FFS and value-driven care are continuing to evolve — creating challenges and opportunities for physicians and institutions.
Fee-for-service (FFS) has been the primary determinant of physician payment for decades. FFS is relatively simple. The doctor does something; the doctor is paid for it. This yields several advantages. The system directly pays the physician who performs the service, the payment is based on the required resources to perform it, and the payment amount is transparent and predictable. Despite these advantages, FFS has been criticized due to the following two main shortcomings: FFS incentivizes overutilization, and payment is not tied to quality. Over the past 12 years, these shortcomings have resulted in a policy pursuing value, built around lowering cost (reducing utilization), and increasing quality.
The Economics of Social Need
Policymakers and payors are recognizing the importance of social determinants of health.
What does it take to keep people healthy? Certainly, high-quality clinical care is important. But the relative contribution of clinical care is lower than we think. Data suggests that clinical care impacts only 10–20% of overall health.1 Think about that for a moment. Clinical care addresses only a small percentage of population health. About 80–90% of overall health is determined by social determinants of health (SDOH).
A Review of Rule-Making
The Commission on Economics has provided rule-making comments for decades.
One of the core activities of the Commission on Economics is engagement with CMS on Medicare payment policy. This occurs on multiple fronts, but it largely centers on the regulatory, rule-making process. CMS is required to share updates to its payment systems through annual proposed rules, a process which allows for a public comment period before a final rule is released. Any member of the public may submit comments, and the ACR does so on behalf of our members and the radiology profession. Proposed and final rules are released for the Medicare Physician Fee Schedule (MPFS), the Quality Payment Program (QPP), the Hospital Outpatient Prospective Payment System, and the Inpatient Prospective Payment System, among others. The Commission reviews each of these documents. This task is not a small one. Every year, CMS releases around 10,000 pages of rule-making documents. For 2020, the MPFS and QPP Notice of Proposed Rule-Making (NPRM) document is more than 1,700 pages long.
Appropriate Use Criteria:
Claims and Billing Guidance Arrives
CMS is committed to advancing AUC, motivating radiologists to implement the program.
On July 26, CMS released two documents updating the Appropriate Use Criteria (AUC) program, mandated by PAMA.1,2 The document restates the implementation timeline from previous CMS communications, including last year’s Medicare Physician Fee Schedule Final Rule. The anticipated guidance on billing claims is provided below. The education and operations testing period begins on Jan. 1, 2020, with full implementation of the AUC program expected Jan. 1, 2021.
The Economics of the Hippocratic Oath
When we discuss healthcare economic principles with patients, we build upon their trust in us.
“I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.”
Delving Into Radiologist Payment Policies
The ACR 2019 Economics Forum focused on MACRA, CPT® code valuation, Medicaid payments, and other topics.
ACR 2019 included a half-day Economics Forum, organized by the ACR Commission on Economics. I wish to thank the faculty who contributed, as well as the audience who made the session interactive and thought-provoking. Here are the three themes that emerged from this year’s forum:
How Did We Do in Year One?
The results are in for radiology-specific Quality Payment Program performance for 2017.
The first performance period of the CMS Quality Payment Program (QPP), affecting 2019 payments, took place in 2017. In February 2019, I wrote about broad multispecialty trends under the QPP from 2017. This included scoring and performance under the Merit-Based Incentive Payment System (MIPS). In that column, I communicated that the median score across all eligible clinicians was 89 and that 93 percent of eligible clinicians and that 93 percent of eligible clinicians received some bonus payment. Simply put, physicians performed well.
In this column, I will focus on the recently released CMS specialty and geographically specific data (see below). I will comment on two of the performance categories used to determine our final MIPS score: Quality and Improvement Activities (IA).
The Times They Are a-Changin’
We must build an infrastructure and commit resources to respond to a fluid political climate.
AUC: A Brief History
With PAMA, the radiologist’s challenge now centers on implementation.
QPP in Year 1
How did radiologists do in the first performance year?
New Year, New Codes
Radiology has the greatest number of new CPT® codes in recent years.
Evaluation and Management Codes Are Relevant to Radiology
Recent CMS changes could have primary and secondary consequences for the specialty.
