Naughty or Nice

Which list will CMS be on this holiday season?

CMS Naughty or Nice, ACR Bulletin, December 2014

Performance-based incentives are nothing new and are certainly not unique to health care.

When I was growing up, my parents leveraged the power of Santa Claus to change our behavior to great effect. As we’d write our letters to the man at the North Pole, we were well aware of the link between pay and performance! Nice children would find toys and treats in their stockings on Christmas morning, whereas those who’d been naughty could expect only a lump of coal.

I no longer write a letter to Santa Claus these days, but this December I will certainly be reflecting on who’s been nice this year and who deserves a lump of coal in their stocking. One of the difficulties of writing this column so far in advance is that some who have in the past been less than nice may have changed their tune come December. I know I often did! So I’m going to hope that CMS has made the right call on a number of very important decisions for our profession and, much more importantly, for the health of the patients we serve.

As I write in late September, more than 70 organizations (including the American Cancer Society, Lung Cancer Alliance, Society of Thoracic Surgeons, and American Thoracic Society) had joined the ACR in sending a letter to CMS urging coverage for screening for lung cancer with low-dose CT. I’ve written in an earlier column ( about the randomized controlled trial that demonstrated the benefits of lung cancer screening with CT so effectively that it was stopped early. This was endorsed by the USPSTF in August 2013 with a B grade recommendation, meaning under the terms of the Affordable Care Act private insurers must pay for the service in 2015. Unfortunately, this mandate does not apply to CMS, which has had wiggle room in deciding whether or not to cover the service. By the time you read this, we will know whether CMS has decided to extend this life-saving benefit to our seniors or to effectively hand them a lump of coal.

I’m certainly also hoping that CMS has decided to delay its proposal to stop paying for the costs associated with film and instead equate the costs of a PACS system to those of a desktop computer. Everyone likes a bargain, especially around the holidays, but that’s ludicrous. Try buying a PACS system for what they’re charging at Best Buy for computers these days and you’ll get as much performance as when my dad forgot about the “batteries not included” for the Barbie sports car.

Joking aside, there is nothing funny about this policy that could cost us a 10 percent overall reduction in payments. In response to the Proposed Rule, we assembled a team of informatics and industry experts, met with CMS, and committed to work together to bring the practice expense database into the 21st century with inputs appropriate to the costs of building a safe, effective PACS system. I hope CMS has made the right decision in the Final Rule.

In the spirit of being nice, however, we recognize the need to collaborate with the payer community and we continue to work collaboratively with CMS on issues of HOPPS billing and quality measures. This year we took a big step toward making participating in value-based payments easier for members when CMS accepted the ACR’s National Radiology Data Registry as a Qualified Clinical Data Registry (read more at In essence, this makes the NRDR a one-stop shop to qualify for the increasingly important value-based payments offered by Medicare. That’s quite a holiday gift.

One of the most fallacious policies applied to imaging over the past few years has been the multiple procedure payment reduction for our professional services as radiologists. At time of writing, we’re still waiting for CMS to follow Congress’ mandate to divulge the logic used to derive this reduction. Unfortunately, there has been some naughty behavior from commercial insurance companies who, seeing a chance to save money, have proposed implementing the same erroneous reduction. Private payers, we’re watching you and you’ll be hearing from our members and our patients if you try to fob them off with cut-price care.

There is a lot of cynicism about our Congress these days, but in my book they are still on the nice list because of a landmark piece of legislation that will mandate the use of clinical decision support for advanced imaging in the Medicare program effective 2017.  Read more about this at Lawmakers recognized radiologists’ unique ability to deliver value through managing appropriate use of imaging, and this will be a gift that keeps on giving to our patients and the U.S. health care system for a while. Not only will it reduce costs in the system but it will improve care. That’s nice.

Looking within, how have we been doing? Even those of us who don’t celebrate Christmas can use the shorter days and the closing of the year to reflect on the year’s accomplishments and areas for improvement. I am fortunate to meet many radiologists as I speak around the country, and I am so proud of our profession and the way we have
 embraced uncertainty and change this year. We hear that the future will inevitably involve these two disruptive forces, and it would be so easy to give in to doom and gloom. Is there anxiety? Sure. With continued payment cuts, it’s inevitable. But as a professional community, we have taken a clear stand for our patients, the reason we all do what we do, and I see this supporting and sustaining us through these challenging times.

So how would I ask Santa (who is definitely real, by the way, in case my niece and nephew Emma and Connor in Park City are reading this) to reward us? Well, since Santa and his elves make toys, not payment policy, we’ll leave them to their very important work this Christmas. But I’d ask policy-makers and payers to recognize the unique value that we as radiologists can deliver to our patients and to make sensible policy decisions that incentivize that value. That’s not too much to ask, is it?

As always, you can reach me at This email address is being protected from spambots. You need JavaScript enabled to view it. and I encourage you to follow me on Twitter at @DrGMcGinty.

Geraldine B. McGinty, MD, MBA, FACRFrom the Chair of the Commission on Economics
By Geraldine B. McGinty, MD, MBA, FACR, Chair


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