The value-based care era predates the passage of the Affordable Care Act in 2010, but that landmark event sufficiently reordered the rules of the game that modern pay-for-performance (P4P) watchers do well to start there.
Key subsequent developments included the Medicare Access and CHIP Reauthorization Act of 2015 (aka MACRA, aka the “permanent doc fix”) and the P4P system it spawned, Medicare’s Merit-Based Incentive Payment System (MIPS, which went live on New Year’s Day of 2017).
Ever since the latter date, diagnostic radiology has been one of the most challenged of all medical specialties to show its value via MIPS reasoning and reporting parameters.
A significant difficulty has been demonstrating imagers’ contributions apart from reading exams quickly and accurately. The whole “non-patient facing” thing enters the picture right about there—for both radiology groups and individual radiologists.
Fast-forward to the summer of ’22. The Journal of the American College of Radiology recently asked three experts on radiologist compensation for a written answer to a pressing question:
- In creating the ideal practice-level P4P program, what elements must be considered, avoided and emphasized?
JACR published the responses online August 1 [1]. For RB readers lacking access to the journal, here are money quotes from each of the three.
Ryan Lee, MD, MBA, Chair of Radiology, Einstein Healthcare Network (Philadelphia): P4P “can mean performance in metrics specific to radiology, but it can also represent compensation for non-productivity-based tasks,” Lee writes. “Ideal nonproductivity elements to be included can involve categories that track performance of educational, administrative and patient-facing activities. The metrics in these different categories, and the worth of each, can vary based on the nuances of each practice.” More:
Including these other elements in radiologist compensation reduces the incentive of only looking at volume and increases recognition that other radiology activities are also important. However, it is important to remember that revenue generated by radiologists’ clinical services (RVUs) ultimately dictates the pool of money available to be apportioned to these other activities.”
Geraldine McGinty, MD, MBA, Senior Associate Dean for Clinical Affairs, Weill Cornell Medicine (New York City): “Use of extant metrics such as those created by the ACR will obviate a practice from having to develop its own,” McGinty points out. “Metrics development is challenging, and failure to set appropriate parameters can render measures useless. Practices should be wary of the ‘folly of expecting A while rewarding B.’” More:
If the only component of performance measurement is tracking RVU productivity, then we should not be surprised if some radiologists neglect more complex cases or fail to do the clinical follow-up and relationship building that are also essential components of a high-quality practice. A ‘balanced scorecard’ approach to performance measurement with components related to both productivity and practice building, as well as quality, not only will mitigate unintended consequences of misaligned incentives but will also recognize the diversity of skills across a practice so that all can feel valued in their contribution.”
Lauren Nicola, Chief Executive Officer, Triad Radiology Associates (Winston-Salem, N.C.): “Enforcing accountability in terms of performance measures can be just as toxic as enforcing productivity in terms of RVUs unless several factors are considered,” Nicola comments. “First, a P4P program at the practice level must be achievable, not aspirational. … Second, when it comes to choosing what to measure, quality-of-work products again trump quantity. … Third, if the goal of a P4P program is truly to improve health at a population level, the program cannot divorce quality from cost.” More:
Performance measures must account for resource use, otherwise any gains in quality will be erased by a bankrupt system. Are we really doing our patients a service by creating a system that incentivizes the detection of every tiny pulmonary nodule and recalling every screening mammogram without regard for overutilization and overdiagnosis? In the modern era of healthcare, the success of any P4P program depends upon its impact on both quality and cost of care.”
The paper’s corresponding and senior authors, Joshua Liao, MD, and Christoph Lee, MD, MBA, both of the University of Washington in Seattle, conclude by remarking that any performance measure “will be open to ‘gaming the system’ when tied to financial incentives, and thus practices will have to revisit and reassess P4P structures on a regular basis to ensure that they align with the mission and vision of the practice.”
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.