A Haunting Proposition
Radiologists who ignore programs designed to help them transition from volume- to value-based care do so at their own peril; here are four areas to look out for in the coming year.
The Danish philosopher Søren Kierkegaard once said, "There are two ways to be fooled. One is to believe what isn't true; the other is to refuse to believe what is." Never has this saying been more accurate than when applied to the way some physicians have reacted to changes occurring in medicine.
Several new initiatives emphasizing value over volume have emerged over the past few years, and radiologists who choose to remain in the dark will incur penalties in the coming years, either monetary or otherwise. Four efforts in particular — meaningful use (MU), the conversion to ICD-10 code sets, the Physician Quality Reporting System (PQRS), and radiologists' roles in accountable care organizations (ACOs) — hold real consequences for those radiologists who choose to neglect them during the coming year.
The Long Shadow of Meaningful Use
CMS's Electronic Health Record (EHR) Incentive Programs offer financial inducements to physicians who can prove, or "attest" to, meaningful use of certified EHR technology. Eligible professionals and hospitals can successfully attest by satisfying a series of objectives marked out in various MU stages. The program is currently in its second stage, and providers must achieve meaningful use under the Stage 1 criteria before moving on to Stage 2.
Since CMS has exempted a few specialties — including radiology — from penalties associated with noncompliance with meaningful use, some radiologists have decided to sit out this round to see what impact EHRs will have on medicine. However, for those who wait too long to participate, MU will cast a long shadow. "Although radiologists won't be liable for meaningful use penalties for the time being, CMS can revoke this exemption at any time," explains Adeel Siddiqui, MD, assistant professor of neuroradiology at the University of Tennessee Health Sciences Center. "Say in 2018, for instance, CMS decides to institute penalties? Radiologists who haven't attested up to that point might have to go back and re-attest for several years."
Siddiqui says that the major reason radiologists adopt this conservative approach is because they believe that meaningful use was developed for primary care physicians and not for them. Since some of the benchmarks involve actions such as e-prescribing, maintaining medication lists, and counseling on smoking, Siddiqui states that many radiologists do not take meaningful use seriously. But embracing this attitude is a mistake, he says, because they're not seeing the bigger picture.
"The purpose of Stages 1 and 2 is to get everyone to standardize medical records into an electronic format," says Siddiqui. And once everyone is on a level playing field, MU will allow health-care providers to utilize other value-enhancing products that they may have otherwise been unable to use. One such product is ACR Select™ decision support software, the web service version of ACR's Appropriateness Criteria®. Apart from the financial rewards that accrue to radiologists participating in MU, practitioners with an eye to future viability would be wise to begin the attestation process.
ICD-10 Code Sets Cometh
Another major change facing medicine is the conversion from ICD-9 to ICD-10 code sets. Radiologists must have completed this transition by October 1, 2014, to continue successfully conducting health-care transactions. With competing priorities, however, many radiologists have chosen to put off preparations to make the changeover. But doctors and billing coders who wait much longer face the specter of a steep learning curve.
The potential consequences of missing the implementation deadline are numerous. "First of all," explains Ezequiel Silva III, MD, chair of coding and compliance at the South Texas Radiology Group in San Antonio, "implementing the new codes is not a choice, as there is no transition period after October 1, 2014, in which ICD-9 and ICD-10 codes may be used interchangeably. Since ICD-10 is required for all HIPAA-governed transactions, private payer claims must use ICD-10 also. Groups that are not fully transitioned will not have their claims processed. Radiologists also face possible compliance risks associated with improper billing of patients in the event of claims denials."
Silva notes that there may be an upside to strategically timing implementation, however. "It is easy to feel overwhelmed by the magnitude of the change, and practices may be prone to procrastinating," he says. "The good news is that there is plenty of time. In fact, I would argue that the task of training coding and billing staff on the specific codes should be delayed. Knowledge gained too far in advance and then not applied may be lost, leading to the additional expense of retraining."
