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Payment and Population Health Management

How can radiologists prepare their practices to be reimbursed in a PHM environment?

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Redefining a radiologist’s job in a population health management (PHM) model is undeniably tied to payment. The Medicare Access and CHIP Reauthorization Act (MACRA) and the Merit-Based Incentive Payment System (MIPS) set the stage for value-based payments and have already started putting some payment at risk.

The diagnostic work of radiologists benefits patients predominantly through directing care pathways. Decisions as to whether to treat and how to treat are often based on the results of a diagnostic imaging examination. The cognitive work of radiologists therefore plays an important role in managing care and affects the associated costs. As policymakers increase their focus on population health, radiologists must stress the importance of this care management role and, potentially, seek reimbursement for these services.

“Because imaging affects patients throughout the healthcare system, radiologists’ payments will likely hinge on how they approach and embrace PHM initiatives,” says Ezequiel Silva III, MD, FACR, chair of the ACR Commission on Economics. “Much of our work is going to be scored and graded in quality and in our ability to lower costs.”

Value Versus Volume

According to Silva, volume-driven care is moving to value-driven care. “It’s happening,” he says, “but probably slower than we may have anticipated. And I think that’s just because it’s proven to be harder than policymakers and practitioners expected.” Silva notes that because PHM differs from conventional healthcare by emphasizing value rather than volume, radiologists need to question the value of each imaging study ordered.

Richard Duszak Jr., MD, FACR, professor and vice chair for health policy and practice at Emory University School of Medicine and affiliate senior research fellow at the Harvey L. Neiman Health Policy Institute®, agrees. “Since PHM hinges on optimizing value throughout the care continuum, and since appropriateness is a critical component of value, optimizing imaging appropriateness is one of the most important things that we as radiologists can do to enhance value and help our health systems successfully navigate new population health delivery models,” says Duszak.

According to Duszak, historically, some radiology groups have looked at patients showing up in their departments — appropriately or inappropriately — for testing as something that magically happens, over which they have no control.

“‘Just do it’ was the motto, whether it was necessary or not,” says Duszak. “But that old model of churning examinations of dubious appropriateness costs a lot and could prove financially disastrous for health systems as they increasingly assume financial risk for patient care.”

New Payment Models

According to Duszak, to succeed in PHM, radiologists need to roll up their sleeves and look at the resources the ACR provides on how to be successful under MACRA and alternative payment models (APMs).

“Radiologists need to understand that when we get involved in multispecialty APMs, we need to be sure we are well-represented at the table so early disease detection is accounted for in the resources for early intervention,” says Bibb Allen Jr., MD, FACR, ACR immediate past president and chief medical officer of the ACR Data Science Institute™.

In Allen’s view, radiologists have a key advantage progressing into this long-term vision. “The ACR’s Imaging 3.0® initiative provides the framework for how we can change the culture from a transactional process in which we do a test, provide an interpretation, and then go on to the next patient — to a culture in which radiologists are longitudinally involved in the care of the patient,” he says.

Looking to the Future

Duszak believes that as reimbursement moves from volume to value, and specialists are held financially accountable for patient health outcomes, reimbursement is going to revolve around improving care and wellness.

Silva agrees. He believes one way for radiologists to accomplish this is through structured reporting to make their findings consistent and actionable to both referring clinicians and patients. Another way, says Silva, is participating in the ACR data registries. Registries allow practices to capture evidence-based data that help radiologists make the best care and treatment decisions and compare the performance of other healthcare providers on patient outcomes (acr.org/registries).

“Structured reporting and registry participation hit across several specialties, like mammography, lung cancer screenings, and CT colonography,” says Silva. As someone who has accomplished all this in his own practice, he assures small practice providers: “It’s doable.”

ENDNOTE

  1. Krishnaraj A, et al. The Impact of the Patient Protection and Affordable Care Act on Radiology: Beyond Reimbursement. J Am Coll Radiol. 2015;12(2):29–33. Available at bit.ly/JACR_Reimbursement.
    By Nicole B. Racadag, MSJ, managing editor, ACR Bulletin, and Wendy Meyeroff, freelance writer, ACR Press

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