Radiology practices that focus on the broad goal of using data to effectively drive high-value care will find success in the ever-changing landscape of Medicare payer performance programs.
Recent health care payment reforms, the impact of the new legislation on radiologists, and suggestions for preparing for implementation of upcoming legislative changes highlighted a Thursday session presented by Gregory Nicola, MD, finance chair and board member for Hackensack Meridian Health Partners and member of the executive leadership at Hackensack Radiology Group.
In the world of merit-based performance plans, Dr. Nicola said radiologists may have no idea if their organizations are in a shared savings program, and it is important for them to educate themselves and seek leadership positions so they can fight for payments that are theirs.
"We have to be really proactive in making sure we're striving toward quality and value goals to reduce long-term costs," Dr. Nicola said.
Federal legislation enacted in 2015 through the Medicare Access and CHIP Reauthorization Act (MACRA) sought to boost the quality and value of health care by linking physician payment to those metrics rather than through traditional fee-for-service models.
Implemented in 2017 within MACRA, the Quality Payment Program (QPP) was designed to compensate physicians according to performance in quality and value categories.
Dr. Nicola said physicians are paid via two broad models in QPP: Merit-Based Incentive Payment System (MIPS) a program that is essentially a fee-for-service program with limited component of income at risk and Advanced Alternative Payment Models (AAPP), which carry a somewhat more significant financial risk in the value measurement.
According to Dr. Nicola, within QPPs, there are numerous clinician types and numerous pathways to participate. "In MIPS, the most common clinician type is the MIPS Eligible Clinician. These clinicians can report into the value-based measurement process as individuals, a group or part of a virtual group."
He said everyone participating in MIPS receives a final score of 0-100 that is awarded based on measures of quality, improvement activities, promoting interoperability and cost with additional incentives for those who exceed performance thresholds.
Graduated Performance Thresholds Require Careful Planning
With MIPS, the risk increases as the years progress. "Medicare sets performance thresholds to pick winners from losers. These were initially low to encourage engagement resulting in lots of winners, and few losers," Dr. Nicola said. "The program is still too easy because we haven't set a baseline, but the higher threshold set for 2020 will be more challenging with more money given to clinicians who report accurately."
One significant change in the quality performance category for 2020 is that the reporting threshold for quality measure has increased to 70%.
Looking to the MIPS APM breakdown, Dr. Nicola said the quality performance category provides several ways to participate, and participants tend to be large systems with lots of specialties who can take advantage of being judged on many measures.
Radiologists perform particularly well in MIPS using the MIPS APM pathway. "We had more clinicians participating in 2018, and our 'above threshold' numbers were nearly 100%. They are scoring better than anyone else regardless of group size."
Dr. Nicola suggests practices seeking to maximize MIPS performance employ a "physician champion" to pursue optimal program participation and overcome obstacles to success. He said it is imperative to look ahead and plan for changes in the guidelines.
"It is important to have someone engage physicians in the group to help them better understand why it is necessary to capture data in the reports. Finally, it can be a challenge to create an effective feedback mechanism so the data gathered becomes actionable in the practice," he said.
Do you believe health care reform is headed in the right direction for radiology? #RSNA19— RSNA (@RSNA) December 5, 2019