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.

Much of the commission’s FFS efforts focus on the Medicare Physician Fee Schedule, but our activities also extend to Medicare’s Hospital Outpatient Payment System (which pays hospitals for outpatient services) and the Inpatient Prospective Payment System (which covers inpatient services). We also recognize that challenges exist with private payers as well. The challenge of maintaining payments in FFS resides on three fronts:
• Protecting existing values when they are identified as potentially misvalued
• Creating new codes for emerging and innovative technologies
• Ensuring coverage for our services with government and private payers

Policymakers continue to focus on identifying potentially misvalued services. Research confirms that radiology has been disproportionately affected by the potentially misvalued initiative. An astonishing 46 percent of noninvasive radiology codes have been identified through a potentially misvalued screen, compared with only 22 percent of other codes.2 And yet, radiology services continue to be included in discussions surrounding targeted devaluations, such as the June 2018 report of the Medicare Payment Advisory Commission.3 Therefore, the importance of defending existing values remains.

It is equally important for us to create new CPT® codes to report new and innovative services. However, even when creating new codes, we must ponder the effects on existing codes. When we create new codes, CMS requires that we also review other codes in the same family. For instance, a new code for imaging of a body part may trigger a re-review of other imaging services for that body part. Regardless of this risk, our willingness to pursue new and innovative services is high. And we have several new CPT codes that illustrate this commitment, such as fetal MRI, contrast-enhanced ultrasound, MR elastography, and ultrasound elastography.

New CPT codes do not always lead to payment. Coverage by payers and adoption by our referring physicians can be a challenge. For example, we have CPT codes for several screening services, including lung, colon, and breast. All three face challenges. Clinical adoption of low-dose CT for lung cancer screening has been slow. The reasons for this are multifold: low facility payments (technical component), decreased performance of the required shared decision-making visit by referring physicians, and even denials of coverage in independent diagnostic testing facilities. CT colonography has supportive literature, an A grade from the U.S. Preventive Services Task Force, and coverage as a preventive service under the Patient Protection and Affordable Care Act. But it remains uncovered by Medicare. Even breast cancer screening services face challenges. For instance, we face issues with coverage of digital breast tomosynthesis, along with mammography, particularly within the private payer community.

The ACR Commission on Economics is working to address these payment shortcomings, which are limiting patient access to important screening services. Our commitment to doing the same for the rest of our FFS payment systems is as strong as ever.

By Ezequiel Silva III, MD, FACR, Chair

1. Silva E. What’s Next for the Commission on Economics. ACR Bulletin. May 2016. Available at bit.ly/Econ_Commission.
2. Rosenkrantz A, Silva E, Hawkins C. Relativity Screens for Misvalued Medical Services: Impact on Noninvasive Diagnostic Radiology. J Am Coll Radiol 2017;14:1412–1418. Available at bit.ly/Relativity_Screens.
Accessed July 1, 2018.
3. June 2018 Report to the Congress: Medicare and the Health Care Delivery System. Available at bit.ly/MedPAC_Report. Accessed July 1, 2018.

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