Radiology and Population-Based Reward Systems
What role will imaging play in the next generation of payment models?
With the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the way physicians will be paid going forward will look very different from how we have been paid in the past.
The move toward Alternative Payment Models (APMs) will involve two-sided financial risk in which health systems and practitioners are responsible for the care of a cohort of patients — including the cost of their care. Some states have already moved to a relatively high penetrance of risk-based contracting. My home state of Massachusetts is among those. Having moved to this state approximately four years ago, I was impressed by the degree to which our commercial contracts involve two-sided financial risk. Insofar as these experiences may inform what life looks like once government payers adopt similar risk-based contracting, I thought it would be helpful to share some ways in which radiologists may participate in population-based reward systems.
The at-risk contracts managed by Partners HealthCare are coordinated through an internal performance framework that defines the metrics by which we measure our performance in the care of the relevant population-based cohort. This framework also lays out the way we distribute reward dollars among practitioners should we see an upside to the risk. Measures are broken into three broad categories: reducing medical expense trends, quality and efficiency strategies, and quality measures (including both ambulatory and hospital-based measures). Radiology impacts all three domains, directly or indirectly.
Our greatest impact may be felt through efforts to assist in reducing medical expense trends for our health systems. Paramount to this effort is ensuring that our services are used only when appropriate. Here, leveraging Appropriate Use Criteria for decision support at the time a radiology order is entered can have a profound impact on the imaging services in at-risk contracts. ACR Select® provides the means by which the ACR Appropriateness Criteria® can be delivered to the point of care. This information is invaluable to practitioners contemplating which, if any, imaging exam would be most appropriate for their patients. A relate tool, ACR Assist™, provides the opportunity for radiologists to be more uniform in the recommendations they make consequent to imaging findings.
Going a step further, Massachusetts General Hospital, Boston, has developed a shared decision-making tool that guides practitioners to the appropriate interventional (IR) or surgical procedures for their patients. Most directives leverage home-grown appropriateness guidelines for IR and surgical procedures ranging from carotid endarterectomy to total hip arthroplasty. In some cases, pre-authorization is waived for surgical procedures that are planned using this shared decision-making tool. One IR procedure has been incorporated into this mechanism: inferior vena cava filter placement. While use of this tool has not grown beyond our home institution, time will tell whether it may be beneficial for further reducing variation in IR and surgical procedures as a means of controlling total medical expense trends.
The management of outside images vexes nearly every radiology practice. Practitioners commonly bring their patients' images on compact discs to our reading rooms, and image upload and potential interpretation is often viewed as a nuisance. Importing and storing outside images on an internal PACS can help reduce the need for repeat imaging and the associated expense and possible radiation exposure. Moreover, bringing outside images into one's system for interpretation or at least consultation may help improve care coordination. Coordinating care for patients managed through at-risk contracting can help avoid downstream hospitalizations and their associated costs. Such patients also require clear understanding of their medical conditions, potential risks, and downstream expenses. Without accurate forecasting, at-risk contracts may be poorly negotiated, leaving the practitioners vulnerable to downside risk. Imaging can play an important role in this prognostication by accurately defining current disease and forecasting future conditions. Only with good data can accurate predictions help practitioners and their contracting groups manage medical expense in a meaningful way.
Few, if any, of us work in a network that is free of competition. Patients often seek out-of-network imaging services owing to a variety of conditions that may range from geographic convenience to out-of-pocket expense. However, out-of-network imaging confounds at-risk contracting in two respects. First, decision-support tools adopted by one group may not be present in competing practices, allowing practitioners to circumvent the utilization management afforded with in-network imaging services. Second, the cost of out-of-network imaging must be borne by the network from which the patient "leaked." Thus, it is incumbent upon radiologists to assist in managing out-of-network utilization by reducing as many barriers as possible to in-network imaging. Such barriers may include limited access to imaging services owing to long backlogs for a scheduled appointment and pricing that exceeds local standards. While many of these issues may go beyond the control of the individual radiologist or group, it is incumbent upon us to do all that we can to promote in-network utilization and avoid losing patients to competing practices.
Our greatest impact may be felt through efforts to assist in reducing medical expense trends for our health systems.
Among quality and efficiency strategies intended to improve population health, increasing ambulatory access for imaging services keeps imaging in-network but also avoids ER visits referred exclusively to obtain imaging for acute patients. For example, some practitioners may send their patients to the ER for a CT scan to rule out appendicitis because they have no other means of getting a CT scan in a timely fashion. Such practices clog our ERs with patients who delay care for those truly in need of emergency services.
Increasing patient engagement for image-based cancer screening is another means by which radiologists can contribute to strategies intended to improve the quality and efficiency of our population health management efforts. Social media campaigns intended to promote breast cancer screening with mammography, colon cancer screening with CT colonography, and lung cancer screening with low dose lung CT may help ease the burden on primary care practitioners who seek to meet targets for cancer screening compliance among their patient panel. Under risk-based contracting, failure to meet such targets counts against one's ability to document improved enrollee health on a broad scale. Such benefits are also realized when radiologists avail themselves of opportunities to consult with patients or their caregivers regarding critical findings detected on imaging examinations. Sometimes simple explanations can pay dividends in helping coordinate care and by potentially avoiding downstream costs associated with needless additional testing or hospitalizations. Such consultations may occur either in person or through electronic conferencing tools.
Finally, regarding cancer screening compliance, radiologists may also participate in targeted interventions intended to reduce missed opportunities for image-based screening. These may occur through text messaging reminders to vulnerable populations as well as offering same-day screening services to patients who may not return to the clinic for a follow-up appointment owing to their socioeconomic status or other factors. I have been impressed by how much our primary care physicians appreciate even small efforts on the part of radiologists to assist in coordinating the care for their patient panel.
These population health initiatives align well with the APMs enabled under MACRA. The three aims of APMs are as follows: improve quality, increase care, and lower costs.
The ACR has several initiatives underway to help radiologists transition from fee-for-service models described under the Merit-Based Incentive Payment System to APMs. These include the Radiology Support, Communication, and Alignment Network (R-SCAN®), a program created to educate referring practitioners on the use of decision support for reducing inappropriate imaging. (Learn more at rscan.org.) The ACR has also produced white papers describing various means by which radiologists may participate in bundled payments for services, such as mammography, lung cancer screening, and stroke evaluation. Moreover, the inpatient cost evaluation tool (ICE-T), developed by the Harvey L. Neiman Health Policy Institute®, helps radiologists understand their fair share of bundled payments. (Access ICE-T at neimanhpi.org/ICE-T.)
Undoubtedly, the ACR will continue to build tools and services that will help radiologists transition to population-based reward systems, which will become increasingly prevalent among commercial and government insurance contracts. As Yogi Berra once said, "The future ain't what it used to be." And how physicians will be paid going forward has little resemblance to how we have been paid in the past. If we prepare now, the transition to risk-based contracting will be seamless.
James A. Brink, MD, FACR, Chair
Dr. Brink would like to acknowledge the roles of McKinley Glover IV, MD, MHS, and Sandhya K. Rao, MD, of Massachusetts General Physicians Organization, and Partners HealthCare Center for Population Health, Boston, in the development of this column.