May 26, 2016 -- Like it or not, the shift from fee-for-service to quality-based Medicare payments is on the horizon, sparked by the passage last year of the Medicare Access and CHIP Reauthorization Act (MACRA). So how can radiologists best navigate the new model?
Even though the rules aren't yet completely set, there are some practical tools available to help radiologists position themselves for success, according to the American College of Radiology (ACR).
"The payment paradigm is changing," Dr. Ezequiel Silva, chair of the ACR's Commission on Economics, told AuntMinnie.com. "We're walking out onto the field to compete, but the problem is, the rules aren't yet completely defined."
Making sense of MACRA
Last month, the U.S. Department of Health and Human Services (HHS) issued a proposed rule on implementing MACRA provisions. Passed in 2015, MACRA eliminated Medicare reimbursement changes using the sustainable grow rate (SGR) formula and called for the establishment of payment policies based on healthcare quality, rather than the fee-for-service system that has long been in place in the U.S.
The timeline the HHS has established is short, so radiologists need to be proactive, Silva said.
"The services we provide starting in January 2017 will become part of the composite performance score that determines our payments in 2019," he said.
MACRA is meant to consolidate what has been a patchwork of alternative payment models and quality incentive initiatives into a single framework called the Quality Payment Program. To help its members understand the proposed rule, the ACR posted an analysis earlier this month that explains the program's two paths: The Merit-Based Incentive Payment System (MIPS) and advanced alternative payment models (APMs).
Most radiologists will participate in the program through the MIPS, which is a 100-point system that consists of four performance categories:
These performance category scores will be combined into a total score, which will then be compared to a MIPS performance threshold to determine whether clinicians will receive an upward or downward payment adjustment.
"The MIPS system will allow CMS to rate clinicians on a graduated scale," he said. "The system is budget neutral: Medicare will pay bonuses out of money taken from the penalties."
The MIPS performance measures will take into account clinicians such as radiologists who tend to have less direct patient contact, or what CMS calls a "nonpatient-facing MIPS-eligible clinician," Silva said. These are individuals or groups who bill for 25 or fewer direct patient encounters in a calendar year; CMS estimates that a quarter of MIPS-eligible doctors will qualify under this category.
"CMS has historically struggled to describe the work radiologists do," Silva said. "This 'nonpatient-facing' term is ironic, because we've been working hard to encourage our members to come out of the reading room and deal directly with patients when possible. We'll be emphasizing to CMS that even if radiologists don't have direct contact with patients, as a specialty we are patient-centered."
As for the APM path, CMS estimates that only about 10% of physicians will be eligible, according to Silva. These participants will have to meet certain electronic health record technology requirements, provide payment for professional services based on quality measures comparable to those required by the MIPS, and carry more than a nominal risk of financial loss.
"Our message to our members is that yes, the APM structure will continue to evolve, but most radiologists will be under the MIPS for the foreseeable future," he said.
There are three actions radiologists can take to position themselves well for the coming payment paradigm shift, Silva said:
What's the bottom line? Be informed about the coming changes, according to Silva.
"No matter what, it's crucial for radiologists to get on board and educate themselves about this new payment paradigm," he said.
HHS is accepting comments on the proposed rule through June 27.