Sea Change

On the journey toward Medicare’s new Quality Payment Program, preparation is half the battle.sea change

The future is now. Ready or not, the era of value-based payment is upon us.

The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) introduced a new Quality Payment Program (QPP) under which physician payments are linked to quality measures.

Although the first payment adjustments won't occur until Jan. 1, 2019, reporting for the first year of QPP begins in 2017. It's time to adjust your sails.

What Is QPP?

The new payment paradigm is further away from fee-for-service than ever before, says Gregory N. Nicola, MD, chair of the ACR MACRA committee and vice president of the Hackensack Radiology Group in Hackensack, N.J. "For most radiologists, payments will be heavily tied to quality. Not only will there be a major transformation in payments, but also in practice."

According to CMS, QPP is designed to improve Medicare by helping physicians "provide better care and smarter spending for a healthier America." Under QPP, physician payments are linked to quality measures through two pathways: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

"Radiologists are left wondering which of the pathways they should be following," says Ezequiel Silva III, MD, FACR, chair of the ACR Commission on Economics. "Unless you're a radiologist already in an accountable care organization, the APM model likely won't apply to you in 2017. Initially, the performance of most radiologists will be evaluated under MIPS."

How Does MIPS Work?

MIPS replaces existing CMS quality programs (PQRS, the Value Modifier quality measurement, and Meaningful Use) with four new components: quality, clinical practice improvement activities, advancing care information (ACI), and resource use. MIPS also streamlines the value-based program by reducing the number of required quality measures and providing flexible participation options for 2017.

Participants in MIPS earn a performance-based payment adjustment to their Medicare payment, which can either be a bonus or a penalty of up to 4 percent in 2019. The payment adjustment increases over time until it caps out at 9 percent. MIPS allows clinicians to be paid or penalized based on their success in four performance categories that are weighted as follows for 2017:

Quality: 60 percent for the 2019 payment year, 50 percent for the 2020 payment year

Under QPP, CMS reduced the reporting threshold for quality measures from nine (under prior programs) to six and eliminated the requirement to report across three National Quality Strategy domains. Of the six measures reported, one should be an outcome measure. If an outcome measure is not available, then another high-priority measure should be reported. CMS also removed the requirement for reporting a cross-cutting measure by any clinician.

Cost: 0 percent for 2019, 10 percent for 2020 and 30 percent for 2021 payment years

For all MIPS-eligible clinicians, CMS set the cost category to zero, thereby exempting the category from the performance criteria for the first performance year (2017). CMS will still calculate cost measures with the intent of providing clinicians with feedback regarding their cost performance during the first year.

Advancing Care Information: 25 percent for the 2019 payment year

CMS will likely reweight the majority of ACR members to zero for the ACI category based on their classification as non-patient-facing eligible clinicians and hospital-based eligible clinicians. In such cases, the quality category would have a weight of 85 percent.

Improvement Activities: 15 percent for the 2019 payment year

Non-patient-facing MIPS-eligible clinicians will be expected to report one high-weighted or two medium-weighted activities to meet the full performance criteria. CMS included a list of over 90 possible quality improvement activities, which are now available on the QPP website (check it out at Participation in the Transforming Clinical Practice Initiative (TCPi) — including ACR's Radiology Support, Communication and Alignment Network (R-SCAN™) — is considered a high-weighted improvement activity.

The statute allows considerations for non-patient-facing clinicians who may not have measures to report into all of the MIPS performance categories. In the final rule, CMS defined non-patient-facing "as an individual MIPS-eligible clinician who bills 100 or fewer patient-facing encounters" during the period. For more information about patient-facing definitions and requirements for individuals and groups, visit

When Does QPP Start?

The first reporting year (2017 performance year, 2019 MIPS payment year) will be treated as a transition year with reduced performance thresholds. You can "pick your pace" for participating in QPP during 2017 to avoid negative payment adjustments in 2019:

1. Test QPP. Clinicians submitting partial data (including data after Jan. 1, 2017) will avoid a negative payment adjustment.

