May 19, 2020

Outgoing Economics Commission Chair Discusses His Work for the ACR

Ezequiel Silva III, MD, FACR
Outgoing ACR Economics
Commission Chair
Starting during his radiology residency, Ezequiel “Zeke” Silva III, MD, FACR, learned to appreciate the important connections between clinical practice and the economics of medical imaging.

Dr. Silva credits Associate Professor Cliff Whigham, Jr., DO, for his earliest exposure to the business side of radiology. This occurred during his interventional radiology rotation as a resident at Baylor College of Medicine in the late 1990s. Like other residents, Dr. Silva was asked to append applicable CPT codes to every interventional procedure he performed. He took the exercise seriously enough to continue learning CPT coding during his fellowship year in vascular and interventional radiology at Massachusetts General Hospital. He then applied this knowledge in his practice, the South Texas Radiology Group, in San Antonio. There he oversaw the group’s coding and compliance and served as the group’s treasurer.

Dr. Silva added practice and organizational skills along with a knowledge of state health care regulations and federal reimbursement policy to his professional palette after he became chair of the economics committee of the Society of Interventional Radiology (SIR) in 2008. This experience led to an appointment in 2009 as the American College of Radiology (ACR) alternate advisor to the AMA/Specialty Relative Value Scale Update Committee (RUC). The RUC makes recommendations to the Centers for Medicare and Medicaid Services (CMS) on CPT billing codes and their valuation.

Dr. Silva succeeded Geraldine McGinty, MD, MBA, FACR, as the College’s advisor to RUC in 2012. He again followed her with his appointment as chair of the ACR Commission on Economics in 2016 when she began her four-year term as chair of the ACR Board of Chancellors. In 2016, Dr. Silva was named the ACR representative to the RUC panel.

Through his career, Dr. Silva has learned that economics is anything but a dull discipline when applied to radiology and clinical care. In his final week as ACR’s Economics Commission chair, he answered questions from Advocacy in Action about his experiences.

Could you describe the ACR’s achievements while you served as its Advisor to the RUC?

When I became Advisor, I thought the role would involve the creation of new codes and new valuations for innovative services. The job, however, became more about preserving and defending the existing value of radiology services due to a broader initiative looking at “potentially" misvalued services across the Medicare Physician Fee Schedule. Our team took the job and responsibility seriously. In general, we were successful in maintaining fair and appropriate valuations for our services across diagnostic radiology, interventional radiology, nuclear medicine and radiation oncology.

How important was collaboration with other specialty societies during RUC deliberations?

We always respected the need for collaboration during RUC related discussions. For instance, when we addressed interventional radiology codes, such as CPT codes for liver biopsies, the ACR partnered with SIR. We would survey our respective members together and go to the RUC table to address the panel’s questions together. We wanted as many stakeholders as possible in the House of Radiology represented, but more importantly, we wanted everyone’s clinical perspective gathered and represented.

How did your duties change in when you were appointed to serve on the RUC Committee itself?

My job as advisor was focused on representing the ACR. The RUC panel is different. Though I occupied the ACR seat, my job as a panel member was to be an independent participant in the code valuation process.

What key issues did the Commission on Economics consider during your four years as chair?

I became chair not long after passage of the Medicare Access CHIP Authorization Act. MACRA replaced the Sustainable Growth Rate (SGR) and, importantly, created the Quality Payment Program (QPP). The QPP formed the blueprint for the transition from volume-to-value based Medicare reimbursement.

Most radiologists were accustomed to fee-for-service (FFS). We were quite effective in influencing how radiologists were reimbursed under the FFS system. MACRA and the Quality Payment Program required that we formulate how radiologists would be scored and reimbursed through the Merit-Based Incentive Payment System ‒ while maintaining and protecting our place in the fee-for-service system. At the same time, the Economics Commission pondered radiology’s future role in alternative payment models.

How did the commission address these developments?

The Economics Commission realized the QPP requirements involved extensive performance measures, historically the responsibility of the ACR Commission on Quality and Safety. We expanded and enhanced the collaboration between the Commission on Economics and the Commission on Quality and Safety. We formalized those types of interactions. For example, we created the MACRA Committee and populated it with experts from fee-for-service and economics. We also included experts on quality and safety, standards development, informatics and accreditation to collaborate and collectively inform the QPP’s maturation.

How did these initiatives help raise the visibility and reputation of radiology?

We knew that radiology has been historically viewed as a referral-based, non-patient facing specialty. However, this perception is changing thanks to initiatives such as Imaging 3.0. We saw this when we presented several new mammography and breast imaging-related codes at a RUC meeting. We were able to gain higher valuations because it became obvious to the panel that our mammographers were not just interpreting the images, but also interfacing with patients to inform them of their findings and guiding their therapies. What was remarkable was that this acknowledgment came from non-radiology physicians engaged in the process.

What is the status of mandatory use of appropriate use criteria and clinical decision support?

We are now in a testing and operations period where the program is voluntary. By voluntary, I mean, CMS expects consultations to occur, but there is no penalty this year for non-reporting of AUC consultation. Based on the existing regulations, the go-to-live date is January 1, 2021 ‒ the date when penalties will be imposed for non-reporting. We could see a delay because of the COVID-19 crisis, but to date, CMS has not done so.

What will be the greatest challenges the commission will face moving forward?

Dr. Greg Nicola, the incoming Chair of the Economics Commission and his team will face a challenging period as radiology, and the rest of medicine, recovers from COVID-19. Men and women in every medical specialty, every business, and every industry are asking themselves the same questions. What does the future hold? What lessons can we learn from COVID-19? What do we keep? What do we replace? How do we adapt?

Speaking for radiology, our field is going to change because of this crisis. We are seeing several trends driven largely by regulatory allowances, which apply during the COVID-19 public health emergency. These include telemedicine allowances, more teleradiology from home and lower supervision requirements. Some of these policies may need to go and some will be retained, but we must be purposeful and meaningful in how we evaluate those options and outcomes. This is going to require the input of every commission in the college, but importantly every ACR member and every ACR practice as well.

What’s next for you?

I loved my time as Economics Chair. The past four years have been the most fulfilling of my career. I am certainly not ruling out further leadership opportunities within the ACR. Frankly, wherever the College needs me is where I will go.

I will continue to do my best to represent the ACR on the RUC panel and with the AMA. ACR expects that responsibility of me. I have been doing economics for a very long time and gathered quite a bit of historical perspective along the way. I will always be a resource to the ACR as questions arise and when historical perspective becomes necessary.