On the Road to Value-Based Care
How can a newly funded CMS grant program position you for success in demonstrating value and making a difference in patient care?
The journey to value-based reimbursement is full of twists and turns, ups and downs. On paper, the map to the future of health care seems simple enough — provide the best possible care for patients and you’ll be rewarded.
However, in reality, defining and measuring quality care are more complex tasks and especially challenging for specialties like radiology.
On Sept. 29, radiologists on the road to value-based care got a serious boost when the ACR received a nearly $3 million CMS grant as part of the Transforming Clinical Practice Initiative. The grant is part of a comprehensive strategy advanced by the Affordable Care Act to enable new levels of care coordination, continuity, and integration as health care payment systems transition from volume-driven to value-based and patient-centered. “This grant represents a huge opportunity for radiologists, working with our referring health care professionals, to lead medicine in making significant change that positively impacts patients and promotes cost efficient care,” says William T. Thorwarth Jr., MD, FACR, CEO of the College.
Previously known as the Value-Based Radiology Practice Quality Improvement Project, the newly funded Radiology Support, Communication, and Alignment Network (R-SCAN) will enable a broader multidisciplinary scope that includes engaging state chapters, sister specialty and primary care organizations, and other national medical organizations. A key goal is to embed a process supporting value-based radiology in the clinical practice of our members and their partnering referring physicians so that it becomes part of clinical routine.
An Initiative for All Members
While emphasizing radiology’s value to the health care team, R-SCAN participation offers radiologists the opportunity to earn ABR-approved Maintenance of Certification Part 4 credit. R-SCAN will also help position members for success under the Medicare Access and CHIP Reauthorization Act’s (MACRA’s) new value-based payment structures, which will govern how radiologists are paid.
The concept was developed by Max Wintermark, MD, a member of the ACR Commission on Research and chief of neuroradiology at Stanford University. “We envisioned engaging radiologists nationwide in an endeavor to collect practice data that demonstrates their integral role as members of the health care team,” says Wintermark.
To demonstrate that role, participants focus on improving the ordering of imaging exams and, specifically, on 10 Choosing Wisely imaging guidelines. This direction was a natural tie-in with the ACR Appropriateness Criteria® (AC) and clinical decision support (CDS) initiatives that serve as the project’s core tools. “It integrates with Imaging 3.0™ by providing a way for radiologists nationwide to begin addressing the issue of overutilization of imaging — and thereby demonstrates value in their local community,” says E. Kent Yucel, MD, FACR, a member of the R-SCAN advisory panel and radiologist-in-chief at Tufts University School of Medicine in Boston.
The ABCs of R-SCAN
R-SCAN participants are guided by a step-by-step plan. Once the Choosing Wisely exam topic is chosen, participants access a customized the appropriateness of exams ordered and create project reports. Participants have access to extensive Web-based resources ranging from articles detailing how to communicate with referring clinicians, to podcasts about how to overcome image ordering dilemmas.
“R-SCAN provides a truly turnkey methodology for engaging ordering physicians,” notes Wintermark. “As an added benefit, R-SCAN participation is a very efficient way to complete a practice quality improvement project.”
Meeting Value-Based Requirements
Just as important as fulfilling ABR MOC Part 4 requirements, the R-SCAN project will help members demonstrate the value they bring to patient care, a major determining factor in Medicare payment adjustments in the years to come through MACRA’s Merit-Based Incentive Payment System (MIPS) and alternative payment model (APM) incentives.
“R-SCAN participation will be an excellent starting point for practices looking to succeed in a value-based payment world,” says Geraldine B. McGinty, MD, MBA, FACR, chair of the ACR Commission on Economics. “Whether a practice is planning to qualify for MIPS bonus payments or the alternative payment model incentive, this will be an excellent way to start preparing.”
Effectively managing health care resources is another key consideration in the new world of alternative payment models. “For radiologists to claim that they are active stewards of health care resources, they need to demonstrate their role in managing utilization,” explains Mythreyi B. Chatfield, PhD, ACR’s senior director for data registries. “Becoming familiar with CDS tools and engaging more with referring physicians can only be a positive step forward.”
And it’s no longer just CMS that is establishing performance-based metrics to determine reimbursement levels. “Increasingly, commercial insurers are implementing performance-based payments,” concludes McGinty. “When a practice can approach a payer or ACO partner with data that proves their commitment to appropriate imaging with the attendant reduced costs and improved care and outcomes, that will be a powerful negotiating tool.”
Reports from the Field
In 2014, ACR member volunteers participated in a pilot program that led to R-SCAN funding. These early users share their experiences partnering with their colleagues to improve patient care.
Mount Desert Island Hospital
John Benson, MD, FACR, a radiologist at Mount Desert Island Hospital in Bar Harbor, Maine, and president of the Maine Radiological Society, encouraged Clinton Weiss, MHA, to spearhead a value-based radiology program focused on reducing unnecessary imaging in patients with acute, nonspecific low back pain. Weiss, a third-year medical student in Tufts University School of
Medicine’s Maine Track MD Program, was serving a rural clerkship at the hospital.
A retrospective review of the medical records of 109 MRIs ordered for low back pain over an eight-month period in 2014 showed 6.4 percent of the exams were inappropriate. Weiss met with the 24 clinicians identified as having the highest referral volume. “The face-to-face educational intervention was very collegial,” says Benson, who notes the program serves as a good opportunity to get the message out about the AC and prepare clinicians for CDS. “The initial scans ordered post-intervention have shown a 24 percent improvement in appropriate scans ordered,” reports Benson.
Coastal Radiology in New Bern, N.C., took a slightly different tack. “We adopted a ‘teach the radiologist to teach the clinician’ approach and started off by having the radiologists learn about the appropriate recommendations for ovarian cyst follow up,” says practice president Catherine J. Everett, MD, MBA, FACR. The practice chose this topic because they receive many orders for ovarian cyst evaluation from the emergency department and specific follow-up recommendations often were not included in the radiology report. “Although we may not know whether a cyst is symptomatic, we still should provide a recommendation to help the emergency physician determine whether to refer the patient to the OB-GYN or for ultrasound follow-up.”
While final results are not yet available, Everett comments, “The biggest result is that we’re now putting recommendations into the report where previously, by and large, we were just not including follow-up of ovarian cysts.”
The best advice L. Alexandre Frigini, MD, provides for successful R-SCAN participation is to select a Choosing Wisely topic that will impact your practice the most and target a clinician group willing to collaborate. “If the referring clinicians don’t buy in, it will be difficult to succeed,” says Frigini, assistant professor of radiology and director of quality assurance at Baylor College of Medicine in Houston, Texas, who found a strong collaborator in the chair of Baylor’s emergency department.
The chair of the emergency department, like Frigini and his radiology colleagues, believed unnecessary CT angiography scans were being performed for evaluation of pulmonary embolism. Frigini implemented an educational intervention for emergency medicine clinicians. A review of pulmonary embolism orders at four weeks post-intervention showed the educational effort was successful in decreasing the rate of inappropriate scans for pulmonary embolism evaluation by nearly 13 percent.
By Nancy Fredericks, R-SCAN project director, and Chris Hobson, Imaging 3.0 senior communications manager