Economics Goes Local

Thanks to MACRA, some changes to the way we practice are
originating at the regional level before rolling out nationwide.

The Medicare Access & CHIP Reauthorization Act (MACRA) is often described as a shift in payment policy from volume to value. MACRA could also be described as a shift from national to local.

Compare the traditional Medicare Physician Fee Schedule (MPFS) to the new payment systems under MACRA. The MPFS has applied one national fee schedule for decades, with payment amounts determined through recommendations by a central AMA committee called the Resources-Based Relative Value Scale Update Committee and then finalized by CMS. MACRA’s payments are more local. Granted, the general rules and regulations of MACRA will be determined nationally, but implementation strategies will vary across local practices. And local experiences and
successes will inform national policy.

This circumstance is important to the ACR Commission on Economics. We must enable strong bidirectional communication between national policymakers and local organizations, such as health care systems, institutions, and even ACR state chapters. In this column, I discuss examples of this national-to-local policy shift.

The more common payment pathway for radiologists in the early years of MACRA is the Merit-Based Incentive Payment System (MIPS). The MIPS performance category of Improvement Activities (IAs) illustrates the importance of local experience and bidirectional communication. CMS has provided approximately 90 different qualifying IAs, but the descriptions are general. As such, the manner through which these activities are applied will vary among practices. CMS is soliciting new IAs from the public. The ACR will propose IAs that make sense for our profession, but we are also looking for new activities that have resulted in local practice improvement. The ACR Commission on Economics is in a good position to communicate IA guidance to our members but also to share meaningful local strategies to national policymakers for potential countrywide adoption.

The second payment pathway, which will take longer to mature but could have more lasting impact, is Alternative Payment Models (APMs). Two bodies are actively evaluating new payment models: the CMS Innovation Center and the Physician-Focused Payment Model Technical Advisory Committee (PTAC). Both rely on local experiences to inform their new models.

The goal of the Innovation Center is to test payment and delivery models that result in lower costs and/or improved quality. The impact of the Innovation Center has been farreaching. CMS estimates that 207,000 health care providers are participating in Innovation Center models and in initiatives serving over 18 million patients.1 This means that many individuals reading this column provide radiology services at a participating facility. Successful institutions will employ strategies to succeed within their model, and the innovation center is relying on these local data to determine which models will be expanded nationally. The ACR can serve as a conduit for communication between national policymakers and local entities. The College can also help share successful strategies and best practices.

The PTAC evaluates stakeholder proposals and provides comments and recommendations to CMS. As of June 2017, the PTAC had reviewed and submitted comments regarding three proposals. Only one of the proposals originated from a large national medical society. The two others came from smaller regional provider groups. For example, Project Sonar, which relates to treatment of inflammatory bowel disease, was led by the Illinois Gastroenterology Group, which employs about 50 physicians. The PTAC recommended Project Sonar for only limited-scale testing.

In other words, this model originated from a local domain and will be tested locally. Like the Innovation Center, only locally successful models will be translated nationally. In the future, the ACR may submit a model to the PTAC. But, in the meantime, it is conceivable that a radiology-specific model could be presented by a more local organization. This
creates an opportunity for collaboration between the ACR and such local organizations.

The ACR has had a strong presence influencing national policy. The MPFS is an example. But MACRA is prompting an evolution to more locally directed initiatives, creating a twofold responsibility for the Commission on Economics.

We must not only inform our members on MACRA-related policy but also learn from local experience and communicate those that are successful to other radiology professionals and national policymakers. Bidirectional communication will be important to improving radiology patient care.

 dr silvaEzequiel Silva III, MD, FACR, Chair




  1. Centers for Medicare & Medicaid Services, Centers for Medicare and Medicaid Innovation. Report to Congress. December 2016. Available at Accessed June 14, 2017.

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