Our Continued Commitment to Fee-for-Service
Volume-based payment remains important to radiology's growth,
and the ACR is committed to protecting it.
I became chair of the ACR Commission on Economics in 2016. At that time, my first ACR Bulletin column described several guiding principles for the commission, one of which was protecting our place in fee-for-service (FFS) payment systems. Since then, most of my columns have centered on value-based payment systems.1 My focus on new payment models makes sense, because the rules and regulations associated with the MACRA-created Quality Payment Program are evolving quickly. We will be affected. But I would not want there to be the impression that our commitment to protecting legacy payment systems has lessened during that time. As I have stated before, FFS payment systems will remain a significant contributor to our revenue and will form the basis for new payment models for the foreseeable future. As such, our commitment is as strong as ever.
What Is the QQ Modifier?
Here’s a look at the new clinical decision support mechanism modifier.
The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program under which an ordering provider of advanced diagnostic imaging studies must consult a clinical decision support (CDS) mechanism at the time of ordering. The program is slated to begin on July 1, 2018. This date is the start of a voluntary participation and reporting period using a new Healthcare Common Procedure Coding System modifier, “QQ.” This column describes how billing claims will occur during this voluntary reporting period and provides background on the broader move toward full CDS implementation.
The Slowing of the Quality Payment Program
What does the delay in implementation mean for your practice?
In 2015, MACRA was introduced to considerable fanfare. The new legislation replaced the Sustainable Growth Rate physician payment formula with the Quality Payment Program (QPP). MACRA promised to stabilize physician payments, consolidate and simplify quality reporting programs, and provide a useful on-ramp to new value-based payment models. The legislation passed with overwhelming bipartisan support in both houses of Congress.
The Economics of Population Health Management
Elevating radiology’s role in these initiatives may require greater integration and accountability.
The ACR Commission on Economics supports population health management (PHM). That may be the easiest position I have ever taken as chair of the commission. After all, who doesn’t want our population to be healthier?
The ACR Commission on Economics supports the Commission on Quality and Safety as we move toward meaningful measures.
Radiologists are being scored on more measures than ever before. For instance, the Merit-Based Incentive Payment System (MIPS) scores us on four performance categories, which include 271 quality measures (plus 30 more if we were to include the ACR Quality Clinical Data Registry [QCDR]), two cost measures (with more episode-based cost measures to come in 2019), 15 Advancing Care Information measures, and 93 improvement activities. That totals 411 measures. Granted, not every one of these measures applies to radiology. But you get the idea — that’s a lot of measures. CMS administrator Seema Verma, MPH, agrees. In the fall of 2017, she stated, “We have too many measures. We are measuring processes and not outcomes…And we’re announcing today our new comprehensive initiative, ‘Meaningful Measures.’”1
Proper Coding of Diagnoses and New Payment Models
ICD-10 diagnosis codes inform risk adjustment, an increasingly important determinant of payment under the CMS Quality Payment Program.
Billing for radiology services requires two main billing codes: Current Prodedural Terminology (CPT®) codes and ICD-10 diagnosis codes. CPT codes describe which service was done, and ICD-10 codes describe why it was done. For example, a brain MRI claim may include the CPT code for the MRI itself and the ICD-10 code for acute stroke. Historically, greater focus has been placed on accurate CPT codes to ensure maximal, but still compliant, payment. Diagnosis codes have been necessary, but the complexity and number of diagnosis codes associated with claims have not directly affected payment amounts. This circumstance is changing. Under new payment models, payment amounts can vary with the level of illness of patients, informed by ICD-10 diagnosis coding. This shift is relevant to radiology, since making diagnoses is at the core of what we do.
Cost — Rarely Understood but Highly Relevant
Practices may review their Quality and Resource Use Reports to better understand how they are doing with cost.
Cost, cost, cost. More and more, we hear that physicians are being held accountable for cost.
The Importance of Speaking Econ
Economic terms are complex, but learning how to apply them can pay dividends.
The language of radiology is complex and, in many ways, different from the language of the rest of medicine. This difference has immediate implications for our profession.
