Q&A: MACRA Proposed Rule and Radiology

Last week, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would make changes to Year 2 of the Quality Payment Program (QPP). This rule is required under the Medicare Access and CHIP Reauthorization Act (MACRA).

The proposed rule's goal, CMS officials said, is to make the program easier, particularly for smaller, independent, and rural practices while bolstering financial stability and ensuring the delivery of high-quality care. Diagnostic Imaging spoke with Ezequiel Silva, MD, chair of the American College of Radiology's Economics Commission, to determine how this proposed rule could impact radiologists.[[{"type":"media","view_mode":"media_crop","fid":"61115","attributes":{"alt":"Ezequiel Silva, MD","class":"media-image media-image-right","id":"media_crop_5116728495516","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7729","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;","title":"Ezequiel Silva, MD","typeof":"foaf:Image"}}]]

Diagnostic Imaging: What are the major points or highlights of this proposed rule?

Silva: Many aspects of the QPP are continuing unchanged. One point that's relevant is that CMS is continuing the program at a "pick your pace." This allows practitioners and clinics to continue to ease into the program. For radiologists, this means we still have time to understand the program, the measures, incentives, and participation without being fearful of large reductions or having to engage in large amounts of activity to maintain payments. The downside, and this is a very subjective statement, is that people will need to find the motivation to start participating beyond financial impact. We have to have a forward-thinking mindset. But, this year, you can do the bare minimum and have a neutral adjustment. There's no downward penalty.

Diagnostic Imaging: What's new that radiologists need to pay attention to?

Silva: One highlight is particularly relevant - the virtual group. When MACRA first passed through, CMS sort of dampened the enthusiasm that might have existed for virtual groups. Now, that enthusiasm has been renewed. The whole concept is this: imagine I'm part of a small practice or I’m a solo practitioner. It might be hard for me as an individual to participate by myself. In other words, I might not have the number of patients or the infrastructure to participate effectively. But, if I potentially form a virtual group in which I partner with other smaller groups or practitioners to collectively report to CMS as one group, we can be scored on similar measures and similar performance. Originally, we thought virtual groups were going to be geographically ground and specialty- or practice-specific. But, if I'm reading the proposed rule correctly, there's a relatively open slate that would allow for expansion. This is significant to radiology and an opportunity for organizations, such as health care systems or regional providers, as well as organizations like the ACR. We're working to help our members participate.

But, it's early. We're still trying to determine what this all means. We have a lot of questions. it's important to remember this is a proposed rule. At the ACR, we're going through the language, determining what we like, don't like, and what we'd like to change. We'll submit a comment letter, and the final rule will be published later in the year, going into effect in 2018. Next year begins the performance period for the payment adjustments that will occur in 2020.

Diagnostic Imaging: Is anything changing with Appropriate Use Criteria (AUC)?

Silva: AUC is also interesting. There's already a law that requires ordering physicians to consult AUC before ordering any diagnostic imaging. The ACR supported this from the beginning. We were disappointed to see, in Year 1, that AUC as an action was not better recognized in MIPS. We were disappointed that providers and physicians weren't better recognized for engagement in clinical decision support that improves imaging and appropriate use to ensure patients receive the right study at the right time.

This year, CMS is proposing giving credit for this activity. The ACR has been fairly vocal about the appropriateness activity, saying providers who do it should be recognized and awarded quality points. They want to improve patient care, and it's a great way for radiologists to show how we positively impact patient care and the importance of that contribution.

One of the concerns is that MACRA and PAMA are already law. There's a concern that CMS would look at AUC and clinical decision support as something providers have to do anyway because it's part of PAMA. So, rewarding or not penalizing providers might be considered double-dipping. Our message has been that AUC should be recognized as a high-weighted improvement activity within the QPP.

Diagnostic Imaging: What else do radiologists need to know?

Silva: Nonpatient facing providers is something worth mentioning. The definition remains the same for year 2. It's defined as having fewer than 100 patient-facing encounters a year. At the group level, it's 75% or less of group members who have fewer than 100 patient encounters.

CMS has also opted to increase the low-volume threshold. It had been $30,000 in Medicare payments per year or 100 patients. But, this year, it's been upped to $90,000 in yearly Medicare payments or fewer than 200 beneficiaries that are cared for. In these cases, providers are exempt and don't have to report MIPS measures. There's no possibility that CMS will penalize them, and there's no downward adjustment. If there's a downside - you don't get a bonus either. According to the language, though, you may be able to opt in and participate, but we need more details about that.

For hospital-based physicians, of which many radiologists are, there is language about some additional exemptions for physicians, such as from advancing care information. We need to watch that and keep an eye on it. It could allow for more of us to be exempt. We're seeing language moving toward facility-based physicians being scored on the same scale and measures as their respective institutions, which is also a change.

Diagnostic Imaging: How do these changes affect radiology and radiologists?

Silva: It's the scale. For Year 1, CMS set the performance threshold at the low number of three. That meant it was an easy score to achieve. Not a whole lot of physicians are being penalized, but that also means there's not a lot of money in the pool to provide bonuses. In the "pick your pace" program for Year 2, the performance threshold is higher. There's also a greater maximal negative and positive adjustment. While it may not be announced until the final rule, I predict the scaling factor will be higher in Year 2. It's safe to say that the potential penalties and bonuses will have a greater magnitude than in the past.

Changes are also being proposed for physicians in small and rural practices. Imagine radiology groups in small rural settings, maybe with one or two people. It's more challenging for them to participate because they don't have the same infrastructure as large practices or institutions. They don't have the same resources.  CMS has made a number of concessions that will help those practices be more successful in the program and help position themselves to participate better going forward. The ACR has really pushed for this because we are concerned that small practices get left behind, and we want them to provide good care to patients.

For example, within the quality category, the number of points they receive is potentially higher. CMS is proposing giving them bonus points on their final score simply because they are smaller and more rural. They also have greater exemptions from Advancing Care Information (the old Meaningful Use) categories. They don't have to do Meaningful Use, and they don't get penalized for it.

In the cost category - which used to be referred to as resource use - there's going to be a 0% score applied in Year 2.  But, within the cost category, they're creating new episode groups to determine the cost score in the future. Those episode groups are being created as we speak. The ACR and other organizations are engaged in those groups even though cost isn't necessarily scored for next year. This could be significant in the future.

CMS is also changing how you're allowed to report. Previously, you could report via claims, the registry or other mechanisms, but not necessarily both. There wasn't an easy means for multi-mechanism reporting. Some measures may still only allow for one type of reporting, but practices who are particularly savvy will be able to use a combination of mechanisms and routes for measure reporting.

Diagnostic Imaging: What do radiologists need to know or do in order to comply and prepare? What is the timeline?

Silva: I think many practices have been doing the minimum, and, I think, this proposed rule is starting to create more specificity of how this program is going to go in the future. Practices now have the opportunity to build on their first year. Practices that were maybe only reporting on one or two quality measures can build on that experience to get up to what CMS is allowing for in 2018. We should really start to see some improvement in care and potential financial bonuses. I think the fact that we're seeing the cost category, even though it's 0%, getting close to being scored is relevant to payment. Our understanding is that the cost category is now a feedback mechanism that CMS will provide. In my opinion, that's hugely relevant. Cost will be an important differentiator in the future.

Now is an opportunity for practices and organizations, like the ACR, to actively engage and get involved. I also think practices will come to a greater understanding of what certified electronic health record technologies (CEHRT) are, and they'll think about how best to embrace them in practice. It's also a call for the vendor community to embrace means to create even greater performance improvement through CEHRT. For radiologists, it's an avenue for them to improve their place in health care overall.