Now That ACA Survives, It’s Back to Value for Radiology

Last week, the Supreme Court ruled in favor of the Affordable Care Act and affirmed that tax credits are available to Americans in all 50 states, even if their state relied on the federal exchange and didn’t establish their own.

It’s mostly business as usual for radiologists, according to Richard Duszak, Jr, MD, vice chair for health policy and practice, department of radiology and imaging sciences at Emory University School of Medicine. Duszak is also the Chief Medical Officer of the Neiman Health Policy Institute.

Hospital-based radiologists, especially, dodged a bullet because a different King v Burwell decision could have reduced the already low 28% of radiology services in the emergency department that are not reimbursed, according to a paper in the Journal of the American College of Radiology.

“This ruling, at least, preserves the status quo as it is today,” Duszak said.

“In a reverse King v. Burwell scenario, CMS and a lot of other people would be scrambling and not moving ahead with other things on the horizon,” Duszak explained. “I think [now], from a point of view from CMS, they are not going to be distracted with an unravel of the ACA, so they will continue to challenge their energies in some of the directions they’ve been going most recently; I think the biggest initiative that’s been put forth is the very ambitious timeframe that’s been outlined for transitioning from fee for service to fee for value.”

“That’s a little bit scary for radiologists because right now we really don’t, in my opinion, have very good, robust metrics of value in radiology,” he said. “We can wait for CMS to come forth with some value-based metrics for radiology, but that means having nonradiologists come up with those metrics, or we can collectively be small test tubes of innovation and develop some of our own quality and value-based metrics.”

Between the CMS value metrics and what congress has done in the SGR fix, Duszak said we are in an environment of full steam ahead in value-based payments.

“The scary piece about that is the Yogi Berra quote, ‘if you don’t know where you’re going, any road will get you there’,” he said. “I think we all intuitively know what value is, we know it when we see it, but if dollars are going to be on the line, the real challenge is going to be how do we measure this thing called value. We need to start taking it out of the ether, making it less elusive and more tangible.”[[{"type":"media","view_mode":"media_crop","fid":"39373","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7495118708782","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3945","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":"height: 211px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Kev Draws/Shutterstock.com","typeof":"foaf:Image"}}]]

Informing CMS
There is a lot of talk, and skepticism, on the radiology side about proving value, but Zeke Silva, MD, vice chairman of the ACR Commission on Economics, feels confident that the field is well-positioned for the coming health care revolution.

In the effort to quantify radiology’s value, Silva referred to the Merit-Based Incentive Payment System (MIPS), established by the Medicare Access and CHIP Reauthorization Act (MACRA), or the “SGR fix.”

“MIPS will give each individual physician a composite performance score, which will determine if [physicians] are paid a bonus or imposed a penalty on their fee-for-service payments,” Silva explained. “MACRA gives radiology and the ACR guidance on the general categories and how we can define our place.”

The MIPS is made up of four performance categories: quality, resource use, clinical practice improvement activities, and Meaningful Use. The physician’s composite score will depend on how they perform in these four categories. As Silva explained, scores will range from zero to 100 and will be compared to a performance threshold, generally the mean or medial for all physicians. Scores above the threshold will likely see a bonus. Negative scores, or those below the threshold, are likely to see a penalty.

The good news, according to Silva, is the four MIPS categories are largely translations of programs that currently exist.

“For quality, the current program that exists is PQRS, and the ACR and other organizations have been actively involved in creating PQRS measures that are applicable to diagnostic radiology,” he said. “Radiologists are fairly successful in the PQRS program and the ACR is recognized by CMS as a Qualified Clinical Data Registry, so we are pretty well positioned in the quality category.”

 “For the practice quality improvement, we already have to do that for our MOC participation,” Silva said. “So we are pretty well positioned there as well.”

The Meaningful Use policy has been statutory for a number of years and is already in Stage 3, Silva explained. Assuming radiology can define its role within the current Meaningful Use system, Silva believes there is reason to be optimistic that by 2019, radiology will be positioned to thrive in that paradigm.

Radiology, it seems, is not in as bad shape as expected. The fourth performance category, however, is where the challenge for radiology really lies.

“Resource use is a challenge for us,” Silva said. “CMS began to define resource use metrics with the ACA, which created the value based modifier to look at physician’s resource use on Medicare beneficiaries, see how much physicians spend in the Medicare program, and tie their cost measures to quality, and use that to determine subsequent payment adjustments.”

These metrics are based on episodes of care, or episode groupers, Silva explained. Episodes can be defined by certain clinical conditions, like COPD, Silva said. Conditions where radiology has a role, as patients with COPD often will receive chest X-rays and CTs.

“Radiology is intimately involved in most of these episodes of care, but we may not be the physician to whom that particular Medicare beneficiary is attributed,” Silva said. “That’s usually going to be the primary care doctor that’s coordinating patient care and seeing them in a more traditional clinical setting.”

The challenge for the ACR and radiology, therefore, is to establish quality resource use metrics that are specific for imaging and less about the full episode of care. Silva assured that the ACR has staff and volunteers that dedicate a significant amount of time defining these imaging-specific metrics.

MACRA also addressed alternative payment models (APM), which are less about episodes of care and more about multispecialty models that are responsible for populations of patients. This is another model that radiology has a role in. One of the provisions of MACRA is that the Secretary of Health and Human Services has to define specialty-specific models that are applicable to specialists, and not just conditions.

“It’s for physicians that contribute to specific aspects of the general health care of the population, but maybe don’t have quite as wide the spectrum of care,” Silva said.

That’s another challenge for the ACR: defining an imaging-specific APM. Silva sees this as a synthesis of radiology’s data on spending, type, and nature of imaging, and packaging and presenting the model in a form that CMS would be accepting of.

Silva said the Secretary of Health and Human Services has to come out by the end of 2016 with specific criteria for the specialty-specific APMs. The ACR’s strategy is to inform those criteria before they are created, rather than waiting to hear what the government proposes.

“The ACR recognized a long time ago that this change is happening and while fee-for-service worked well in a number of ways, it has shortcomings that are now being recognized,” Silva said. “We started to define steps that radiologists could take and Imaging 3.0 is the platform that we use for the concrete steps radiologists need to take to be successful in the next paradigm of quality and physician payment.”