Rads should anticipate payment changes with PPACA

New payment models in Medicare and Medicaid programs under the Patient Protection and Affordable Care Act (PPACA) will redefine the way that radiologists are paid, requiring them to demonstrate safe and efficient imaging, according to an article published online Jan. 21 by the Journal of the American College of Radiology.

With federal instatement of the PPACA, fee-for-service reimbursement is expected to be replaced with approaches that reward performance and value. According to the article’s author, Andrew B. Bindman, MD, of the University of California-San Francisco, the change will affect all specialties, including radiology.  

The Centers for Medicare and Medicaid (CMS) are testing a variety of new payment models in order to establish an evidence base for the approach or combination of approaches that generates the highest healthcare quality at the lowest cost. “The strategies being tested all incentivize performance to a greater degree than does the fee-for-service system, but they vary in the size of the available financial reward and risk providers face in providing care,” wrote Bindman. “The greater the financial risk a physician is willing to accept for the cost of care, the greater the opportunity to be financially rewarded if care is demonstrated to be of high quality.”

Specifically, CMS is trying pay for performance, bundled payments, and shared savings through accountable care organizations (ACOs) to improve care quality and reduce expenses. Pay for performance, the most basic approach, attempts to incentivize high-quality care through use of financial bonuses and penalties. Participation in a quality improvement program, such as reporting radiation doses from imaging studies to a registry, could reap financial bonuses for radiologists.

In addition to pay for performance, CMS is also testing bundled payments for discrete episodes of care. This model encompasses the physician, hospital, and post-acute care costs. Clinicians involved are paid a fixed amount that is based on an average payment for care that takes into account previous average costs associated with complications from the procedure. Those that provide care with lower than average complication rates will experience financial profits, while those with higher than average complication rates are at financial risk of providing additional care without additional resources. “Clinical teams that receive bundled payments will be looking to limit unnecessary costs, and thus radiologists will need to be prepared to demonstrate the value of imaging in providing service,” wrote Bindman.

Shared savings through ACOs target a broad population of Medicare beneficiaries that have a multitude of clinical needs. ACOs are accountable for all costs related to the delivery of care to target populations and for the quality of care received. Though they assume financial risks, ACOs have the potential to share in cost savings with CMS. They also have financial incentive to identify clinical problems at earlier, less expensive stages of disease. Bindman articulated: “There will be opportunities in these organizational arrangements for radiologists to determine that increased use of imaging, such as the use of CT scanning of tobacco smokers to identify early lung cancer, can contribute to cost-effective screening and prevention programs that build on the success in breast cancer to include other clinical conditions.”

As of now, ACOs must pass 33 quality metrics to partake in potential shared savings. However, none of these quality metrics are tailored to radiology. Additionally, radiology’s chain of events may affect its function within a model that follows shared savings through ACOs. “Although radiologists do not directly order imaging studies, the way they communicate with their clinical colleagues about the role of imaging studies in different clinical circumstances, as well as findings from studies and recommendations for follow-up studies, could influence ACOs’ rates of testing and their ability to provide cost-efficient care,” wrote the article’s author.

Bindham suggests that radiologists in ACOs consider their interests, as well as those of their organizations, by creating new consultant roles within the ACOs.  He believes that the advent of radiology consultant roles could increase appropriate use of imaging studies, eliminate unnecessary imaging, and ensure that the minimal amount of radiation dose is used in studies.

“How fast and how far ranging these changes ultimately will be is not predetermined,” wrote Bindham. “However, radiologists can anticipate that the basis for how they are paid will change and that they will need to play a greater role than has been required of them in the traditional fee-for-service payment system to demonstrate that imaging studies are used safely and efficiently.”