Navigating the Site-Neutral Payment Debate
As policymakers craft site-neutral payment policies, the ACR considers its strategies.
Medicare and private insurers commonly pay more for a service in the hospital than they do in the office. For instance, a lumbar spine X-ray pays almost five times more in the hospital than the office.
2018: More Transitions and Opportunities for Preparation
In the coming year, let’s get involved and start reporting clinical decision support codes and patient-relationship categories and codes.
In last month’s column, I described 2018 as being a transitional year for the new Medicare Quality Payment Program (QPP). The following two other important CMS initiatives are also transitional in 2018 and should be on our radar: appropriate-use criteria (AUC) for ordering and patient-relationship categories and codes. We can use this transitional year to delay action or to prepare. I suggest that we take advantage of this time to test implementation strategies and to gain experience — without having to worry about potential payment reductions. The ACR Commission on Economics will continue to lead in preparing members for these upcoming mandates, and it will also work with policymakers to ensure a successful implementation.
Radiology Considerations Under Year Two of the QPP
CMS is calling on physicians to ramp up their QPP participation in 2018.
Next year, 2018, is the second transitional year for the Quality Payment Program (QPP) before full implementation in 2019. CMS still offers the “pick your pace” option for level of participation.
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.
The Cornerstone of Radiology Economic Policy: Our Volunteers
The members of the ACR Commission on Economics make far-reaching contributions to health care.
As the chair of the ACR Commission on Economics, I lead more than 700 devoted volunteers. This column allows me to thank these volunteers and invite more ACR members to join us.
How We Got Here
Radiologists in the United States have a history that is different from that of other physicians — and understanding this history is important to the future of radiology.
Health care and payment policy are evolving rapidly in this country. New laws and regulations are voluminous, and the decisions we make are far-reaching.
MACRA and Informatics
How do technology tools factor in to new reimbursement models — and what does it all mean for radiology?
As I'm sure you've heard, 2017 is the first performance period of the MACRA-derived Quality Payment Program (QPP). The QPP includes two payment pathways, and almost all radiologists will be scored under the Merit-Based Payment System (MIPS).
TBD: Radiology's Role in Alternative Payment Models
Radiology must evaluate its role in the rapid evolution to alternative payment models.
Fifty percent of all Medicare payments will occur through alternative payment models (APMs) by 2018. This ambitious goal was first introduced by the secretary of the Department of Health and Human Services early in 2015.
Patient Experience and Payment Policy: One and the Same
The Commission on Economics is committed to ensuring opportunities for radiologists contribute to an improved patient experience.
Continually improving patient experience is what we strive for; it is the right thing to do. But if that were not motivation enough, policymakers have made patient experience an integral component of radiology payment policy.
The Highs and Lows of Lung Cancer Screening
All eligible patients should have access to lung cancer screening.
Screening studies are among the most important services radiologists provide. Our ability to deliver these services requires scientific evidence that demonstrates improved outcomes.
Pick Your Pace Under MACRA
The ACR Commission on Economics stands ready to provide tools for radiologists to achieve Quality Payment Program Success.
The Medicare & Chip Reauthorization Act (MACRA), now referred to as the Quality Payment Program (QPP), will impact radiology payments beginning in January 2019. But the performance period for 2019 started on January 1, 2017. Well, sort of.
Want to Get Paid More? Take Some Risk.
The ACR Commission on Economics is evaluating the role of risk in expanding alternative payment models.
Practicing radiology is risky. Running a radiology practice is risky, given not only the capital-intensive nature of what we do but the complicated regulatory environment that surrounds us.
The Challenge of Protecting Mammography
The ACR Commission on Economics continues its efforts to maintain the economic viability of mammography services.
The coding and payment structure for mammography services changes on Jan. 1, 2017. Over the past three years, the Commission on Economics has worked to ensure the best outcomes for mammography services.
More than 140,000 clinicians will be transforming their practices over the next four years. The ACR Commission on Economics wants radiology engaged.
"Better care, smarting spending, and healthier people." CMS has committed $685 million to support these important goals through the Transforming Clinical Practice Initiative (TCPi). It is imperative that we are engaged in this effort. In this column, I describe ways in which radiology can participate.
