Bundling up...In August?

The ACR economics team is focused on positioning radiologists to thrive in both existing and emerging payment models.bundled up

You might wonder why I am talking about bundling up when I hope this column finds you enjoying the warm summer weather. Well, "bundling" is quite a buzz word in health care payment policy these days. Its impact on radiologists will be far reaching and, in fact, has already been significant.

First, a little background. Bundling initially appeared on our radiology radar screens when CMS began mandating a shift from the component coding system, which we were all familiar, to bundled codes. (Read about coding in the Imaging 3.0™ toolkit at http://bit.ly/Img3Coding.) The initial targets were services commonly performed together, such as the surgical codes and guidance codes for many interventional procedures. CMS believed that component coding had inherent inefficiencies and duplication of effort. Our arguments that the component codes had been expressly developed to avoid any duplication fell on deaf ears. The initial threshold for bundled code development was 95 percent, which netted the codes for CT of the abdomen and pelvis. The result was the painful approximately 25 percent reimbursement reduction that went into effect in 2012. Inevitably, with CMS seeing the "success" of the bundling effort, reimbursement for valuable services was again significantly cut. The threshold dropped, and the most recent bundled codes were developed from codes performed together 75 percent of the time, including the codes for image-guided breast biopsy.

CMS might feel satisfied with its accomplishment, but with the breast biopsy codes in particular, it might want to think a little harder about what success means. Image-guided breast biopsy represents an advance in clinical care, with women no longer undergoing surgical procedures to either diagnose breast cancer or confirm a benign finding. Coming on top of so many other cuts in payment, some practices may be forced to reduce access to this valuable procedure or even stop performing it. Patients may have no other choice than surgical biopsy.

While our specialty's experience of bundling has been mostly at the individual-code level, that is not what most of the bundling buzz is about. Whether this is for a defined clinical episode, like a joint replacement surgery, or for the health of a population over time, as with the concept of accountable care organizations, bundled payments are touted as the panacea for aligning incentives and improving outcomes.

But think about some of the misaligned incentives our current system, particularly the focus on volume over value. It's clear that there is room for improvement. Are bundled payments the answer to all these problems? Probably not, but they are a primary vehicle for the delivery of health care reform. And because of this, your economics team is focused on ensuring that radiologists' value is recognized and reimbursed in existing and emerging payment systems.

Since bundled payments are going to be a big part of our future reimbursement schema, does it seem shortsighted for us to spend a significant amount of time and energy on maintaining our fee-for-service reimbursements? Not at all. Ezequiel Silva III, MD, FACR, vice chair of the ACR Commission on Economics, articulated this very clearly at AMCLC this year (see the presentation at http://bit.ly/UpdateRUC). As we make the transition from volume to value, most of us receive the bulk of our reimbursement under the fee-for-service system. The current value-based incentives and penalties, such as Physician Quality Reporting Systems, are paid as percentage on top of the fee-for service structure. Even in a fully integrated payment system, fee-for-service will stay play a role. Read more about the relative value unit system at http://bit.ly/RVUBulletin.

So while we are keeping a close eye on the fee-for-service system, we would be remiss if we did not also develop strategies for reimbursement of radiology services within the bundling concept. We also realize that when it comes to bundling, the RBRVS has a glaring omission: It does not recognize the value of a service in terms of the outcome it delivers, and this is where we have some great opportunities as radiologists. We have multiple concurrent efforts ongoing to carve out a place for radiology in this model. I'm excited about the Neiman Health Policy Institute's research into screening payment models that capture not only the initial event but also any downstream imaging over a defined time period. This type of bundled payment could provide not only an opportunity to advocate for a no-cost-sharing payment for our patients (which may improve compliance) but also a way to capture and reimburse the types of Imaging 3.0™ activities that are essential to good care. We continue to collaborate with outside stakeholders, such as the Brookings Institution, so that our voice is heard on how specialists should be recognized in new payment models. After a day-long meeting at ACR headquarters this spring, we concluded that compared to other specialties we are actually ahead of the process. While there is no magic bullet, we are on the right track with our focus on the patients and our clear stance on appropriate imaging.

As always, I'd love to hear your feedback at This email address is being protected from spambots. You need JavaScript enabled to view it. and encourage you to follow me on Twitter at @DrGMcGinty.

dr mcgintyBy Geraldine B. McGinty, MD, MBA, FACR, Chair

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