March 04, 2016

ACR and CMS Discuss Clinical Practice Improvement Activities

American College of Radiology (ACR) representatives advised Centers for Medicare and Medicaid (CMS) officials at a Feb. 29, 2016, listening session about how radiologists can qualify for and participate in its new clinical practice improvement activities (CPIA) category under the Merit-based Incentive Payment System (MIPS).

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the use of the sustainable growth rate in calculating the conversion factor for Medicare’s physician fee schedule and now offers possible incentives for physicians to earn bonuses by either providing services in a fee for service model with an associated value-based performance program (MIPS) and/or providing services through alternative payment models (APMs). The MIPS focuses on performance in four categories: quality (initially based on the existing Physician Quality Reporting System- PQRS), resource use (derived from the cost component of the Value Modifier program), use of electronic health records (EHR) technology (modified Meaningful Use program) and the new CPIA category. Six subcategories of MIPS clinical practice activities are covered in this CMS chart.

CMS invited ACR to comment on the CPIA category and how radiologists might qualify in this and the three other MIPS categories.

Geraldine McGinty, MD, MBA, FACR, chair of the ACR Commission on Economics, advised CMS and their consultants that radiologists primarily rely on referrals to provide patient care and, therefore, are not always in control of utilization, costs and related factors. However, “radiologists bring value to the care of all patients who require medical imaging studies,” she said.

ACR’s Imaging 3.0 initiative was developed to bring radiologists into the new era of adding value through more frequent patient interaction and better relationships with the medical community. The “Value Chain” series, published in the Journal of the American College of Radiology, describes in detail how radiologists can measure the impact of adding value and improving quality. Measurable services that illustrate some of the ways radiologists can participant in CPIA include patient scheduling, structured reporting, actionable reporting, and radiologist-to-physician and radiologist-to-patient consulting.

Also, radiologists and referring physicians will soon be required in the Medicare program to use clinical decision support (CDS) which offers the opportunity to improve the appropriate use of imaging. This puts the radiologist at the center of accountability for utilization and lowering costs. Through use of CDS tools, these efforts can be measured.

Zeke Silva, MD, FACR, vice-chair of the ACR Commission on Economics, addressed the six categories of CPIA activities:

  • Expanded practice access
  • Population management
  • Care coordination
  • Beneficiary engagement
  • Patient safety
  • Practice assessment, and
  • Alternative payment models
In discussion with CMS and its consultants, Silva described radiology as a 24/7 specialty that offers care coordination through CDS. He advised the centers that CPIA activities should include radiology’s maintenance of certification (MOC) part 4. “Peer-review programs, such as RADPEER and tumor boards, should be recognized,” he said.

Judy Burleson, senior director of ACR Quality Management Programs, described ACR’s programs and a wide variety of patient safety activities and measures included in the National Radiology Data Registry (NRDR) databases, which include the Dose Index Registry (DIR), CT Colonography Registry (CTC), National Mammography Database (NMD), General Radiology Improvement Database (GRID) r, and the Lung Cancer Screening Registry (LCSR). She noted two new registries are being developed - Interventional Radiology (in collaboration with the Society for Interventional Radiology) and a CDS registry. Other formalized programs include the Diagnostic Imaging Centers for Excellence (DICOE), RADPEER and the Radiology Support, Communication and Alignment Network (R-SCAN). R-SCAN, which focuses on appropriate imaging related to Choosing Wisely imaging topics, received funding from CMS’ Innovation Center to aid in clinical practice transformation. It provides an opportunity for the referring physician and radiologist to participate on a “trial” basis in CDS and would complement the Protecting Access to Medicare (PAMA) legislation.

The ABR’s MOC part 4 program, is comprised of practice quality improvement activities to help radiology practices to improve. This should count towards CPIA, Burleson said. All these programs can track radiologists’ performance improvement efforts.

ACR asked that the definition of CPIAs be as broad as possible and for CMS to consider participation in any of the aforementioned activities as CPIA to allow radiologist an opportunity be successful in MIPS. CMS did say that the intent is to help physicians to qualify and not to increase provider burden any more than necessary. For those categories where reliable measures do not exist that are attributable to radiologists, ACR asked that CMS keep an open dialogue.

The call concluded with an offer by ACR to share more information and to work with CMS on the ordering of appropriate imaging. This is an education process for CMS. The Centers are in the midst of learning what resources are already available to radiologists and how they plan to contribute to the transformative process from fee-for-service and pay-for-reporting systems to physician bonuses for improved patient care, lower costs and better care coordination.