“There is fatigue around the word ‘value,’” Richard Heller, MD, national director of pediatric radiology, Radiology Partners, said at RSNA 2016.
Citing colleague frustration with overuse of the buzzword in medical journals and conferences, Heller said there is a reliance on value and what radiologists should care about is the measures used to quantify value.
“I think we are in the first mile of a marathon and we have just begun,” he said. Today, talks surrounding value should concentrate on the details and how the stressors in a radiologist’s world directly affect value. From payer and hospital consolidations to change in payment models and disruptive technology, there are many stressors that can diminish value and create further inefficiencies, Heller shared, who spoke about the role value plays in reimbursement.
Value-based payment models cover an increasingly larger volume of patients each year, including many of the 73 million Americans who utilize Medicaid annually as well as other governmental and private payers, he said. “This is clearly the trend on both the public and private sides of the fence and affects every radiology practice,” Heller said. “The value-based payment ship has already sailed and we are on it.” Using metrics to quantify value is essential.
He discussed further the two current value-based payment models most practices use related to the Medicare Access and CHIP Reauthorization Act (MACRA) passed in 2015, Merit-based Incentive Program (MIPS), and the alternative payment model (APM). Current systems are often homogenous and focused more on primary care, he said. Radiology’s uniqueness requires a pay-for-performance model that would ideally be meaningful to patients and outcomes, realistically measured, and under radiology’s direct control.
While Heller acknowledged that most radiologists currently use the MIPS scoring model under a non-patient facing category that incentivizes through the two measures, quality (85%) and improvement (15%), “MIPS has confusing rules, an asymmetric field of play, and there are ways to game the system by altering templates,” he said.
Thus, Heller said he sees the future shifting to a special subset APM known as an advanced APM that removes radiologists from MIPS requirements, offers a 5% bonus annually for many years followed by a future annual increase that is three times the size of other physicians who are not participating in an advanced APM.
“CMS is trying to use a particular kind of carrot that is clearly trying to incentivize us to go this way,” Heller said. He noted, to CMS’s credit, they recognized that the starting point of an advanced APM is primary-care focused and that they needed to get other specialties involved. Creating a pathway that radiologists will most likely follow, Heller said physician-focused payment models (PFPM) in which Medicare is the payer to a physician or physician practice that’s finding a new way to deal with quality and/or cost.
If you have a PFPM that can fulfill the criteria required for an advanced APM including the active use of certified electronic health record technology, quality measures in place, and some level of financial risk, Heller said your PFPM automatically becomes an advanced APM with all the benefits associated with it, which is a goal radiologists should strive for.
The Physician-Focused Payment Model Technical Advisory Group (PTAC), made up of 11 committee physician members, has developed a criteria for PFPM models that will help broaden APM’s to include under-represented specialties, such as radiology, Heller said. “We are kind of the belle of the ball,” he said. PFPM’s that are creating bundled payment initiatives can satisfy their requirements by including radiology where it is relevant, as well as identifying radiologist’s contribution to cost with the Inpatient Cost Evaluation Tool (ICE-T).
“APM is where the future wants to go and I think it is where it probably should be going,” Heller said. He offered two ways to look at where radiology currently stands in relationship to value-based payment: “You can see this as the view in the rearview mirror with the sun setting, it was a great run but that day is over,” he said, or alternatively, “You can look at the road ahead, the sun is rising and it is a new day. Yes, I expect there to be significant challenges, but I also expect wonderful opportunities for us, for our patients, and for the system.”