April 16, 2015, marked the beginning of a seismic shift in the healthcare landscape. On that day, the U.S. Senate passed H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), which repeals the sustainable growth rate (SGR) formula, extends the Children’s Health Insurance Program (CHIP) for two years, institutes a 0.5% increase in Medicare reimbursement over the next four and a half years and encourages physicians to transition to alternative payment models (APMs). MACRA also establishes the Merit-Based Incentive Payment System (MIPS)—and with it, major implications and potential changes for radiology.
Like all medical disciplines, radiology will feel the punch from MIPS beginning in 2019, when it first takes effect. The program streamlines and aligns three existing clinical quality assurance programs implemented by CMS into a single modified fee-for-service program that includes four components: quality, resource use, meaningful use of electronic health record (EHR) technology and clinical practice improvement activities.
According to ACR, the quality component will likely encompass measures from the Physician Quality Reporting System (PQRS), while the current Physician Value-Based Modifier (VM) cost measures are expected to form the basis of the resource use component—at least, initially, says ACR Commission on Economics Chair Geraldine McGinty, MD, MBA, FACR.
Certain elements of the meaningful use program will likely comprise a portion of the EHR component. Clinical Practice Improvement Activities—a new wrinkle in value-based payment programs—should include practice quality improvement projects; those executed for MOC Part IV constitute one example.
Under the MIPS umbrella, 30% of positive and negative provider payment incentives will be based on quality; 30%, on resource use; 25%, on electronic records technology; and 15%, on clinical practice improvement. Radiologists and other physicians will be assigned a composite score contingent on their performance in each of the four categories, with scores ranging from zero to 100. Scores will be compared to a performance threshold (typically, the mean or medial for all physicians), with scores exceeding the threshold earning clinicians a bonus and those below the threshold (including negative scores) likely resulting in a penalty. Annual MIPS thresholds will be determined by the Secretary of Human Health Services, based on performance the previous year.
Additionally, in line with MIPS, current potential penalties associated with PQRS, the VBM, and EHR meaningful use will grow to 8% of payments by 2018, before being phased out. Maximum payment reductions will total 4% in 2019, increasing to 9% in 2022. Bonuses, sources say, may be more than triple penalties incurred. Incentives to participate in such APMs as ACO, patient-centered medical homes, and the like will be available, and APM participating providers will be exempt from the MIPS program.
Pluses and minuses
As for MIPS’ positive and a negative radiology punch, on the plus side, the four MIPS components are for the most part iterations of existing programs, McGinty points out. For example, she states, the current quality program is the PQRS—with which radiologists have been relatively successful.
The ACR, she observes, has been active in the task of developing PQRS measures that apply to diagnostic radiology, helping matters along. That the ACR’s National Radiology Data Registry also has garnered CMS recognition as a Qualified Clinical Data Registry bodes well for the specialty. “The registry really makes the measures more do-able and should make the process of MIPS participation and compliance much easier,” McGinty notes.
Meanwhile, the fact that some clinical practice improvement activities already fall under the MOC requirements umbrella means a good position for radiology on this score. Much the same is true for the EHR component, as radiology has been migrating to an EHR platform in line with meaningful use.
“The real challenge and negative for radiology, however, is resource use,” McGinty asserts, noting that resource use metrics were first defined with the Affordable Care Act (ACA) in order to assess physicians’ resource use on Medicare beneficiaries, pinpoint physicians’ Medicare program-related expenditures, forge a connection between cost measures and quality and leverage the result to calculate appropriate subsequent payment adjustments.
“The metrics tie in to episodes of care, and radiology has an involvement with most of these,” McGinty explains. “However, the radiologist isn’t necessarily the (clinician) to whom a Medicare beneficiary is attributed. That person is usually the primary care physician. Complicating matters, because of the nature of radiology, we cannot directly impact cost the way other specialty physicians who provide treatment do.”
Given these challenges and in order to move forward in a MIPS world, McGinty says, it is incumbent on the ACR and radiology as a whole to establish imaging-specific quality resource-use metrics, rather than metrics that center on full episodes of care. For its part, the ACR is engaging with CMS to ensure that all measures and metrics are relevant and do not put radiology at a disadvantage.
In additional MIPS-related advocacy initiatives, metrics development work by the ACR’s Metrics Committee is underway and is being complemented by the efforts of a Quality Management Committee. A Value-Based Payments Committee is expanding upon the work of the ACR’s Radiology Integrated Care Network and our Future Trends Committee.
A moving target
McGinty emphasizes that for radiology, as for other specialties, MIPS is a moving target and will remain so; hammering out details will be an “ongoing, involved process,” she asserts. CMS will approach MIPS through law-making, McGinty notes, but the ACR plans to continue to seek out and share with the agency other information—for instance, case studies— in hopes of making the initiative work well for radiology.
“MIPS is not a cut-and-dried solution to anything,” McGinty continues, adding that the ACR also wants its constituents to add their voice to its advocacy efforts. “We all must engage for an ongoing positive outcome,” she concludes.