But radiologists should not confuse a deferral for total inaction. "I do think it is a good idea to organize an internal team and create a general plan for implementation," Silva asserts. "Critical to that task will be communicating with the software vendors or the outsourced billing entity. Assurance that both will be up to speed by the time of implementation is critical and should be received in writing. Practices should not be shy about looking elsewhere if the vendors are not confident in their readiness." Read more about the transition in the August Bulletin at http://bit.ly/UnsubstantiatedClaims.
Reimbursements on the Chopping Block
In addition to facing a deadline in the conversion to new code sets, radiologists are also running out of time when it comes to reporting on quality measures. PQRS is a voluntary program instituted by CMS that awards payments to physicians who successfully report data on such measures. These metrics are related to covered professional services for Part B Medicare beneficiaries. Physicians who do not participate in the program during 2013, however, will be penalized 1.5 percent of their Part B Medicare reimbursements in 2015.
According to David J. Seidenwurm, MD, FACR, neuroradiologist at Radiological Associates of Sacramento in Sacramento, Calif., avoiding this penalty should not present much of a burden to radiologists. Although radiologists report to the PQRS in higher numbers than physicians generally, their levels of participation are still relatively low. The reason for this? "The measures called for in the PQRS seem a bit abstract and removed from what radiologists often consider to be the quality practice of radiology," says Seidenwurm. In other words, the metrics can be perceived as specific to certain types of imaging practices and not applicable to most diagnostic radiologists.
Although these measurements may seem remote from practice, Seidenwurm suggests that asking radiologists to think about quality in circumscribed areas will encourage them to develop the habit of thinking about quality in all that they do. And there is another benefit: In the next year or two, the government will add a public disclosure component to PQRS. This effort, called Physician Compare, will allow users to locate physicians and other health-care professionals enrolled in the Medicare program. Since the criteria used to benchmark one physician against another will be in quality measures, such as PQRS performance rates, radiologists would be wise to start participating now.
The Spirit of Collaboration
The emphasis on quality care is as important to PQRS as it is for those radiologists participating in ACOs. As members of a health-care organization that bases provider reimbursements on quality metrics and reductions in the total cost of patient care, radiologists in ACOs must advocate for shared savings payment models in which they are fairly compensated. Doing so, however, requires that they become influential members of the organization.
"At some point, physicians in the ACO are going to have a conversation about how imaging will be utilized," says Geraldine B. McGinty, MD, MBA, FACR, chair of ACR's Commission on Economics. "If you're not at the table, you should expect that your views won't be represented." She recommends that radiologists get involved in committees to advocate on behalf of their department. "There will be different opportunities based on the setting," says McGinty. "Some may not be fun, like the infection control compliance committee that meets at 7 a.m. on a Friday morning. But this is where you start to build your influence."
Many radiologists hesitate to take a more active role because they are confused about how to navigate the shifting tides of health care. In particular, radiologists often have difficulty knowing how to advocate for fair compensation within the ACO model. This is where decision support software, such as ACR Select, can come into play. The software allows radiologists to assume the role of imaging consultant to referring physicians, thereby increasing their value to the organization. "Some radiologists may see ACR Select as potentially decreasing their reimbursement and relevance in an era of declining Medicare reimbursements," says McGinty. "But what they should understand is that decision support won't work optimally without radiologists performing the essential peer-to-peer consultations to help referring providers work through borderline and difficult situations. If anything, it shores up our relevance."
Whether it's complying with meaningful use requirements, laying the groundwork for the transition to ICD-10 code sets, reporting quality measures through PQRS, or shouldering greater responsibilities within ACOs, radiologists find themselves tasked with participating in programs that will help ensure a transition volume- to value-based health care. The natural reaction to this is a fear of the unknown. But with a renewed sense of resolve, successful compliance will secure a place for radiologists at the center of quality patient care.
By Chris Hobson