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.
CMS has already achieved an earlier stated goal of tying 30 percent of payments to APMs by 2016. The vehicle to implementing this rapid transition is the Medicare Access and CHIP Reauthorization Act (MACRA) and its Quality Payment Program (QPP), but the details are still evolving. In this column, I provide background on APMs and pose several questions regarding their relevance to radiology.
Why is APM participation important to radiology?
The most favorable category of APM is the Advanced APM. To be classified as an Advanced APM, an APM must bear more than nominal financial risk, use certified electronic health record technology, and include quality metrics. Physicians with sufficient levels of APM participation are considered qualified participants (QPs), and the advantages of this status include the following:
1. QPs are exempt from the merit-based incentive payment system (MIPS), which is complex, and could result in sizable payment reductions.
2. QPs receive a 5 percent bonus on their Medicare payments from 2019 to 2024.
3. Beginning in 2026, QPs will receive greater annual increases in the conversion factor (an important determinant of payment).
What are radiology's options to participate in APMs?
In 2017, those accountable care organization tracks, that include sufficient downside financial risk are currently radiology's only option. But this circumstance could change rapidly as more APMs are introduced across multiple clinical conditions, procedural services, and medical specialties. Our facilities and other specialties practicing in those facilities could move toward APM participation. Several of these new APMs could include radiology services, giving radiology little choice to participate. Under this scenario, a radiology practice would have to determine radiology's terms of participation, financial compensationo, and level of assumed financial risk.
Who is creating and evaluating these potential new APMs?
MACRA mandated the creation of the Physician-Focused Payment Model Technical Advisory Committee (PTAC). The 11 PTAC members have been appointed, and the PTAC processes for the submission of proposed physician-focused payment models (PFPMs) were released late in 2016. The PTAC has held its first meetings and is actively evaluating several potential APMs, such as a proposal by the American College of Surgeons for bundled surgical episodes and another by the Digestive Health Network for colonoscopy in colorectal cancer screening and diagnosis. Both include radiology services in their models.
What is radiology's approach to the PTAC?
The PTAC is still relatively young, so the ACR is carefully evaluating the committee, its actions, and proposals brought before it. In the meantime, we have several questions we must ask ourselves. First, do we accept that APM participation is desirable and that radiology, including interventional and radiation oncology, can contribute to such models? If so, how aggressively do we wish to pursue the creation of a radiology-specific PFPM, and what would such an APM entail? As I described in my December column, risk can be uncomfortable, and we must evaluate the associated risk carefully. How much downside risk are we willing to assume? For instance, if we create a PFPM in which we assume accountability for follow-up of critical, relevant, or incidental findings, how much financial risk are we willing to assume? Moreover, advance APMs require the use of certified electronic health record technology. Do we have the proper tools available to us, such as registries, and the ability to enable end-to-end reporting to satisfy this requirement?
In this column, I have presented background on the APMs and posed several questions regarding APMs, that the Commission on Economics is actively pondering. I realize I have presented more questions than answers, but this a responsible approach to take at this early stage. The call to act, informed by local and national experience, as well as health policy data from organizations like the Neiman Health Policy Institute®, is upon us. How we answer these questions will have far-reaching implications for our profession. These questions should be considered in a careful, informed manner.
By Ezequiel Silva III, MD, FACR, Chair