How Radiology is Approaching Alternative Payments

The move to tie medical payments to value rocketed this year, leaving radiologists wondering how their work fits in with alternative payment models. In January, Health and Human Services Secretary Sylvia Mathews Burwell laid out payment goals for Medicare, with reimbursement rates affected by how physicians meet quality standards. Then in April, President Obama signed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This repeals the sustainable growth rate (SGR) formula and institutes a new payment system based on quality and value.

“This is a once in a lifetime opportunity for our specialty, to be part of shaping the payment policy system,” said Geraldine McGinty, MD, chair of the ACR’s Commission on Economics. “The last time this happened was when the RVU (relative value unit) system was developed.”

Burwell’s plan calls for 30% of fee-for-service Medicare payments to be tied to quality or value through alternative payment models by the end of 2016, rising to 50% of Medicare payments using alternative payment models by the end of 2018. By the end of 2016, she wants 85% of traditional Medicare payments to be linked to quality or value.

Under the MACRA act, physicians can earn bonus payments or be penalized during 2019–2025, based on the new Merit-Based Incentive Payment System (MIPS). Until MIPS takes effect in 2019, the current Physician Quality Reporting System (PQRS), physician value-based purchasing program, and meaningful use program will continue. In 2019, they’ll cease as MIPS takes over. MIPS will base merit payment on quality and efficiency measures, meaningful use of electronic health records, and clinical practice improvement activities.

What will these measurements look like for radiologists, and who has a seat at the table to influence the decisions?[[{"type":"media","view_mode":"media_crop","fid":"41958","attributes":{"alt":"radiology value","class":"media-image media-image-right","id":"media_crop_7748441081708","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4498","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; height: 185px; width: 200px; border-width: 0px; border-style: solid; margin: 1px;","title":"©Digital Storm/Shutterstock.com; ©sfam photo/Shutterstock.com","typeof":"foaf:Image"}}]]

What the ACR Is Doing
Payment based on value isn’t a new concept for the ACR. “We had already been thinking over the last few years about what value-based payments in imaging would look like,” said McGinty.

The ACR is pulling several of its commissions together for a full college effort, including the Economics, Quality and Safety commission, Informatics commission, and Education. They’re convening a work group in October to draft a proposal for CMS with imaging metrics and alternative payment models relevant to radiology.

While this is their major internal effort, the ACR is also working with several other related CMS groups. McGinty said that the Center for Clinical Standards and Quality is coordinating CMS efforts, which includes the Centers for Medicare and Medicaid Innovation and the Health Care Payment Learning and Action Network. The latter brings together external stakeholders like private payers, consumers, employers, providers, and state Medicaid programs.  

Value is sometimes easier to show in other specialties. “We’re very aware we may have some challenges when CMS thinks about how radiologists can be measured on components of the MIPS such as resource use, given that we may not have had the opportunity to control the ordering of imaging tests.” She said the ACR is also engaging with other “non-patient facing” specialties like pathology, in order to stay proactive.

While CMS has a structured process for changing policy, they also have an informal process, such as issuing requests for information. McGinty said the ACR is responding to both types of processes by supplying information in the requested format. “I’d like to think we’ve developed a collaborative process with them.” Currently, the ACR is focusing on helping to educate CMS about radiology’s contributions to high value care. They’re sharing Imaging 3.0 case studies with CMS to show successful radiology practices that have shifted from volume to value.

As the process moves forward, ACR will offer assistance when CMS develops language for the federal rule-making process about how claims are paid and which boxes physicians need to check off to show that they met incentive payment criteria. Currently, though, McGinty said it’s important to share ACR initiatives to show how radiologists are becoming more collaborative in the care team, and being as expansive in that as possible.

She acknowledges that when developing the value-based payment metrics and models, it’s not going to be one size fits all. “We’re certainly looking at organizing around different conditions or modalities,” said McGinty. “We hope to have a menu or broad offering of potential metrics.”

What Are Other Radiology Stakeholders Doing?
“The ACR has a unique role as the voice of radiology with policy makers,” said McGinty, “but we work closely with other organizations.” That includes the Radiological Society of North America (RSNA), American Society of Neuroradiology (ASNR), and the Society for Interventional Radiology (SIR). “This is something that everybody is thinking about,” she said.

Members of the SIR met with CMS in August. “Telling the story of IR and the work we are doing in providing evidence-based care is an important part of the process. We also appreciated the benefit of hearing CMS’s ideas on how IR can be a multiplier in care coordination and care appropriateness,” said Donald F. Denny, Jr, MD, in a statement. Denny is SIR’s executive councilor for health policy and economics.

It’s Not Just CMS
While CMS may be leading the charge, other payers are jumping on board with value-based payments. The Health Care Payment Learning and Action Network states that “making operational changes will be viable and attractive only if new alternative payment models and payment reforms are broadly adopted by a critical mass of payers. When providers encounter new payment strategies for one payer but not others, the incentives to change are weak. When payers align their efforts, the incentives to change are stronger and the obstacles to change are reduced.”

McGinty adds that the new value-based payment system will affect other payers as well, trickling down to affecting all doctors. “Private payers are part of this initiative,” she said. “CMS has encouraged that. I think every radiologist will be impacted by this.”

As part of the process, CMS is actively soliciting information from private payers, she said. “They want similar quality metrics for all payers.” If doctors want the participation bonus for alternative payment models, they’ll have to meet the patient target composed of both Medicare and private payer patients.

Part of McGinty’s goal for CMS is to make sure they’re committed to a payment model that recognizes who radiology is in the care team. “For some of the services we provide, we may not be seeing the patient, we may not have as much influence as other providers in the team. I’d like to make sure they’re prepared to develop programs that are relevant to us as care providers.”

And she said the ACR goes into the process recognizing that the best care for patients requires that all the care providers work together. “This new payment policy should incentivize that collaboration.”