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.taking the reins

July 4th is a great American holiday. As a naturalized citizen, I love everything about Independence Day, from the national anthem to the fireworks.

I even love those hot dogs of indeterminate composition, although I feel a little queasy about the thought of consuming 69 of them in 10 minutes as Joey Chestnut, seven-time winner of the annual Coney Island 4th of July hot dog eating contest, did this year.

For the ACR economics team, however, Independence Day is not usually all about celebrating the birth of our great nation. Rather, we typically spend the 4th poring over hundreds of pages of the Medicare Proposed Rules for the Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (HOPPS). Both documents are usually released just before the holiday, and our goal is to communicate the major changes to our leadership and members as soon as possible. After that, we begin working on detailed comment letters to address our concerns to CMS, which issues the rules. Those comment letters and your comments directly to CMS have been invaluable over the years in mitigating some of the harsher reimbursement cuts for imaging services. The flood of opposition to the proposed 50 percent multiple procedure payment reduction (MPPR) for professional component (PC) payments in 2011 was certainly instrumental in persuading CMS to decrease the reduction to 25 percent, not that this was an ideal result. Our comments to CMS often seem to fall on deaf ears, but in this case, we were able to have some impact.

This year's proposed rules were a mixture of good and bad news. The overall impacts on radiology and radiation oncology services are, by CMS estimates, expected to be a 1 percent reduction for diagnostic radiology, a 4 percent reduction for interventional radiology, a 5 percent reduction for radiation oncology, and 1 percent increase for nuclear medicine. A detailed summary of the proposed rules can be found at http://bit.ly/2014MPFS.

For 2014, CMS decided not to expand the MPPR across all imaging services. While that is good news, it makes an earlier CMS decision to impose a PC MPPR on advanced imaging services seem even more specious. If, as CMS has always contended, there are real efficiencies when more than one study is read on the same day, why does this rule not apply to all modalities? ACR has steadfastly maintained that there are no meaningful PC efficiencies in these situations and that the decision was a cost-cutting move. This decision not to impose the MPPR on lower-cost services seems to support that hypothesis. That said, we certainly are happier that the MPPR was not extended to all services. We will also use this evidence of illogical decision making on the part of CMS to encourage lawmakers to support our bills in the House (HR 846) and Senate (S623) that would block the MPPR for all imaging services.

While the news is positive on the Physician Fee Schedule side, it is anything but positive on the HOPPS side, where there are unfortunate downstream effects. The formulae and cost assumptions used in deriving the payments to hospitals are complex, but suffice it to say, accurate cost reporting from hospitals is essential for appropriate payments. For various reasons, many hospitals do not report cost data separately for CT and MRI. For 2014, CMS is proposing to use FY 2011 cost data to establish payment rates for CT and MR. This will cut hospital outpatient payments for CT and MR studies by 18-38 percent and will cause various anomalies, including a drop in the technical payment for CTs that will place the payment for the procedure below that of a chest X-ray. This is obviously ridiculous, but the ripple effect is worse. Due to the provisions of the Deficit Reduction Act, payments in the Medicare PFS (MPFS) are now inextricably linked to HOPPS payments. And when HOPPS payments fall, so do MPFS technical component (TC) payments. This new cost-reporting requirement will cause the HOPPS technical payments to fall below the rates in the PFS, reducing the PFS payments to the lower level. We estimate that this will reduce MPFS TC payments by approximately 6 percent for CT and 3 percent for MRI.

The ACR has been following this issue and providing comment to CMS since 2008. In the last few months, the ACR and other radiology stakeholders met with the Office of Management and Budget and twice with Medicare's staff to discuss this problem. However, CMS has chosen to move forward and propose these changes anyway. Your vigorous response to CMS will be essential in pushing back on this misguided policy. Please check the ACR website advocacy section for how to respond.

While the MPFS and HOPPS rules are normally released just before the 4th of July, this year, we received a reprieve from CMS and were all able to enjoy the holiday. The waiting around for the rules to drop, as well as the frustration with the fact that CMS imposed policies that clearly defy logic (despite ample evidence to support the opposing view), got me thinking. Rather than be at mercy of a system that clearly wants to make fee-for-service so unpalatable, what can we do as a specialty to be less dependent on policy-makers? Rather than waiting anxiously to see what new cuts CMS is going to impose on us, how can we shape our own destiny more effectively?

Well, the good news is that we are already starting to do that. The ACR's Imaging 3.0™ initiative under the leadership if Vice Chair Bibb Allen Jr., MD, FACR, is all about enabling radiologists to tell the story of the value that we provide in delivering high-quality health care. The tools that will support this include decision support aided by peer-to-peer consultation, as well as patient-engagement methods such as web portals and more effective image sharing. Imaging 3.0 allows us to see the way forward to a higher-profile role within the care-delivery process. We must avoid being labeled as commoditized ancillary service providers, and the time to rebrand ourselves is now. You can find out more at http://bit.ly/Imaging3Tools.

Yes, there are significant hurdles to changing perceptions both within our specialty and outside it. But only when we are seen as a critical and integral part of the delivery of high-quality, value-based care can we expect to be appropriately rewarded for the services we provide.

article 2 headshotBy Geraldine B. McGinty, MD, MBA, FACR, Chair

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