June 10, 2016

Successful Coping with MACRA Linked to Metrics

Three aspects of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) were clear to Ezequiel Silva III, MD, FACR, the new chair of the American College of Radiology Commission on Economics, as he addressed a May 18 session at ACR 2016: The Crossroads of Radiology(R).

First, MACRA killed Medicare’s Sustainable Growth Rate policy, a misbegotten cost-control scheme that had amassed more than a $110 billion liability for future Medicare physician payments before its repeal and replaced it with alternative payment models (APMs) and the Merit-based Incentives Payment System (MIPS).

Secondly, he assured members the ACR is doing everything in its power to insure radiology is well-positioned to adjust to MACRA’s mandate to shift Medicare from fee for service to value- and quality-based reimbursement.

And, thirdly, he emphasized MACRA is highly complex and evolving quickly. MACRA implementation begins on Jan. 1, 2019, which means the payment performance period that lays the basis for its payment rules will begin Jan. 1, 2017. It is clear to Silva that physicians will be subject to MACRA and its mandated options to participate in an APM or MIPS.

What is less clear is how the regulations for assessing the value and quality will be structured, Silva said. These circumstances place a premium on radiologists applying tools that will enable success no matter what the rules hold. Access to accurate financial utilization data drawn from past clinical experience and the ability to analyze such data to respond to future contracting opportunities will be especially important.

Silva noted that the ACR and the Neiman Health Policy Institute (HPI) has been on the forefront of such advocacy by acquiring more than a billion lines of Medicare claims data covering the years 2001 to 2014, developing data mining and analysis software, and making both available to analysts, radiologists, media and the public.

Introduced at ACR 2016, HPI’s Inpatient Cost Evaluation Tool (ICE-T) is the latest addition to the radiologist’s tool box for data mining and analysis. Silva illustrated its application by describing hypothetical negotiations between a hospital and its radiology group for imaging services associated with the facility’s participation in Medicare’s new Comprehensive Care for Joint Replacement Model (CCJR). This alternative payment model, which was launched on April 1, 2016, assigns a single payment to providers for all services for lower joint replacement (MS-DRG 469 or MS-DRG 470) from initial hospital admission to 90 days after discharge following surgery.

Using ICE-T, Silva learned that imaging accounts for only about 1.4 percent of the total hospital payment for an episode-of-care. The mean national imaging costs from DRG 470 were $39.86 per patient. Comparing this data point to a practice’s own operational cost and patient mix can inform such discussions. Though regional and hospital-specific data would also have to be examined, this simple illustration shows how even a small dose of relevant information moves the radiologist into a more knowledgeable negotiating position, Silva said.

MACRA’s MIPS also encourage the use of qualified data registries to identify and set quality standards, Silva said. The ACR was an early adopter of registries that led the Centers for Medicare and Medicaid Services (CMS) in 2014 to recognize its National Radiology Data Registry (NRDR(R)) as a Qualified Clinical Data Registry (QCDR). Under the Medicare Fee Schedule Final Rule, radiologists can meet Physician Quality Reporting System (PQRS) quality requirements by participating in QCDR.

In a separate ACR 2016 session, Richard Duszak, MD, FACR, vice-chair of policy and practice at Emory University, predicted that most radiologists will decide to participate in MIPS, a modified fee-for-service plan that will include value-based payment mechanisms. After MACRA implementation. PQRS will be rolled up into MIPS, thereby creating an additional incentive beyond its inherent performance improvement opportunities for radiologists to participate in QCDR.

Data mining and analysis similar to a research collaboration between Jonathan Flug, MD, a radiologist at the University of Colorado Health Science Center, and HPI researchers could provide a basis for new MIPS value-based goals, according to Duszak. Flug’s study focused CMS’s efforts to discourage radiologists and non-radiologists, who often self-refer to office-based equipment, from performing so-called the double scans involving chest CT scans acquired pre- and post-contrast administration. The often unnecessary second scans have been the object of CMS cost- and radiation reduction metrics since 2006.

Based on an evaluation of Medicare data from 2001 to 2012, Flug found radiologists dramatically reduced their use of combined- pre- and post-contrast abdominal CT after CMS published its metric. For non-radiologists, double scan utilization declined far more slowly and remained at a comparably higher rate than for radiologists.

Duszak said he would love to see MIPS metrics that reward or penalize physicians using such criteria.

“If we don’t create these metrics, someone at CMS will do it for us,” Duszak said. “This is a situation where we lead or will be led.”