Great Expectations

Unprecedented practice transformation is underway, and radiologists need to get involved.great expectations

Now more than ever, patients expect the right care, at the right time, and at a reasonable cost. To reach that goal, health providers must achieve practice transformation on an unprecedented scale.

And CMS is deploying new programs to help providers move from volume-based practices to value-based, patient-centered services.

One of the largest federal investments in large-scale practice transformation is the Transforming Clinical Practice Initiative (TCPi). In 2015, CMS awarded nearly $700 million to 39 national and regional collaborative health care transformation networks and supporting organizations:

• Practice Transformation Networks (PTNs) provide technical assistance in delivering care in a patient-centric and efficient manner. PTNs can focus on regional, statewide, or local initiatives, and each organization can determine its own structures, methods, and measures to support transformation.
• Support and Alignment Networks (SANs) utilize national and regional organizations (such as the ACR) and public-private partnerships to provide tools and services to drive transformation.

The ACR was selected by CMS as one of only 10 SANs across the country to play an active role in the collaborative learning process. In September 2015, the ACR was awarded up to $2.9 million to support the transformation of physician practices toward value-based reimbursement through the ACR Radiology Support Communication and Alignment Network (R-SCAN™). R-SCAN will help at least 24,000 member radiologists and their referring physician colleagues reduce unnecessary testing and procedures.

TCPi will ultimately support nearly 140,000 clinician practices in their efforts to expand quality improvement, engage in shared learning, and leverage health data to boost performance. 

Opportunities for Radiologists

One of the PTN grant recipients is the New Jersey Innovation Institute (NJII), which will engage over 15,000 clinicians to use clinical quality measures, improve chronic care management, and improve costs and efficiency. While many radiologists believe that TCPi is geared strictly to primary care physicians, Gregory Nicola, MD, vice president of the Hackensack Radiology Group in Hackensack, N.J., quickly saw opportunities for radiologists.

"When we reached out to NJII, we discovered that two of its 12 transformation measures are radiology centered," he says. "One of them is inappropriate use of imaging in back pain; the other relates to imaging use in cardiac stress tests. The NJII team was seeking collaboration with the PTN to help members with the imaging-specific metrics, and we were ready to respond thanks to our participation in R-SCAN."

The possible partnership between PTNs and SANs like R-SCAN is ideal, says Nicola. "As radiologists, we can pair with doctors who are working to achieve the radiology metrics, and we can use R-SCAN to help them order appropriate imaging," he emphasizes. "Working with the PTN, we can partner with primary care doctors who are motivated to work with us. Even though they know they're not supposed to order inappropriate imaging, they might not know what that means. That's where the radiologist comes into play."

Not in an area with a PTN? You can still participate in transformation initiatives via a nationwide SAN such as R-SCAN. Says Nancy Fredericks, MBA, R-SCAN program director, "R-SCAN meets radiologists where they are. Through R-SCAN, participants have access to the resources they need to support the culture change and workflow redesign necessary for participation in value-based payment models. The network concept advanced under the TCPi program and exemplified by R-SCAN connects radiologists and referrers in pursuit of appropriate image ordering for nearly a dozen specific Choosing Wisely® topics."

Collaboration Across SANs

Another opportunity for radiologists to participate in TCPi comes via a unique collaboration among SANs to reduce inappropriate imaging. The ACR is partnering with the American College of Emergency Physicians (ACEP) to link R-SCAN with the Emergency Quality Network. Among other initiatives, this network is focused on helping emergency departments reduce avoidable imaging in low-risk patients through Choosing Wisely recommendations.

"Over the next four years, we plan to recruit over 24,000 emergency clinicians working in 2,000 EDs across the country," says Arjun Venkatesh, MD, MBA, MHS, assistant professor of emergency medicine at Yale University School of Medicine and co-lead of the ACEP Emergency Quality Network. "We provide an opportunity for emergency clinicians to partner with local radiologists and work toward a common goal, so everyone is speaking the same language and looking at the same data."

At Hackensack, Nicola would like to leverage the partnership between R-SCAN and the Emergency Quality Network to enhance radiology-specific quality improvement projects in the ED. "We would like to pair the two programs together, keeping the departments informed about appropriate imaging via Choosing Wisely topics like pulmonary embolism, sinus CT, and back pain," he explains. "After joining R-SCAN, the first thing radiologists need to do is reach out to other departments and find advocates who are also interested in controlling imaging utilization. For example, find an emergency room doctor who is participating in the Emergency Quality Network and work together to get a project implemented."

Venkatesh notes that, while many successful partnerships between emergency physicians and their colleagues are already in place, everyone can benefit from joining a SAN initiative. "Whether you are successful in quality improvement or just starting the journey to improve, these learning network are invaluable," he stresses. "When you bring together different groups in virtual collaboratives, everybody learns and improves together."

MACRA, MIPS, and ACOs (Oh My!)

There is also a financial advantage to participating in TCPi thanks to the Medicare Access and CHIP Reauthorization Act (MACRA) and the proposed Merit-Based Incentive Payment System (MIPS). Under MIPS, CMS outlines four performance categories for which physicians will earn a composite performance score tied to a potential bonus, penalty, or neutral adjustment.

Nicola stresses that to earn the highest composite score (and consequently, the maximum bonus), is it mandatory to participate in clinical practice improvement activities. "Medicare has identified over 90 activities — one of which is to participate in a PTN or SAN initiative," he says. "Whether it's R-SCAN, ACEP, or a regional option like NJII, if you participate, you will get credit for a clinical practice improvement activity under MIPS and help your practice reimbursement."

Joining a TCPi project can also help position your practice for advanced payment models that will likely include quality improvement targets, says Venkatesh. "For the first time, CMS has reached out to engage clinicians. We're sitting on the cusp of a wave that will be the biggest change in physician payments ever."

Nicola agrees, "As ACOs mature, they will need to look deeper to find ways to save, and they're going to look at inappropriate imaging. Participating in R-SCAN now can show an ACO that your radiology group is proactive and already managing imaging patterns. It's better to be early than late to this game, because ACOs may find ways to control imaging utilization without you — and then you're a commodity."

By Linda G. Sowers, freelance writer for ACR Press

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