MIPPA’s Impact on Imaging

At the 2009 annual meeting of AHRA: The Association for Medical Imaging Management in Las Vegas, Nevada, on August 12, two representatives of the ACR presented “Quality and Safety Response to National Initiatives.” The information was presented by Krista Bush, ACR director of diagnostic modality accreditation and director of the nonbreast imaging accreditation programs, and by Judith Burleson, ACR director of metrics. The focus of their presentation was on explaining the impact on radiology of the Medicare Improvements for Patients and Providers Act (MIPPA), passed by Congress in July 2008, and they also presented updates on pay-for-performance value-based purchasing. According to Bush and Burleson, medical imaging facilities should gird themselves for increased scrutiny in the areas of quality and efficiency. MIPPA has six key provisions. First, the law blocked the 10.6% cut in physician payments that was scheduled for July 1, 2008, and it provided a 0.5% update through the end of 2008. It also blocks the 5% cut scheduled for 2009 and provides a 1.1% update for 2009. Second, it reapplies the budget-neutrality adjustment for recent RVU changes to the conversion factor, rather than to work RVUs, effective January 1, 2009. Third, MIPPA extends the Physician Quality Reporting Initiative (PQRI) through December 31, 2010, and increases the PQRI bonus from 1.5% to 2% for 2009 and 2010. Fourth, the law makes improvements to the PQRI, including a requirement for the endorsement of measures by a consensus-based, standard-setting entity. It permits group practices to report, using a sampling methodology, on measures targeting high-cost, chronic conditions. Fifth, MIPPA allows the secretary of HHS to post, on the CMS Web site, the names of physicians (or groups) who satisfactorily submit data on quality measures through PQRI. Sixth, it requires the HHS secretary to provide confidential feedback to providers regarding their resource use and to submit a plan to Congress regarding transition to a value-based purchasing program for physicians. Parsing MIPPA More specifically to medical imaging, MIPPA requires providers of the technical component for advanced imaging (MRI, CT, and nuclear medicine/PET) to be accredited before January 1, 2012, by an entity identified by the secretary of HHS for those providers to be eligible for the technical-component payment. The presenters report that the HHS secretary must designate accrediting organizations by January 1, 2010, and the accreditation organizations must have criteria to evaluate medical personnel, medical directors, supervising physicians, equipment, safety procedures, and quality-assurance programs. MIPPA also establishes a two-year, voluntary demonstration program to test the use of appropriateness criteria for advanced diagnostic imaging services by January 1, 2010. Hospitals are not included under these regulations, unless they are hospital outpatient facilities that bill for the technical component under part B. Bush notes that many of the quality requirements of the legislation are already components of ACR accreditation. Another area of interest to medical imaging facilities is the MIPPA requirement for validation site surveys. “Currently, the ACR performs random site surveys and scheduled site surveys,” Bush says. “MIPPA has language in its regulations stating that accrediting organizations must somehow validate that the facilities receiving accreditation are maintaining the requirements—that they are keeping up with what they said they were going to do.” The ACR’s random site visits do not cover everyone, Bush continues, “but MIPPA wants the accrediting organizations to validate this somehow. In response, the ACR is implementing validation site surveys, and every site would be subjected to a site survey once every three years. These are not replacing the random site visits and scheduled site visits; these would be in addition to them.” Bush adds, “These surveys are still intended to be educational. We will send the facility a final report advising it of what it is doing right and what can be improved, and if there is anything that it has to submit for corrective action, we would tell it what it needs to do.” The ACR expects to begin implementation of the validation site surveys in about six months. Pay for Performance and Value-based Purchasing On the subject of pay-for-performance initiatives, Burleson states, “There are a number of health systems and health plans that have implemented pay-for-performance programs, such as UnitedHealthcare’s Premium Physician designation, HealthPartners’ Partners in Quality program, and Cedars-Sinai Medical Group’s Measuring Quality Patient Care.” Burleson notes, “There has been a growth of local and regional quality-improvement organizations, and that has called for coordination through public agencies (primarily state agencies).” According to Burleson, “There are more than 20 regional measurement organizations and reporting efforts underway across the United States.” Burleson describes regional health information organizations (RHIOs) as another component of the quality campaigns. “One of the primary goals of a RHIO is to share information across jurisdictions using common and nonproprietary standards, so that the information can be shared,” she says. “CMS is also conducting several pilots in collaboration with RHIOs.” As for the impact on radiology of MIPPA’s provision that CMS must begin transitioning toward value-based purchasing, there are four outpatient imaging efficiency measures that are analyzed through claims data:

• MRI of the lumbar spine for low-back pain,
• mammography follow-up rates,
• abdominal CT with the use of contrast material, and
• thoracic CT with the use of contrast material.

The ACR has expressed opposition to the use of the mammography measure, as it is not robust enough “to get at whether or not the mammography that is being practiced is efficient or effective,” Burleson says. “We proposed to CMS the use of three core metrics to look at how well a mammography practice is doing,” she says. “In addition to the follow-up–rate measure, we suggested positive predictive value and cancer-detection rates, thinking that those three measures together will provide a better idea of what is going on in the mammography practice.” The four outpatient imaging efficiency measures are now in the public-comments phase, and the ACR plans to submit additional comments. As for the future, Burleson provides this outlook: “What we see coming is a greater focus on efficiency—the examination of resources—through programs such as resource-use reporting and inclusion of measures such as such imaging efficiency. More specifically, we’ll see CMS moving away from claims-based and chart-based quality measurements to the use of electronic medical records and registries. The value-based purchasing plan also will be transitioned from pay for reporting to pay for performance. More and more, the incentives that are achieved will be based on actual performance, rather than just on reporting information.”Steve Smith is vice president, client services, The Imaging Center Institute, Tustin, California.