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
The ACR has already been affected by this move to improve process measures, create more outcomes measures, and decrease the number of measures altogether. Each year, the ACR National Radiology Data Registry must be re-approved as a CMS QCDR, a process we completed earlier this year. This process has become more challenging, as our QCDR measures (referred to as non-MIPS measures) are subject to greater scrutiny. At the same time, the ACR is expected to craft new MIPS measures for CMS’ consideration.
To understand our challenge in defending our measures, let’s first discuss how process measures and outcomes measures differ. Process measures reflect generally accepted recommendations for clinical practice. For example, MIPS Measure 146 relates to the inappropriate use of BI-RADS® category 3 during screening mammograms. Outcomes measures reflect the impact of a service or intervention on the health status of the patient. MIPS Measure 421 is an outcomes measure that pertains to three-month follow-ups for inferior vena cava filters for potential removal.
Most radiology quality measures are process measures. Remember that when the MIPS quality category’s predecessor, the Physician Quality Reporting System, was created in 2007, it was a claims-based system. In other words, CMS relied on billing claims in order to document measure performance, which generally favored process measures.
A challenge with process measures is that many are reported successfully at such a high rate, they are topped out. This puts them at risk for removal from MIPS altogether. For those that remain, a lower number of points within the quality category is allowed.
Despite these challenges, process measures are not going away. Process measures just need to be improved. And to that end, the ACR Quality Measures Technical Expert Panel continually drafts new, and more useful, process measures. Creating outcomes measures is more difficult. Generally, clinical outcomes are the result of numerous factors beyond a single intervention, so creating single-specialty outcomes measures is a challenge.
And what about the push to decrease the number of measures? At first glance, this would seem to be a good thing. After all, who doesn’t want to see the regulatory burden of MIPS decrease? But we need to be careful. MIPS requires that radiologists report six quality measures annually. This is easy enough when sufficient measures are available to us. But CMS recently tried to consolidate several of our measures, including our turnaround time, breast screening, and dose monitoring measures, moving from 12 to only three. We were able to successfully maintain these individual measures. However, CMS’ rapid review and consolidation risks leaving an insufficient number of measures to report under MIPS.
The ACR has been vocal in expressing our concerns regarding measure evolution. CMS must be more thoughtful and systematic in its approach to measures. Retaining meaningful process measures and introducing new, worthwhile ones will allow radiology to thrive under this new system. To make this happen, the specialty societies need time to develop measures, including the outcomes measures being championed. The ACR is moving forward with the knowledge that meaningful measures are here to stay, and the economics team is preparing members for success as the system evolves.
1. Remarks by CMS Administrator Seema Verma at the Healthcare Payment Learning and Action Network Fall Summit. Available at bit.ly/CMS_Speech. Accessed Jan. 3, 2018.
By Ezequiel Silva III, MD, FACR, Chair