) and the Senate (92 votes to 8). This legislation repealed the sustainable growth rate (SGR) payment update formula, which is pretty much unanimously considered to be a flawed calculation. By 2022, under the newly established Merit-based Incentive Payment Scheme (MIPS), we will see payments for our services rendered to Medicare beneficiaries at risk of increasing or decreasing by as much as 9 percent. Additional bonuses will be available for exceptional performance, and participants in yet-to-be-defined alternative payment models will be eligible for a 5 percent bonus payment instead of MIPS payments. While the details are worked out, we will see Medicare payments stabilized for 10 years with small annual increases programmed in.

The SGR formula established as part of the Balanced Budget Act of 1997 was originally intended to ensure that spending on Medicare did not outstrip spending on other programs. The “spigot” that would regulate this was the conversion factor, the scaling factor in the Medicare payment formula set by Congress each year. However, as Medicare spending grew, large cuts would have needed to be implemented to scale back overall expenditures as defined in the formula. Due to advocacy by physician and patient groups, these cuts were never implemented year after year. Even though the cuts were never implemented, the threat destabilized the Medicare system, made beneficiaries anxious, and hobbled attempts to change the payment formula to incentivize value over volume.

Even though the MIPS program does not go into effect until 2019, we need to get to work quickly to ensure that radiologists have a voice at the table. CMS will be proposing episode-of-care models later this year and will be deciding on which APMs it will accept as early as spring of 2016.

The MIPS program essentially rolls up existing value-based payments (such as PQRS, the value-based modifier, and meaningful use) but introduces a new category of clinical practice improvement. CMS has stated that it wants to engage specialties on which measures are meaningful. The agency is also looking to work closely with commercial health insurance plans to make metrics more seamless across different payers and hopefully reduce the burden on physicians, who currently may have to meet different metrics for different health insurers.

At the ACR, we have been developing relevant quality metrics for many years. Before I ever became involved in economics, I was the ACR’s delegate to the newly established National Quality Forum back in 2000. The work of our Metrics Committee under the leadership of Frank J. Rybicki, MD, PhD, FACR, is now being complemented by the Quality Management Committee under the leadership of Jonathan B. Kruskal, MB, ChB, PhD. Under the Commission on Economics, we created a Value-Based Payments Committee last year, chaired by Giles W. Boland, MD, FACR, to build on the work of our Radiology Integrated Care Network and our Future Trends Committee. Our efforts around value-based payments has been expansive, including collaborations with leaders of the ACR Commission on Informatics and our RBMA and AHRA colleagues. We convened a forum last spring to take our pulse on how we were progressing. At that time, we felt that we were on track to meet the challenges of an evolving payment system.

All of the above efforts notwithstanding, we are now gearing up to make sure that radiologists are appropriately positioned for success in a post–SGR payment world. Over the next few months, we will be tasking thought leaders with ensuring that we have a robust model to communicate to CMS and other payers. Input will come from leaders in quality, metrics, and informatics; representatives from various practice types; and stakeholders from within our profession as well as radiology’s allies. You may well be hearing from us this summer with questions like these: What at-risk arrangements do you have now? What are meaningful differentiators of quality for you and your subspecialty or practice type, and what are practical ways to measure them? Our mission is to ensure that radiologists are able to participate in value-based payments in a way that does not negatively impact patient care or their practice environment. We'll leverage our experience bringing structured models for payment of lung cancer screening and implementation of clinical decision support, which have been well received by CMS.

Our profession has traditionally succeeded in times of change like these. The Herculean efforts of James M. Moorefield, MD, FACR, and colleagues to develop and implement a radiology relative value scale were born out of a time of proposed large payment cuts. The resource-based relative value scale that resulted has served us well, and our goal is to learn from these past achievements and position radiologists for success in the future.

As we move forward, we’ll be informed and inspired by the Imaging 3.0™ initiative, making sure that our advocacy efforts have as their foundation the health and well-being of our patients. I’ve asked our Board of Chancellors Chair, Bibb Allen Jr., MD, FACR, to act as the executive sponsor of this project. I know he will ensure that our output will have Imaging 3.0 at its core.

Please don’t hesitate to be in touch with your thoughts and questions on this important effort. As always, you can email me, and I encourage you to follow me on Twitter @DrGMcGinty

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