Cost — Rarely Understood but Highly Relevant

Practices may review their Quality and Resource Use Reports to better understand how they are doing with cost.GettyImages 694746164

Cost, cost, cost. More and more, we hear that physicians are being held accountable for cost.

Within the fee-for-service payment model, the Merit-Based Incentive Payment System (MIPS) includes a performance category devoted entirely to cost, which accounts for 10 percent of our MIPS score in 2018. And almost all new payment models require that participants either control costs or face a penalty.

Despite this growing emphasis, it is interesting to note how little physicians understand about how they are scored on cost. And, many of us overlook the fact that we have already been evaluated on cost for the past two years, thanks to the Affordable Care Act-mandated Value-Based Payment Modifier (VM). How did you and your practice perform in terms of cost, as it relates to the VM? It is relatively easy to find out with the Quality and Resource Use Report (QRUR).

Understanding Your Quality and Resource Use Report

Follow these steps to pull your practice's report and see how you're doing in terms of the Value-Based Payment Modifier (VM) and how you might fare under new payment models.

1. Acquire your Quality and Resource Use Report by contacting your business manager or billing entity. The QRUR indicates performance on the quality and cost measures used to calculate the VM payment adjustment. The recently released QRUR is based on performance in 2016 and affects payments for 2018.

2. Check the risk levels of your patients. The VM allows upward adjustments based on how sick our patients are, referred to as "patient risk." The average risk of our patient population is presented as a nationwide percentile. A higher percentile indicates patients with higher risk, such as those with multiple chronic conditions. By looking at this metric, radiologists easily gain a glimpse into how sick their patients are compared with the rest of the country. Generally, higher risk results in increased costs, which must be factored into cost measures and is referred to as "risk stratification."

3. Find out how you did with cost. For almost all radiologists, the only measure that applies is the Medicare Spending per Beneficiary (MSPB). This measure captures resource use (cost) surrounding a specific hospital stay, from three days before admission to 30 days post-discharge. This measure is based on past billing claims to Medicare. The only time a radiology group would be assigned a specific inpatient admission is when a radiologist has more charges than any other physician for that patient. While not common, this can occur when a patient has a lot of imaging, IR procedures, or radiation oncology treatments but few or no treatments by other specialties. Because some practices have hundreds of admissions assigned to them, the MSPB is a measure worth following.

4. Delve into the MSPB. When requesting your QRUR, be sure to ask for Table 5 of the "Accompanying Tables," which relates to the specific episodes assigned to a practice. Find an inpatient admission assigned to you, and review the imaging and care provided to that patient, obviously respecting and acknowledging the patient's confidentiality. Although every case is different, there may have been opportunities to reduce cost, such as by avoiding unnecessary imaging and procedures or a longer hospital stay than was necessary. Until we look for and identify areas to improve, systematic implementation will be difficult.

5. Engage in data-driven discussion with your hospital about working together to improve performance on cost. The MSPB is one of the many measures applied to hospitals. Hospitals have their own value program, called the Hospital Value-Based Payment Purchasing Program. The results are reported on the Hospital Compare website (medicare.gov/hospitalcompare).

Being proactive on increasing our knowledge of cost may better inform our actions to control spending, while still maintaining quality, subsequently increasing our value and maximizing our payments. Under the Quality Payment Program, MIPS includes four performance categories. Most physicians will score well on quality, advancing care information, and improvement activities. This means that our performance on the fourth category — cost — could be the differentiator between a bonus and a penalty.


dr silvaBy Ezequiel Silva III, MD, FACR, Chair

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