MACRA: The Evolution of Volume-Driven Payments
Gregory N. Nicola, MD, chairman of the ACR MACRA Committee, described how the College has helped mitigate the effects of the Medicare Access and CHIP Reauthorization Act of 2015 and a resulting set of regulations that are so complex that even the name MACRA involves an acronym embedded in another acronym.
MACRA was passed in response to escalating U.S. health care costs annually totaling $3.2 trillion or 17 percent of the nation’s gross national product. Its objectives revolve around a shift in Medicare from reimbursement based on clinical volume to rewards and penalties from a more value-based payment system.
The Quality Payment Program (QPP) is the Centers for Medicare and Medicaid Services’ (CMS) master plan for meeting its statutory obligation under MACRA to change how clinicians are paid. It offers physicians the option to participate in either the Merit-based Incentive Payment System (MIPS) or an alternative payment model (APM).
The ACR has worked hard to provide resources helping members understand their QPP-related options and obligations. The ACR has collaborated with other medical societies to slow QPP’s implementation including efforts that led CMS to allow MIPS clinicians to pick their own pace in the program’s first two years. Mandatory data reporting began Jan. 1, 2017. Also because of a collaboration between the ACR and other medical societies, physicians must submit data for just one quality measure and a single improvement activity to avoid a first-year penalty.
The ACR’s influence is also felt through members serving on key MACRA committees. David Seidenwurm, MD, FACR, was appointed to the expert panel for measure development. Silva, Nicola and Joshua Hirsch, MD, FACR are members of the MACRA Episode Care Groups and Resource Use Measures Clinical Committee.
“The ACR National Radiology Data Registry helps empower radiologists participating in MIPS,” Nicola said. “Participants receive access to high-quality measures, bonus points on those measures and feedback on their progress toward quality goals. R-SCAN is another important asset.”
The Economic State of Breast Imaging
A data-driven presentation by Dana Smetherman, MD, MPH, FACR, prepared radiologists to defeat threats against access to mammography services. Practitioners face possible cuts to the technical component of reimbursement. Misguided screening recommendations could lead women to receive their first screening exam too late and subsequent screenings too infrequently, she stressed. Future shared cost requirements could make screening too expensive for millions of women despite clinical benefits for them and cost savings for the health care system. For more about Smetherman’s powerful presentation, see “ACR 2017: Positive Data Help Defend Mammography” in the May 26 issue of ACR Advocacy in Action.
Artificial Intelligence: A Primer for Radiologists
Keith Dreyer, DO, PhD, FACR, chair of the ACR Commission on Informatics and chief data officer for the College’s new Data Science Institute addressed concerns about the potential threat of artificial intelligence (AI) to radiology.
“AI experts like Geoff Hinton, the father of deep learning, may believe artificial intelligence will drive radiology into obsolescence, but it takes the mind of a radiologist to think through how AI is going to work from an economic point of view,” Dreyer said. “AI developers Microsoft, Google, Apple, Facebook and IBM need radiologists to guide them and manage the process in which their powerful technologies are applied to medical diagnostics,” Dreyer added.
Evolution of Health Insurance Networks Under ACA
“The Patient Protection and Affordable Care Act (PPACA) may have delivered health care insurance to about 20 million otherwise uninsured Americans, but it led to billions of dollars of losses for commercial health care insurers,” said Mark Bernardy, MD, FACR, vice-chair of the ACR Commission on Economics.
The American Health Care Act (AHCA), the Republican answer to Obamacare, passed the House in April. Its main provisions are the repeals of ACA-related taxes and mandates. Medicaid expenditures would be reduced, capped and awarded as block grants to individual states. State-operated high-risk patients care pools would be formed for patients with pre-existing conditions.
Even with a Senate rewrite of AHCA, Bernardy expects any legislation passed by GOP lawmakers to shift authority to the states.
“Health care will be coming to your state soon,” he predicted. “As radiologists, we have an opportunity in our own states to make a big difference in how health care is going to look for the next five to 10 years. “
The State of Risk Sharing Contracts Including ACOs
Sanjay K. Shetty, MD, MBA, president of Steward Health Care System, Boston, presented his pioneer accountable care organization (ACO) as a possible model for how large physician practices can engage in risk-sharing to provide integrated care for large patient populations.
Steward Health Care supports the practices of nearly 3,500 physicians, with 90 percent of its commercial lives and 80,000 Medicare members participating in the ACO under a form of global payment.
Many forces are pushing clinical services toward value-based care, according to Steward. “We need to achieve higher quality to lower costs,” he said. “To do this, we need to understand the tools used by ACOs and how radiologists fit into that role.”
These tools include evidence-based standards and protocols rigorously applied to high-cost patients. These patients are assigned a management team to address their potentially costly transition between episodes of care. Clinical and psycho-social findings are passed from site to site to anticipate the high-cost patient’s needs. Preventive and wellness programs are directed to healthy patients. Opportunities for quality improvement are identified and its pursuit is closely monitored.
Without knowing it, many radiologists may already be involved in the kind of value-based contracting Shetty advocates. He encourages radiologists to assert themselves in the management of ACOs employing their services. “Radiologists need to be at the table to make sure their value to the large enterprise is recognized,” he said.