Understanding the radiologist’s role in episodic payment
Radiologists can benefit from participating in episodic payment models—even those that aren’t radiology-focused. Capitalizing on opportunities to provide imaging during care episodes can push radiologists over the threshold for the positive payment adjustments that come with meeting the criteria for Advanced Alternative Payment Model (APM) participation.
Solving the fragmentation problem
Health policy experts such as former CMS administrator Donald Berwick recognized the need for new reimbursement models as healthcare costs continued to rise during the latter half of the 20th century and into the current millennium. The fee-for-service model had resulted in severe fragmentation of care, with no single group taking responsibility for the health of the patient or the cost of services rendered. In addition, gaps in communication between care providers resulted in repeat services. For radiology, this meant duplicative or inappropriate imaging.
In response, the ACA created the CMS Innovation Center (CMMI) to develop and test new delivery and payment models, including episodic payment models (EPMs).
“The new models focus on heightened care coordination and better integration during the transition between inpatient and post–acute care settings,” wrote Gregory Nicola, MD, et al, in an article in the Journal of the American College of Radiology. “Although these new EPMs are not radiology-specific, many radiologists are nonetheless likely to have their payments influenced by this payment model, either directly or indirectly.”
Three episodic care programs with relevance to radiology are the Bundled Payment for Care Initiative (BPCI), the Comprehensive Care for Joint Replacement (CJR) program and the Oncology Care Model (OCM). Given the role of imaging in various settings the BPCI represents an opportunity for radiologists to partner with other specialists, boasting a favorable risk-reward ratio relative to other payment models. The CJR is more specific, but offers similar benefits, according to the authors.
“As with the BPCI, CJR is built using diagnosis-related groups and is relevant to radiologists given the routine inclusion of imaging during rehabilitation and recovery after joint replacement surgery,” they wrote.
The OCM is another accessible EPM for radiologists, given how imaging often guides clinical decision making in cancer patients. As a caveat, 2017 brings a two-sided risk arrangement for OCM, opening up care providers to possible negative adjustments to reimbursements.
Season 2: New episodes available
CMS introduced three new EPMs in 2016, managing the care surrounding acute myocardial infarction (AMI), coronary artery bypass graft (CABG) and surgical hip and femur fracture treatment (SHFFT). These should expand the scope of episodic payment models in the U.S., according to the authors.
“The high prevalence and relatively homogeneous nature of the three selected conditions are intended to result in a much more diverse range of hospitals gaining experience in episode-based care,” they wrote. “Moreover, the emphasis on chronic conditions (in comparison with the elective nature of lower-extremity joint replacement in the earlier CJR initiative) requires greater consideration of both planned and unplanned care.”
The hospital-focused EPMs are an intentional choice, according to the authors. CMS chose to focus on hospitals because of their centralized role in patient care, relying on them to step up to improve coordination and care planning.
“Hospitals are already involved in such tasks as discharge planning, post-discharge recommendations and quality improvement and may be most likely to have the resources necessary to innovate in care coordination,” wrote Nicola et al.
These new models are mandatory for hospitals in specific geographic regions and can result in a positive or negative adjustment to reimbursement after an end-of-year review, known as reconciliation. Participating in these EPMs can allow physicians to be paid under the Advanced Alternative Payment Model (APM) program, rather than Merit-Based Incentive Payment System (MIPS).
Choose your own APM pathway
Providers who qualify as APM participants are exempt from MIPS and the possibility of penalties, while at the same time receiving benefits—a 5 percent bonus payment from 2019 to 2024, provided they remain APM-eligible. To be eligible for these benefits, a certain percentage of patients or payments must come through an advanced APM: 20 percent of patients in 2019 and 2020, increasing to 35 percent in 2021 and 2022 and 50 percent from 2023 onward.
“At present, Advanced APM pathways will ultimately exist for OCM, CJR and the more recently introduced AMI, CABG, and SHFFT EPMs,” they wrote. “Nonetheless, BPCI has not been altered and continues to not qualify as an Advanced APM.”
Nonetheless, BPCI could remain the best option for radiologists hoping to hit that 20 percent threshold. Imaging exams are heavily involved in treating conditions included in the program, such as stroke, bowel obstruction and orthopedic procedures.
“Ultimately, these opportunities will need to mature, particularly because they allow radiologists to qualify as Advanced APMs, if radiology is to optimize its performance under MACRA,” wrote Nicola et al. “Radiologists could arrange with the risk-bearing hospital to interpret the inpatient and post-discharge imaging relevant to the given condition (for example, joint rehabilitation or cardiac rehabilitation) to meaningfully participate in the hospital’s episode-based payments.”
The 2016 election could have a large impact on episodic payments. The CMMI is on HHS Secretary Tom Price’s chopping block. He also had promised to make all value-based payment programs voluntary, but that will come in the second phase of the GOP’s repeal-and-replace process for the Affordable Care Act (ACA), what he and others have been calling the “regulatory prong.” The House will vote on the American Health Care Act (ACHA) later this week, but it’s increasingly unclear if they will reach the 213 votes needed to send the bill to the Senate. It’s important to note MACRA is a piece of legislation completely separate from the ACA, so ACA repeal does not remove MIPS as well.
Still, ACA repeal-and-replace is not a foregone conclusion, said Chris Sherin, Director of Congressional Affairs for the American College of Radiology, and radiologists should keep their ears to the ground to see how the politics play out.
“Regardless of their eventual form, this interest by the CMMI in specialty practitioner payment models is promising regarding the future outlook for heightened opportunities for radiologists to participate in episode-based payment models in lowering spending while improving care quality and overall levels of health,” wrote Nicola et al.