Catch Your Wave
As alternative payment models emerge, radiologists must find their place in the shifting paradigm.
The tide of health care is turning. On one side is the traditional fee-for-service model, in which radiologists and other physicians are paid according to the number of exams they read and patients they see.
On the other side are alternative payment models (APMs), where radiologists and other physicians are paid according to the quality and cost of the care they provide.
As the health care delivery system attempts to move from volume to value, APMs are carrying more weight, tilting the scales further in the direction of value. In fact, in April, CMS released a highly anticipated proposed rule, forming the Quality Payment Program, an umbrella initiative that formally establishes Advanced APMs and the Merit-Based Incentive Payment System (MIPS) as the new quality payment models for eligible professionals. (For APMs to be considered “advanced,” they must use a certified EHR, base payments on quality measures comparable to MIPS, and bear more than nominal financial risk for monetary losses or follows an expanded medical home model.)
CMS has created financial incentives, beginning in 2019 based on a performance period during 2017, to encourage physicians to participate in these new payment systems. While it’s still unclear how the systems will ultimately be implemented, one thing is certain: radiologists will have to leave their reading rooms and engage their colleagues throughout the health care system, as outlined in the ACR’s Imaging 3.0 campaign, to succeed under these new models.
“APMs in particular mandate that we bring individual, siloed participants in the health care system together to achieve the common goal of providing exceptional patient care at a reduced cost,” says Ezequiel Silva III, MD, FACR, director of interventional radiology at South Texas Radiology Imaging Centers in San Antonio and chair of the ACR Commission on Economics. “Some might think that level of collaboration is difficult for radiologists to achieve, but radiologists are actually well positioned to not just participate in but guide these collaborative discussions.”
To better understand how APMs will impact radiology and other areas of health care, it helps to know how these payment systems were developed. That means reflecting back to 2010, when President Barack Obama signed the Affordable Care Act (ACA), colloquially known as Obamacare, into law.
The ACA formally created two important payment model vehicles. The first is the accountable care organization (ACO), a type of APM that brings physicians, hospitals, and health systems together to deliver coordinated care. The second is the Center for Medicare and Medicaid Innovation (CMMI), a proving ground for new health care payment models that increase quality and decrease expenditures. Pam Kassing, MPA, RCC, senior economic advisor at the ACR, notes that the CMMI has a long list of payment models it’s testing, some of which have been implemented as part of the proposed rule.
Initially, radiologists and other providers watched to see which CMMI-tested payment models CMS would adopt and provided input into the process as opportunities arose. In 2015, providers became even more engaged in the process when Congress voted to replace the sustainable growth rate (the formula CMS previously used to control Medicare spending) with the Medicare Access CHIP Authorization Act (MACRA). The legislation blazed two new pathways for Medicare reimbursement — MIPS and APMs. Then came the proposed rule released this spring, which puts MIPS and Advanced APMs under the new Qualified Payment Program umbrella and proposes performance standards for these new payment systems.
What’s the difference between MIPS and APMs? MIPS is a modified fee-for-service system in which physicians are paid for each service they provide for patients and are financially incentivized to report quality measures. APMs, on the other hand, are completely new payment models. Under a bundled payment APM, a physician, practice, or other entity contracts with a payer to receive one bundled payment for services provided for a patient or group of patients based on specific clinical episodes or conditions. That payment is then divided among the parties involved in providing that care. Under an ACO or shared-savings APM, participating providers who improve quality and reduce costs share in the cost savings. Qualifying APM Participants (QPs), those who have a certain percentage of their patients or payments through an Advanced APM, also receive financial bonuses.
While both the MIPS and APM pathways are available to radiologists and other physicians, CMS is clearly directing providers toward APMs by offering a simpler reporting system and higher annual incentive than MIPS, says Geraldine B. McGinty, MD, MBA, FACR, assistant professor of radiology and assistant chief contracting officer at Weill Cornell Medicine. “The U.S. Department of Health and Human Services and CMS believe in the ACO concept, so they’re trying to make APMs the more attractive option,” explains McGinty, who is also the vice chair of the ACR Board of Chancellors. “But they know some physicians will remain in fee-for-service, so they created the MIPS opportunity. The ACR is working to ensure both APMs and MIPS are meaningful for radiologists.”
Eventually, CMS may require all physicians to join APMs. As radiologists become involved in these payment systems, they must ensure their APM partners understand the value imaging brings to patient care. To accomplish this, radiologists must continue to build relationships with referring physicians and patients throughout their health systems.
