Radiology can participate only sporadically in CMS’s current conception of value-based care. Why?

Because the system relies heavily on episode-based reimbursement—and vast numbers of imaging studies are non-episodic by their very nature.

In fact, around 33% to almost 50% are “one-off” events. Accordingly, to maintain continuity of care at the population level, legislators will need to accommodate some iteration of fee-for-service billings for the foreseeable future.

Radiology researchers present the data and make the case in a research report published Aug. 26 in Current Problems in Diagnostic Radiology [1].

Corresponding author Casey Pelzl of the Harvey L. Neiman Health Policy Institute and colleagues reviewed records placed in Optum’s Clinformatics Data Mart from 2015 to 2015. The database contains de-identified claims made to both CMS and private payers.

To analyze the records, the team divided data into two blocks.

One block used one-year windows starting with the day of initial imaging. For this, Pelzl and co-authors categorized imaging studies as one-off events if no additional imaging claims appeared for the same body region over the subsequent 12 months.

The other block defined a one-off event even more strictly: an imaging claim with no more imaging whatsoever over the subsequent 12 months.

MIPS evolves—only to leave radiology behind?

Computing percentages of one-off events overall and by body region, the researchers found one-off events made up 33.2% to 45.8% of imaging studies.

They also found high rates of one-off imaging for cardiac indications, 80.9% to 87.7%, and low rates of one-off imaging for chest indications, 26.8% to 35.2%.

By site of service, the lowest rates of one-off imaging were in inpatient settings (12.9% to 29.1%) and long-term care (18.6% to 30.0%).

Pelzl and co-authors note CMS’s new-for-2023 MIPS-Value Pathways (MVP) program as potentially problematic going forward.   

The team notes that MVPs were conceived as a steppingstone between the strictly pay-for-performance MIPS and more advanced value-based requirements of APMs.

“While these are all Medicare programs, commercial payers often look to Medicare as a bellwether for payment policy,” the authors point out.  

The persistence of fee-for-service

Episode-based reimbursement mechanisms, they underscore, are out of touch with a major slice of the typical diagnostic radiologist’s workload.

The unavoidably high volume of one-off imaging events thwarts radiology from robust participation in value-based reimbursement or alternative payment models, the authors suggest.  

More:

“Since radiologists are unable to participate in bundled payments, episode-based cost measures or episodic MVPs, policymakers must take into account the need for some form of fee-for-service payments for imaging studies that are categorized as one-off events.”