Dollars and Sense
The Economics Forum focused on payment policies under MACRA, CPT® code valuation, the work of the RUC, and Medicaid payments.
The 2019 Economics Forum, moderated by Ezequiel Silva III, MD, FACR, chair of the ACR Commission on Economics, kicked off with “the payment schedule that loves to be ignored,” said the ACR’s advisor to the RUC, Kurt A. Schoppe, MD. But the role of the Hospital Outpatient Prospective Payment System in reimbursement policy is becoming more important. Schoppe advised radiologists to take an active role in hospital cost reporting, to educate themselves using ACR resources, and to act now by raising concerns with hospital finance departments.
Eric M. Rubin, MD, a member of the ACR Coding and Nomenclature Committee, talked about the College’s work on Current Procedural Terminology (CPT®) code valuation. He stressed the need to protect existing code valuations and to work to ensure new codes accurately describe the work being done. Rubin also posed the question: Why are there no CPT codes for AI?
Lauren P. Golding, MD, vice chair of the ACR MACRA Committee, described some of the current challenges the ACR is facing in light of the 2019 fee schedule, including CMS’ rejection of many RUC recommendations for radiology codes. Golding also noted that Anthem’s nomination of seven high-volume codes as potentially misvalued could be seen as a conflict of interest in an attempt to influence Medicare physician reimbursement rates. “This could be a big win for their bottom line but a big loss for physicians and for patients,” she said.
Part two of the forum featured a debate-style format consisting of five rounds during which two experts presented opposing positions on their assigned topic. After each debate, the “winner” of the round was chosen based on audience applause — indicating which of the two arguments was the more compelling. The goal of the new format was to take the temperature of the room (and thus ACR’s membership) on contentious topics in radiology.
A lively debate centered on whether Alternative Payment Models (APMs) are achieving the desired outcome or not. Americans are spending more on healthcare than ever before, with expenditures topping out at almost 20 percent of gross domestic product. Two-thirds of people who file for bankruptcy cite healthcare expenditures as the reason for their financial downfall, and many find themselves struggling between paying for healthcare and paying for groceries.1 This grim reality has led to efforts at health reform — APMs — that encourage a shift from fee-for-service to value-based payment, which prioritizes efficient and high-quality care over volume growth. This is a transformation that is happening whether radiology likes it or not, it was argued, and though it may not yet be perfect — “Rome wasn’t built in a day and healthcare transformation isn’t going to happen overnight either” — it’s in radiologists’ interests to engage and participate in the reform rather than let it happen and remain uninvolved, which could lead to commoditization of the field.
The argument against APMs called for CMS, third-party payers, patients, and physicians to wake up to the reality that APMs are a sinking ship. APMs have cost CMS 70 million dollars since inception in the state of New York alone — for a program that was designed to save, not lose, money, it was argued.2,3 Seventy percent of participants have indicated they will be exiting the program, which is not indicative of something that’s working.4 Three main reasons for this failure were presented: reimbursement deficiencies, an inherently unfair system, and benchmark deficiencies. This round garnered a tie.
The final debate posed the question, “Price transparency: now or ever?” The argument for more transparency pointed out the “moving train” nature of the issue; it’s already happening because patients are demanding it and legislators are noticing. So radiologists can either become involved and advocate for the field or let others do it for them, at their own peril: “If you’re not at the table, you’re on the menu.”
The opposing argument against increased transparency noted that according to CMS, we already have it — “they’ve hung the ‘Mission accomplished!’ banner on the issue.”5 Not only has transparency failed to provide any real understanding by the public of the costs associated with healthcare, but it’s muddied the waters even more due to the confusing and very individualized costs associated with healthcare. Our focus should be on finding actual meaningful quality measures that reflect patient outcomes and experiences, it was argued, rather than on simply providing opaque lists of costs that are meaningless to the consumer and actually promote a “race to the bottom on price.” Audience response deemed this last round another tie.
By Chad Hudnall, senior writer, and Cary Coryell, publications specialist, ACR Press
1. Konish L. This is the real reason most Americans file for bankruptcy. CNBC. February 11, 2019.
2. Spanko A. ACOs cost government money, but skilled nursing opportunity remains large. Skilled Nursing News. May 19, 2019.
3. Spanko A. Instead of saving $1.7 billion, ACOs cost Medicare $384 million. Skilled Nursing News. April 1, 2018.
4. Inserro A. NAACOS releases survey showing concerns with MSSP model. AJMC. May 2, 2018.
5. Gooch K. 5 thoughts from hospital leaders on the CMS price transparency rule. Becker’s Hospital Review. January 9, 2019.