“The worst situation radiologists can find themselves in is being in an APM where they’re not engaged in the process and they’re not part of the governance,” McGinty says. If radiologists aren’t viewed as valuable members of their APMs, they could be left out of the shared savings, for example, Kassing notes.
Radiologists and other physicians should care about these new payment models because these systems will impact how providers are paid in the near future. “Radiologists must engage in MIPS or APMs,” Kassing says. “If they don’t, they risk not only losing money in the Medicare program but also not being seen as team players by the hospitals and communities that are working in APMs.”
Under MACRA and the proposed rule, radiologists and other physician groups that meet the performance criteria in MIPS will see a payment adjustment, which can be a bonus or penalty, of up to 4 percent in 2019, up to 5 percent in 2020, and up to 7 percent in 2021. In 2022 and beyond, MIPS groups will see an adjustment of up to 9 percent. In contrast, QPs in Advanced APMs will receive an automatic 5 percent bonus in 2019. In 2021, QPs must receive at least 50 percent of their Medicare revenue or combined Medicare and all-payer revenue from an APM or at least 35 percent of their patients must be Medicare patients to receive the 5 percent bonus. In 2023 and beyond, QPs must receive at least 75 percent of their Medicare revenue or combined Medicare and all-payer revenue or 50 percent of their patients must be Medicare patients APM to receive the bonus.
In 2026, the MIPS and APM systems will diverge, with two different conversion factors for qualifying APMs compared to non-qualifying APMs and MIPS. APM QPs that meet certain thresholds will receive a .75 percent annual payment increase, while participants in non-qualifying APMs and MIPS will receive just a .25 percent annual increase. “While half a percent doesn’t sound like a lot, imagine if the system stays in place for 5, 10, 20 years or more,” Silva says. “Then the payment difference between qualifying and non-qualifying APMs becomes fairly sizable fairly quickly due to the compounding nature of the incentives.”
It’s important to note that as CMS institutes these new payment systems it will need a performance period. During this period preceding the payment adjustment, CMS will review practices’ performance data to determine whether they meet the new payment model criteria. The proposed rule recommends using 2017 as the performance period for the first payment adjustment scheduled for 2019. “Radiology groups that are not involved in quality improvement activities by early 2017 can assume their 2019 payments will be adversely affected,” Silva says.
If practices aren’t ready to participate in APMs right away, they can prepare for APMs down the road by participating in MIPS. Gregory N. Nicola, MD, vice president of the Hackensack Radiology Group and a member of the ACR Commission on Economics, says an important thing radiologists can do is participate in the ACR National Radiology Data Registry (NRDR®) and other qualified clinical data registries under MIPS). These registries allow practices to compare their quality performance metrics to other practices nationwide. “Groups will be in a much better position to join an APM if they’ve already gone through the registry reporting process and tried to act on the data they’ve gotten back as a result,” says Nicola, whose group has been involved in NRDR for nearly three years. “MIPS is really a stepping stone into APMs.”
In addition to participating in qualified clinical data registries as part of MIPS, practices should familiarize themselves with clinical decision support (CDS) tools like ACR Select® to prepare for new payment models. Silva notes that the Protecting Access to Medicare Act (PAMA) mandates that physicians must consult CDS when ordering advanced imaging for Medicare patients, so it’s inevitable that CDS will be part of the new payment landscape. (CMS has delayed the 2017 CDS mandate, but the requirement is fully expected to be implemented.) Radiologists who participate in R-SCAN, the ACR’s collaborative clinical practice improvement initiative, get a chance to use ACR Select before the PAMA mandate takes effect. “R-SCAN gives radiologists an opportunity to explore CDS and work with their consulting physicians to put CDS into play ahead of the mandate,” Silva says.
While it remains to be seen which APMs CMS will approve or how exactly these models will be implemented, it’s obvious the tides of health care change are upon us. Now it’s up to radiology to find its place in the shifting paradigm. “These new payment systems give us a chance to step it up a notch and say, ‘Not only do we believe we’re providing quality care, but we’re also willing to prove it,’” Silva says. “Proving value isn’t an easy thing to do, but through organization and commitment, I’m confident that 10 to 15 years from now we’ll be able to reflect on this time and be proud of ourselves for doing it right. It’s an exciting time for the profession.”
By Jenny Jones, Imaging 3.0™ content specialist