Out with the Old, in With the New?

The 2015 Final Rules hint at what's to come in the year ahead.

EconPic

January 2015 

The commission on economics always meets face to face at RSNA, and this year we used the ACR’s new strategic plan to develop our priorities for the year ahead.

The big hairy audacious goal (or BHAG in business speak) is that “ACR members are universally acknowledged as leaders in the delivery and advancement of quality healthcare.” For our part, our overarching goal in economics is that “existing and new practice and payment models recognize the value delivered by radiology; ACR members are prepared to adapt and thrive within the models.” So, as we start a brand new year, we continue to have a dual focus on both the fee-for-service system — in which most of us continue to function — as well as opportunities for radiologists to successfully navigate the transition to more value-based payments. You can read the full plan at http:// bit.ly/ACRStrategicPlan.

The playbook for fee-for-service continues to be the Medicare Fee Schedule. In the Final Rules for 2015, the big positive changes centered on breast imaging. Practices can now bill for tomosynthesis when the procedure is performed in conjunction with full-field digital mammography (read more at http://bit.ly/TomoCoding). However, before we all get too excited, there was a sting  in the tail. While the CPT Editorial Panel created three codes for tomosynthesis (a screening add-on code and two diagnostic stand-alone codes) for unilateral and bilateral studies, CMS created two add-on codes both valued at the same level. This is problematic in that there is no way to bill for a stand-alone tomosynthesis study (which could potentially be performed if a patient is recalled from screening) and no recognition of the inherently more complex and intensive work that surrounds a diagnostic examination. As I’ve mentioned previously, CMS is also mandating review of the existing mammography codes,  so we will be working hard to make sure that the code set that eventually emerges from this not only recognizes the work involved but also reimburses at a level that ensures access to life-saving screening for our patients.

We were disappointed by CMS’ decision to finalize its plan to use the cost of a desktop computer as a proxy for the costs associated with PACS. That simply does not passthe smell test, and we have assembled a group of imaging, PACS, and policy experts to work with CMS to help get accurate inputs.

Our new year also heralds a brand new screening program to start in 2015, with annual low-dose CT to be covered by Medicare and private payers for current and former smokers who meet certain criteria. This was a sensible decision by CMS that will save lives and improve population health. We worked collaboratively with all the other internal and external stakeholders, including patient advocacy groups, to craft a program that would maximize benefits and minimize harms. We look forward to con- tinuing this important collaboration.

We also continue to work to create future payment models and methods that will fairly compensate radiologists for the value that we provide. We recognize, however, the need to support our radiology community through this time of change. I’m very excited about the ACR’s new Quality Management Committee, chaired by Jonathan B. Kruskal, MD, ChB, PhD, of Beth Israel Deaconess in Boston. This committee is charged with helping members navigate and participate in the various value based–payment initiatives. From PQRS to the QCDR, this alphabet soup of incentives and penalties can be overwhelming to unravel.

Another focus for the Commission on Economics is,  at time of writing, still very much in the research phase but holds promise for the future. Bundled payments have been heralded as the magic bullet that can reduce costs and align incentives, but they are not as easy to develop as they sound. From the unintended consequences of   the bundled breast biopsy codes mandated by CMS that threaten to jeopardize access to an already cost-effective and less invasive solution to the failure of a bundled- payment pilot for joint replacement in California (read more at http://bit.ly/CA-Bundled), the road to health care reform is littered with failed experiments. Add to that the challenge for radiologists, who are often not the primary care giver or decision maker along the care pathway, and it might seem as if bundled payments are not going to be part of our reimbursement.

We know that, even in the most robust integrated care systems, radiologists still tend to be reimbursed on a fee-for-service basis. But what if there was a way to create a bundled payment for imaging services  that allowed radiologists to make the care decisions for which we are uniquely qualified? What if we were reimbursed for following patients with incidentally detected lung nodules and incentivized to follow guidelines? What if, instead of CMS telling us how to use tomosynthesis, we made those decisions based on the best use of the available technology tailored to an individual patient? Our phenomenally smart colleagues at the Neiman Health Policy InstituteTM are working with us to learn how we might structure these types of payments to make sure that radiologists are able to invest in and maintain new technology and provide access for patients while optimizing care pathways and outcomes. Watch this space for informa- tion as it becomes available.

Janus, for whom this month is named, was the Roman god of begin- nings and transitions. He is traditionally portrayed with two faces; he looks both to the past and the future. Your economics team is, likewise, determined to preserve existing victories as well as forge new pathways to success for our specialty.

As always, you can reach me at This email address is being protected from spambots. You need JavaScript enabled to view it. and I encourage you to follow me on Twitter at @DrGMcGinty.


Geraldine B. McGinty, MD, MBA, FACR

From the Chair of the Commission on Economics
By Geraldine B. McGinty, MD, MBA, FACR, Chair

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