Are We Ready for Round Two of ICD-10?
It’s time for every radiology practice to identify its ICD-10 champion.
We survived round one of the ICD-10 implementation. As you've probably heard, ICD-10 is the revised system for diagnosis coding.
New Chairs, Same Mission
As the cast of volunteers evolves, the Commission on Economics continues to work to maintain payments and ensure radiology’s place in future payment systems.
The Commission on Economics thanks the outgoing chairs and welcomes the new chairs who will lead the following important committees: Managed Care, the Radiology Integrated Care (RIC) Network, Interventional Radiology (IR), Academic Radiology, and Reimbursement (RUC). I discussed our new MACRA Committee and its chair, Greg Nicola, MD, in last month’s July column.
Understanding Episodes of Care
The Commission on Economics is working to define radiology’s place in episode groups.
What role does radiology play in clincal care? This is a wide-open question with multiple potential answers.
The New MACRA Committee
The Commission on Economics goes into operational mode as it approaches new payment models.
The Commission on Economics has known for years that a transition from volume- to value-based payment is inevitable. As early as 2001, “Crossing the Quality Chasm: A New Health System for the 21st Century,” a report published by the Institute of Medicine, called for “aligning payment policies with quality improvement” and “bundled payments for priority conditions.”
What’s Next for the Commission on Economics
The College is charting a course for success in a changing world of reimbursement and incentives.
This is my first column as incoming chair of the ACR Commission on Economics.
MACRA: One Year On
MACRA’s first anniversary is upon us. Where are we now?
It’s hard to believe that a year has elapsed since the overwhelmingly bipartisan passage of the MACRA (Medicare Access and CHIP Reauthorization Act) legislation that repealed the Sustainable Growth Formula and set us on an accelerated trajectory toward value-based payments.
Beating Back the MPPR
A recent decision from Congress rolls back one of radiology’s most maligned reimbursement cuts.
We’ve faced arbitrary cuts to the reimbursement for imaging services in recent years, but none rankled quite as much as the multiple procedure payment reduction (MPPR) for the professional component (reimbursement for the interpretation of images).
Keeping Patients at the Forefront
As the health system shifts, radiologists must stay in tune with the needs of their patients.
As I write, open enrollment season is closing and many of our patients are selecting their health insurance plans for 2016. Five years after the signing of the Affordable Care Act, we have seen the number of uninsured Americans drop significantly. There have been, however, concurrent significant changes in the design of health care benefit plans.
CMS has postponed the deadline for clinical decision support. But change is coming, and radiologists will be at the forefront.
We've heard the rallying cry so many times now that it almost feels cliché. We need to stop rewarding volume and start prioritizing value in health care. Last spring, Sylvia Burwell, secretary of Health and Human Services, announced an ambitious target — 90 percent of Medicare payments will be tied to value by 2018.
Getting Specific About Patient-Centered Care
The chair of ACR’s newest commission looks at where radiology fits into value-based health care.
For my column this month, I spoke with James V. Rawson, MD, FACR, about his latest role at the ACR, as chair of the brand new Commission on Patient Experience. I’ve worked with Jim for several years in his role as chair of our Committee on the Hospital Outpatient Prospective Payment System (HOPPS) and treasure him as a colleague and friend.
Happy Birthday,Medicare and Medicaid!
Fifty years after their inception, both programs continue to evolve with the shifting health care landscape. Where do radiologists fit in?
This summer retired U.S. Senator Bill Frist, who (as most of you know) was a practicing physician before entering politics, and Drew Altman, president and CEO of the Kaiser Family Foundation, wrote an excellent overview of the Medicare and Medicaid programs in JAMA.
With new payment models throwing health care into transition, now is the time to remember why we became physicians in the first place.
It’s August and I hope that you all are enjoying at least a little downtime this summer. Even my hectic adopted city of New York is quieter these days, and it’s a good time to recharge the batteries.
Medicare’s Proposed Rule for 2016
Changes are just around the corner.
Medicare published the Proposed Rule for 2016 later than usual. Typically it’s issued just before the July 4th holiday, but this year it dropped almost a week later.
