ACR’s Pay for Performance (P4P) Initiatives: Where We Are and Where We’re Going


The ACR's Proactive Movement into P4P: Natural Outgrowth of a Long-standing Commitment to Quality and Patient Safety

Quality is Our Image® is not only a motto at the ACR, but also the guiding force behind every facet of what the ACR does—including its full-fledged response to the swelling demand for performance-based physician reimbursement, also known as pay for performance (P4P). With more than 130 private and public P4P programs already in existence, and Medicare now offering physicians bonus payments for reporting of performance measures, the ACR has responded by making P4P one of its top priorities.

The ACR's commitment to P4P includes

  • ACR's Metrics Committee, composed of ACR physician volunteers who are charged with developing performance measures and designing registries
  • Appointment of ACR physician and staff representatives to outside P4P vetting bodies along with participation in all relevant meetings and conference calls
  • Hiring of full-time, dedicated P4P and registry staff
  • ACR interaction with and input to key governmental and political entities that affect P4P
  • ACR sponsorship of annual national P4P conferences which focus on the practice of radiology
  • An informed membership kept up to date through a new P4P section of our Web site and regular articles on P4P in the ACR Bulletin

P4P is the latest manifestation of the ACR's sweeping quality and patient safety enterprise. Our P4P effort is closely integrated with our long-standing, highly respected accreditation programs; a rapidly growing National Radiology Data Registry, which will ultimately be a treasure chest of clinical data, best practices, and dose safety information that can be quickly mined for quality data and performance benchmarking; clinical guidelines and standards; imaging appropriateness criteria; and peer education/self-assessment programs, including RADPEER (a system of internal peer review for radiology practices).

P4P: Reward and Recognition Opportunity for Radiology's Superior, High-Quality, Value-Added Care

First and foremost, it is the ACR's goal to ensure that any new payment system rewarding superior performance fully acknowledges radiologists' unique contributions to the appropriateness and outcomes of a patient's care regimen. To achieve this, the ACR is positioning itself at the center of all P4P development activities, besides forging partnerships with other medical and health care associations and private and public payers, including the Centers for Medicare and Medicaid Services (CMS).

In developing performance measures, the ACR will be guided by the following principles:

  • Full recognition of radiologists for the superior care they provide and the value they add for patients
  • Representation for all of radiology, including its subspecialties
  • Criteria that are evidence-based or based on expert consensus
  • Use of information that is not burdensome to collect or report
  • Measures that, if they are outcome-related, are risk-adjusted and do not penalize radiologists for elements of care beyond their control
  • Material that is vetted first by our membership
  • Conformity with the specifications of all national performance vetting bodies, as well as CMS
  • Validation through appropriate pilot testing

Where We Are: ACR P4P Activities

The ACR is expanding its development of performance measures on which radiologists can report under CMS's Physician Quality Reporting Initiative (PQRI).

  • Two Performance Measures Completed—Eligible for up to 1.5% Reporting Bonus Under CMS’s Physican Quality Reporting Initiative (PQRI)
    The ACR has already completed two imaging-related performance measures, which are designated as quality measures in CMS's Medicare PQRI, enabling physicians who successfully report to earn a bonus payment of up to a 1.5 percent payment bonus (applied to all Medicare allowable billings). Drafted in conjunction with the American Academy of Neurology, these two measures relate to appropriate imaging for patients with stroke or undergoing stroke rehabilitation. These measures were approved by the AMA Physician Consortium for Performance Improvement (PCPI) and the AQA Alliance, and received final endorsement by the National Quality Forum (NQF) in May 2007.  The 2008 PQRI also includes a number of reportable quality measures eligible for bonus payments relating to interventional radiology and radiation oncology.
  • New Radiology Measure Set Approved for PQRI Inclusion in 2009
    In addition, ACR has played a major role in convening and serving on a special Radiology workgroup with the AMA Physician Consortium for Performance Improvement (PCPI). Eight new radiology measures were developed by this workgroup, which included input of a number of other specialties.  The new radiology measure set will be eligible for a reporting bonus under the PQRI beginning January 1, 2009, and can be seen at:  http://www.acr.org/SecondaryMainMenuCategories/quality_safety/p4p/ApprovedPayforPerformanceMeasures.aspx
  • Ongoing ACR Participation in Major National P4P Activities
    ACR is an active member of the NQF, the AQA, and the AMA PCPI with physician volunteers and staff regularly attending all P4P-related meetings and conference calls. ACR staff and physicians routinely work with CMS staff on issues related to P4P development and reporting, as well as new areas of measures development, such as care efficiency. The ACR also sends representatives to meetings of widespread significance, such as the National P4P Summit. ACR Economics and Government Relations staff members routinely track, analyze, and report on all legislation related to Medicare physician and radiology-specific reimbursement, as well as relevant regulations issued by CMS. ACR staff members, when appropriate, pursue participation and funding in quality-related demonstrations and research offered by CMS or the federal Agency for Healthcare Research and Quality.

Where We're Going: State of the Art for P4P and Challenges Ahead

P4P is an evolving and long-overdue effort to bring our health system's escalating costs and utilization under rational control. With health care costs now consuming 16 percent of our gross national product, we urgently need to change the incentives that drive provider and consumer behavior. The bottom line is that America can no longer afford to just pay for care without regard for whether it is truly needed or has a clear benefit. P4P is the moniker for a wide array of approaches and incentives, all of which focus on achieving a common goal—the right care for the right patient at the right time.

Most current P4P systems in the private sector reward primary care physicians for improved preventive care, for more prudent use of resources, or for better oversight of chronically ill patients. While these programs raise the quality bar by increasing physician compliance rates for key care processes, the ultimate goal of measuring the resulting patient outcomes remains mired in technical complexity.

In addition to the fact that the same patient may be treated by several physicians and other health care providers, outcomes are also affected by a patient's age, sex, medical and medication history, comorbidities, family and genetic factors, geographic influences, and compliance with treatment regimens.

Because of this inherent complexity, initial P4P efforts have focused on process rather than outcomes. By concentrating on process measures that have wide professional consensus and buy-in, P4P is slowly gaining acceptance, allowing the medical universe the time it needs to make a quantum shift in the incentives it provides for patient care.

While interventional radiologists and radiation oncologists play a direct and pivotal role in their patients' outcomes, we cannot underestimate the vital impact diagnostic radiologists have on the cost and course of a patient's care. An accurate CT scan of the heart can avoid enormously expensive heart bypass surgery or save a life by indicating the need for surgery before an acute or lethal cardiac event.

Diagnostic radiologists are the experts at selecting the right imaging procedure for a given patient and condition. The ACR's goal is that these physicians be duly rewarded for ensuring that referring physicians make the most clinically appropriate imaging requests, and that results are reported back with alacrity, allowing needed treatment to proceed without delay.

Down the road, we hope that all providers involved in treating the same patient can share in any bonus for improved care efficiency and outcomes. The ultimate goal of P4P is to unify providers around what is best for the patient, eliminating the lack of coordination and segmentation so commonplace today and allowing quality to take center stage.