MACRA's patient-facing threshold could cause problems for radiologists

In a study conducted by the Harvey L. Nieman Health Policy Institute and published in the Journal of the American College of Radiology, researchers found problems with the current reporting framework for Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-based Incentive Payment System (MIPS). They wrote that reporting could disadvantage several subsets of radiologists, citing a too-low threshold of patient encounters and surgical codes where radiologists are no longer eligible for certain considerations.

Instead, the study authors recommend raising the threshold of face-to-face encounters and excluding certain surgical procedures to ensure radiologists have a fair chance at ample reimbursement.

They argue many of the MACRA/MIPS performance measures are best suited for physicians with frequent face-to-face patient encounters, something often lacking in the dark reading rooms of radiology. One way CMS levels the playing field is through provisions for non-patient-facing specialties, setting an upper limit of 25 face-to-face patient encounters per year.

However, several major radiology organizations have decried the limit of 25 visits as too low, and researchers at the Harvey Neiman Health Policy Institute sifted through Medicare claims data to find out the real world consequences.

If the current threshold remains at 25, 72 percent of diagnostic radiologists would receive the provisions. While it may sound like a significant majority, the remaining 28 percent of radiologists aren’t constantly seeing patients; patient-facing billings make up just 2.1 percent of Medicare claims from those radiologists.

On the other hand, if CMS used a 100-patient threshold and excluded certain surgical codes, 98.8 percent of radiologists would fall under the provisions, with non-patient-facing encounters representing 10 percent of the remainder’s Medicare claims.

“Radiologists without special considerations by this definition would have a higher likelihood of success under MIPS, given the larger fraction of their practice represented by patient-facing encounters, including office visits and consultations,” the authors wrote. “Thus, the use of the larger threshold and exclusion of surgical codes for determining special considerations seem reasonable for diagnostic radiologists to avoid patient-facing encounters constituting a very low percentage of the overall patient care provided by those undergoing standard performance assessment.”

It’s important that imaging practices be able to predict their reimbursement, in order to properly adjust workflows and reporting methods. The two-year gap between the collection of claims data and its adjustments (2017 collection, 2019 adjustment) compounds the importance of knowing which provisions will apply to them.

“If radiologists can anticipate that they will receive the special considerations, then they can develop a successful reporting strategy for MIPS participation with no cross-cutting quality measure, only two activities in the clinical practice improvement category, and no reporting requirement in the advancing care information category,” the authors wrote.