Value-based payments are coming. How is the ACR positioning radiology for success in this new system?
On April 16, 2015, President Obama signed into law a potentially game-changing piece of legislation related to radiology payment policy.
We’re Stronger Together
As we gather for ACR 2015, our message is magnified by our numbers.
"Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has." —Margaret Mead
Lung Cancer Screening Update
As this valuable coverage rolls out to patients, the Commission on Economics works to tie up loose ends with CMS.
On April 6, Dr. Ella A. Kazerooni and I gave a webinar on lung cancer screening. More than 1,500 people signed up for the webinar. We were able to accommodate only 1,000, so a recorded version is available.
Patients and Pricing
Educating our patients about the true costs of imaging reaps benefits throughout the health care system.
I've written before about how we need to take a leadership role in helping our patients understand the value of the care and services we provide as radiologists.
Answer these questions to uncover your superpower and conquer your kryptonite.
I know that none of my esteemed readers ever spends time on the Internet looking at cute cat videos or taking those Buzzfeed quizzes that reveal the answers to life's important questions, like "How Well Do You Know the Thanksgiving Episode of 'Buffy the Vampire Slayer'?"
Out with the Old, in With the New?
The 2015 Final Rules hint at what's to come in the year ahead.
The commission on economics always meets face to face at RSNA, and this year we used the ACR’s new strategic plan to develop our priorities for the year ahead.
Naughty or Nice
Which list will CMS be on this holiday season?
Performance-based incentives are nothing new and are certainly not unique to health care.
Eating Our Seed Corn
Our youngest members are entering practice amid tectonic changes in the landscape of medicine. How are we supporting the next generation of radiologists?
One of the most rewarding aspects of my job as chair of the Commission on Economics is the work I do with the Resident and Fellow Section.
Imaging 3.0™: Where Are We Now?
Taking stock as the radiology wide initiative takes hold and transforms the specialty
In last october's column, I wrote about how Imaging 3.0™ had taken hold across the profession. A year later, I'm pleased to report that it is embedding itself in our culture and informing every activity of the College.
Bundling up...In August?
The ACR economics team is focused on positioning radiologists to thrive in both existing and emerging payment models.
You might wonder why I am talking about bundling up when I hope this column finds you enjoying the warm summer weather. Well, "bundling" is quite a buzz word in health care payment policy these days. Its impact on radiologists will be far reaching and, in fact, has already been significant.
Get to Know Your CFO
Establishing relationships with leaders in your health system can be beneficial for both your department and your patients.
For those of us who work within a hospital system, its corporate leadership can seem very far away from our daily lives. The so-called C-suite (home to the CEO, CFO, CMO, and COO, depending on the local vernacular) often seems to exist on a different planet than the reading room.
A Commitment to Doing It Right
The ACR advocates to bring lung cancer screening to patients in need.
Last December, the United States Preventive Services Taskforce (USPSTF) finalized its recommendation and gave a grade of B to lung cancer screening with low dose CT.
The Price is Right
A comparison of out-of-pocket costs reveals the complexities of imaging pricing.
When does an x-ray cost more than an MRI? I found out recently, when a relative of mine needed both for a sports injury.
Part of the Solution
As the health care system shifts, radiologists are on the frontlines of patient care — but ongoing reimbursement cuts from CMS are hampering physicians and will ultimately affect patients.
As radiologists, we’re all well aware of, and fully on board with, the need to deliver highvalue health care at a lower cost. We’ve been singing from the quality hymnal for years through our leadership in accreditation and evidencebased imaging.
Preparing for the Future
The RFS Journal Club brings together members-in-training to learn about radiology economics now and going forward.
I often hear from radiology residents that they’d like to be more involved in the College’s economics advocacy efforts and that they need to know more about the payment policy process.
As 2013 comes to an end, have we met our goals?
Last January my column was titled “Realistic Resolutions.”(Read the article at http://bit.ly/DrGResolutions.) I talked about ways that we as radiologists could take concrete steps to demonstrate our value. So as we head into 2014, where are we as a specialty, and are those resolutions still relevant?
As we await decisions on CMS policies, radiologists wonder what will be on the table this holiday season.
