The healthcare reimbursement model in the United States has seen both gradual and abrupt changes over the years. We have come a long way from the original Medicare tenet of allowing for “usual, customary, and reasonable charges.” Though the healthcare economic landscape today is different from 1965, when Medicare was born, the model for value-based care surprisingly can be traced back as far as 1973, when the Healthcare Maintenance Organization (HMO) Act was passed — ultimately paving the way for the modern structure of Medicare Advantage Plans. The government has made an explicit push away from traditional fee-for-service (FFS), with the development of numerous alternative reimbursement models. These models are designed to move the reimbursement system away from being volume-based (i.e., FFS) toward being value-based.
The Merit-Based Incentive Payment System (MIPS), essentially a modified FFS model, can be considered one of the gradual changes that CMS has implemented as an in-between step toward its goal of a complete value-based system. MIPS has elements of a value-based model, including rewarding physicians for quality care; however, these rewards are small, especially considering the administrative lift required — which is an incentive to move toward an alternative payment model (APM). At the other end of the spectrum are the advanced APMs, which dispense with FFS in favor of full-on, two-sided risk that incorporates extensive rewards for high-quality care and corresponding severe penalties for poor-quality care. In between MIPS and these advanced APMs are numerous other models which, compared to MIPS, have progressively more value-based elements.
With this clear movement away from a traditional FFS environment, many specialties have progressively increased their involvement with these quality-based models. Radiologists, however, are for the most part still working in a predominantly FFS environment. It is true these newer value-based models are inherently designed more for patient-facing physicians, and this is one reason radiologists have been slower to adopt value-based models. However, as value-based models continue to grow in prominence, it is essential that radiologists engage more in these models — particularly as disincentives for operating in a purely FFS environment continue to grow. As these models appear to favor the more patient-facing specialties, how can radiologists engage in them?
Radiologists must think creatively and outside the box. For example, CDS promotes appropriateness of ordering studies and is a reproducible and transparent method of vetting imaging orders, which obviates the need for radiology benefit managers. Partnering with payors to use CDS instead of radiology benefit managers can improve patient care and save costs. Creating an arrangement of shared savings with payors using CDS can be a source of value generation for all parties.
Taking advantage of AI in opportunistic imaging to direct patient care on studies already performed is another way in which radiology can add value in keeping patients healthy. This decreases downstream costs by reducing acute ER and inpatient visits, which decreases expenses in a fixed reimbursement environment. In addition, this can have implications for a network’s quality scores, which also impact reimbursement.
Speaking of quality measures, radiologists can take leadership roles in many quality metrics. For example, breast and colorectal cancer screening rates are quality metrics used in both MIPS and accountable care organizations, such as the Medicare Shared Savings Program. Many radiology departments today lead these screening efforts in their networks, and we should all follow these models. Another area in which radiologists can lead is in the management of incidental findings. Being leaders means we should take ownership when these types of initiatives fare poorly and result in penalties, but it also means we should be eligible for bonuses when these screening rates grow.
Value-based reimbursement models really form the basis of population health. Although there are various definitions of population health, it ultimately revolves around improving a defined population’s health through deliberate coordinated care that is supported by appropriate reimbursement models. Radiologists are central to this care coordination — think of how diagnostic imaging affects almost all patients in one way or another. This central role of radiology opens opportunities for us to participate in alternative reimbursement models. In fact, the ACR will be forming a Payment Reform Workgroup to further explore these different models. I challenge you to also consider ways in which you can generate additional value for your patients besides the traditional FFS model.