Staying on Course

As CMS' Quality Payment Program gets underway, radiologists try to reconcile more clerical responsibilities with high-quality patient care.Staying on Course

Asking radiologists what they think of the increased clerical responsibilities inherent in CMS' Quality Payment Program (QPP), the care delivery mechanism of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), will yield many colorful answers.

Since composite performance final scores will govern at what levels radiologists are reimbursed for treating Medicare patients, it's a topic of great interest for all physicians.

In addition to how they will be reimbursed, another question on many radiologists' minds is, with the introduction of a raft of new reporting requirements, could MACRA set the stage for a wave of physician burnout? Although no two providers' experiences are the same, if managed correctly, over time the guidelines can have their intended effect of improving patient care while reducing the costs of health care. Getting on board with the transition to value-based reporting from the start can mean the difference between success and burnout.

Words to the Wise

The QPP was designed with an array of practice sizes and settings in mind. Consequently, physicians must meet a range of qualifying criteria depending upon their circumstances. For most radiologists, payments or penalties under the QPP will be formulated for the foreseeable future using performance measures through the Merit-Based Incentive Payment System (MIPS).

Whether providers receive a positive or negative payment adjustment for Medicare patients is determined by their MIPS composite performance final score. And for those radiologists participating in MIPS, the good news is that MIPS represents a consolidation of quality programs in which many radiologists are already participating. 2017 will be the first MIPS performance year, during which patients will be asked to demonstrate the value they are providing to patients.

The quality programs now fall into three or for different areas depending on the performance year — Quality, Cost/Resource Use, Improvement Activities, and Advancing Care Information (or ACI, defined as the meaningful use of certified electronic health record technology, or CEHRT). For instance, when it comes to the Quality performance category, CMS will build on quality measure sets already in use for programs such as the Physician Quality Reporting System, the Medicare EHR Incentive Program for Eligible Professionals, and the Value-based Payment Modifier.

To further smooth the transition to MIPS, CMS has deemed 2017 a "transition year." The hope is this will give physicians time to better acclimate themselves to the changing quality care environment. What this means is that cost performance will be weighted at zero, which will shift the emphasis to the quality category. Beyond that, CMS will offer providers three reporting options during the first performance year, a more flexible arrangement than will be available in future years.

"CMS has eased reporting requirements this year to allow physicians time to become familiar with the subtle changes between the prior CMS performance programs and MIPS," notes Gregory N. Nicola, MD, vice president of the Hackensack Radiology Group in Hackensack, N.J., and member of the ACR's Council Steering Committee. "Those using claims-based reporting may continue to do so but may want to explore an alternative reporting mechanism option."

One such option includes using a Qualified Clinical Data Registry (QCDR), such as one of ACR's NRDR® registries (see an Imaging 3.0® case study about the advantages of registries), which can be used by providers as an alternative to claims-based reporting for submitting quality metrics. "A QCDR may allow physicians to optimize their MIPS final score in subsequent performance years" and also may help to mitigate clerical challenges associated with reporting. So in 2017, all a radiologist has to do is report on one quality measure for a single patient, have a positive performance on it, and they've avoided a negative adjustment," points out Nicola, referring to the Pick Your Pace arrangement. This lower threshold to entry during 2017, Nicola explains, further allows radiologists to concentrate on gaining a better understanding of how MIPS works without having to focus so much on reporting.

Experts are advising radiologists to make the most of this window of time. "Focus on the opportunity to demonstrate your quality," recommends Geraldine B. McGinty, MD, MBA, FACR, vice chair of the ACR Board of Chancellors. "Identify a champion who will keep up with the regulations and educate the group. Engage with your hospitals and your billing company and sign up for the ACR's QCDR." For more information about how to sign up for NRDR, contact This email address is being protected from spambots. You need JavaScript enabled to view it..

Nicola also advises radiologists to seriously consider adopting CEHRT, regardless of whether they participate in ACI. However, he acknowledges that value-based reimbursement schemes up to this point have often let radiologists off the hook when it comes to making information available to patients and demonstrating interoperability with their hospitals' EHR. Thus, it may now be more challenging for them to catch up when needed.

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In addition, predicts Nicola, "Radiologists will limit their ability to participate in alternative payment models — which are value-based reimbursement models wherein physicians take on more financial risk to potentially realize greater bonuses — without having CEHRT up and running. And without this technology, they will be disadvantaged in MIPS in future years."

But there's still time and, as McGinty notes, there's not time like the present to get started: "Get involved, get on the governance committee at your hospital, highlight the value of appropriate imaging, and implement R-SCAN™ to show everyone that they need our help!"

Concerns Persist

Among many imaging experts in small, rural, or independent practices, the concessions made by CMS in the MACRA final rule still aren't enough to make MIPS seem like anything more than a daunting task. Some worry that the increased reporting requirements will cause workflow disruptions and, for those who have in-person encounters with patients, it will cause them to provide diminished care due to an increased clerical workload.

Join Y. Luh, MD, radiation oncologist at St. Joseph Hospital in Eureka, Calif., acknowledges the potential pitfalls inherent as the new changes take effect. He is particularly concerned about the technology radiologists must use to corral and submit data, which sometimes is beyond the capability of those in less resource-rich settings.

"It is important for small and rural practice leaders to become fluent with CEHRT," says Luh, "but it will not be easy or affordable." He points to CMS' Meaningful Use program, which was a precursor to the MIPS Advancing Care Information program, as an example of how implementing CEHRT does not always make attestation easier. In addition, notes Luh, rural practices often lack the human and technical resources to use CEHRT as CMS sees fit.

Nicola says that there is hope for radiologists who simply do not have the necessary resources right now to make CEHRT a reality. "Practices have three options to avoid having to use CEHRT," he notes. "They can meet the non-patient facing threshold definition, they can meet the hospital based definition, or they can apply for a hardship exemption." All three of these options will exempt a physician from the Advancing Care Information requirements.

Although the challenges posed by MACRA and the QPP are real, the good news is that there is still time to make the transition and not incur penalties. Radiologists who are not MACRA-ready should rededicate themselves to laying the groundwork necessary to make their QPP experience a successful one. Whether you're already reporting quality measures or still unsure of where to start, the ACR is here to help.

By Chris Hobson, Imaging 3.0 senior communications manager

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