As I write this column in mid-September, I wish I had a crystal ball. Will we as radiologists have much for which to be thankful when the November Bulletin is printed?
Radiologists nationwide breathe life into Imaging 3.0™.
Imaging 3.0™ was launched at the 2013 AMCLC as a way for radiologists to demonstrate their value in the new health-care world. Now, five months later, where are we in telling and living this important story?
Back to School
While many individuals have filled the past few months with summer fun, the ACR has been busy innovating.
Who can forget that "back to school" feeling? Starting a new school year was always energizing for me, even if there was some regret that the lazy days of summer were over.
Taking the Reins
As the ACR economics team responds to the latest releases from CMS, radiologists ponder ways to enhance their role in care delivery.
July 4th is a great American holiday. As a naturalized citizen, I love everything about Independence Day, from the national anthem to the fireworks.
A Jolly Good Fellow
The College's collective voice is a powerful and influential tool.
By the time this column reaches you, I will have recently joined the ranks of ACR's Fellows. ACR Fellowship recognizes members who "demonstrate a history of service to the College, organized radiology, teaching, or research."
Radiology's Unlucky Number
Understanding the story behind CPT® Code 73721 and what it means for the future medical reimbursement.
CPT® code 73721, non-contrast lower extremity MRI, is the poster child for what has happened on the technical side to radiology reimbursement in the past seven years.
A Tale of Two Radiologists
Let's take advantage of the incentives we have before we lose them.
It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us. — Charles Dickens
A Fiscal Cliffhanger
Don't let political shenanigans distract you from what's truly important — your patients.
I was lucky that in the aftermath of Hurricane Sandy, I only lost my car. So many others' lives were devestated, and many are still recovering.
This year let's set some goals that will benefit our patients, our practices, and our specialty.
If, like me, you make (and break) the same old New Year's resolutions every year, maybe it's time to think differently for 2013.
Challenging ourselves to meet the service expectations of our patients.
I came across an opinion article in the New England Journal of Medicine that I thought had some valuable lessons for radiologists.
What Constitutes a Session?
"I know it when I see it." The phrase became famous in 1964, when U.S. Supreme Court Justice Potter Stewart used it to describe his threshold test for obscenity in Jacobellis v. Ohio.
Déjà Vu All Over Again
When you work at Montefiore Medical Center in the Bronx you pretty much have to be a Yankee fan.
One Size Does Not Fit All
My practice is located on Long Island, New York, and is a largely outpatient multi-specialty and multi-site group, in which 35 of the 65 doctors are radiologists. There, my own role is to exclusively interpret breast imaging.
Taking the Torch
My first column as chair of the ACR Commission on Economics provides an opportunity to survey the landscape and set out our priorities for the months ahead.
Preparing For Transitions
The work of the Commission on Economics is one of several major ways we provide value to its members and our specialty.
Modest victories over Medicare’s irrational payment policies could pay off in the future.
As public policy makers have looked for ways to pay for the ever-increasing costs associated with the Medicare system over the past decade, there have been a number of policy decisions both in Congress and CMS that have specifically targeted and negatively impacted radiology.
Finding Ways to Demonstrate Value
New committee promotes and coordinates efforts to measure the importance of imaging.
To allow the College to play an integral role in coordinating imaging health-policy research, I am pleased to announce that John A. Patti, M.D., FACR, chair of the ACR Board of Chancellors has recently approved the request of the Commission on Economics to create the ACR Committee for Imaging Health Policy and Economics Research (CIPER).
Continuing the Fight
CMS finalizes 25 percent professional component multiple procedure payment reduction.
By the time this article is published, the Super Committee will have provided its report on Medicare payments to physicians, and imaging-specific legislation may have been passed.
CMS Finalizes Payment Reductions
In the Final Rule for the 2011 Medicare Physician Fee Schedule, the CMS finalized its proposals for reduced Medicare payments for imaging services discussed in the notice of proposed rule making.
The Congressional Forecast for Radiology
2010 was another hectic year of the Economics and Government Relations Department. With the election of Sen. Scott Brown, R-Mass., to the U.S. Senate last January, many believed that comprehensive health-care reform legislation could not be passed.