2. Participate for part of the calendar year. You can choose to start any time between Jan. 1 and Oct. 2, 2017. Clinicians who submit data for a minimum of a continuous 90-day period may qualify for a small positive payment adjustment.

3. Participate for the full calendar year. Clinicians who began reporting QPP information in Jan. 1, 2017, may qualify for a positive payment adjustment.

4. Participate in an Advanced APM. In lieu of reporting quality data under MIPS, clinicians receive a 5 percent positive payment adjustment in 2019 if enough Medicare patients or payments are performed in an Advanced APM.

Whatever pace you follow, you must submit your performance data by March 31, 2018. If you don't submit any data for 2017, you will receive a negative 4 percent payment adjustment.

Will There Be Winners and Losers?

In an article in The Economist in 2003, writer William Ford Gibson famously said, "The future is already here — it's just not evenly distributed." That axiom certainly holds true for radiologists under QPP, which either rewards or penalizes you based on how well you perform in comparison to other participants.

"QPP is a budget-neutral program," says Nicola. "So the 'winners' are taking from the 'losers'. If a practice succeeds, it gets an extra payment, which comes from a practice that did not succeed. It's important for radiology groups to know there will be a redistribution of Medicare payments from groups that don't make value-based changes to groups that do."

As a result, Silva emphasized, QPP is poised to drive a transformation in how radiologists practice. "QPP will require a significant culture shift — a sea change in the mindset among radiologists," he says. Silva adds, "Bibb Allen Jr., MD, FACR, recently said, 'You can't read your way out of this one.' Radiology practices have to change their thought processes to allow radiologists time for quality activities. To succeed, we must move away from the idea that volume is the only thing that matters."

Nicola agrees, "Depending on how you approach QPP, there are opportunities for real quality improvement. In my practice, we're learning ways that MIPS can teach us how to add value to patient care. I think that resonates with most radiologists. Yes, some people are just looking at the dollars, but most of us are more concerned with doing the right thing for our patients."

What Steps Should Radiologists Take Now?

To succeed under QPP and emerge as one of the "winners," Silva and Nicola recommend that radiologists take four key steps now:

1. Use the ACR Qualified Clinical Data Registry (QCDR) for reporting. QPP encourages electronic reporting either through an EHR or a QCDR. Says Nicola, "As a QCDR, the ACR National Radiology Data Registry (NRDR®) allows practices to compare their quality performance metrics to those of other practices nationwide. What's more, it offers additional measures and meaningful feedback to assess your performance before you submit data to CMS. The earlier you start, the better chance you have to improve. Then you can report the measures that show your best advantage and help you achieve the highest possible quality score."

2. Sign up for R-SCAN. In the first year of the MIPS program, engaging in a clinical practice improvement activity will account for 15 percent of a clinician's composite MIPS score. "Joining R-SCAN is one of the simplest ways radiologists participate in TCPi, and it will be counted as a clinical practice improvement activity," says Silva. "Beyond that, R-SCAN gives radiologists an opportunity to engage referring physicians in a partnership as well as gain access to the ACR Select® clinical decision support tool."

3. Find a quality champion or become one yourself. Every successful radiology practice needs at least one physician to serve as quality champion. "Physician engagement is imperative to succeed in the quality transformation," says Nicola. "Without a champion to empower physicians to be more patient-focused, the entire radiology group is at risk. Somebody needs to step up. The first thing practices need to do is find their physician champion. The second thing they need to do is to make a philosophical decision at the practice level to create a culture shift toward quality improvement."

4. Be educated. Radiologists should take advantage of all the tools and information the ACR has to offer. Silva notes, "The ACR has a plethora of educational modules, webinars, and ACR Bulletin and JACR® articles that will keep radiologists informed as they make the journey toward value-based care and help them thrive under QPP."

Additional Sources

Here are links to important resources to help you better understand QPP and quality-based changes to radiology care:

QPP Fact Sheet:
ACR MACRA Resources:
Radiology-Specific Summary of MACRA Final Rule:

By Linda G. Sowers, freelance writer for the Bulletin

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