5 minutes with Richard Duszak, MD: From fee-for-service to value-based payment

Last week, Secretary of Health and Human Services Sylvia Burwell announced plans to accelerate the timetable for Medicare’s move from a fee-for-service to a value-based reimbursement system.

HHS’s goal is to have 30% of traditional Medicare payments in alternative payment models such as accountable care organizations, bundled payments or population-based payment by the end of 2016, increasing to 50% by 2018. Overall, HHS will seek to link 85% of Medicare fee-for-service payments to quality or value metrics by the end of 2016, with that percentage increasing to 90% by the end of 2018.

Radiology Business asked Richard Duszak, chief medical officer and senior research fellow of the American College of Radiology’s Harvey L. Neiman Health Policy Institute to give us his take on the announcement by HHS.

Duszak: We’ve all collectively been talking about moving the healthcare payment system from one that’s volume-based to one that’s value-based for quite a while.  I think that’s clearly the direction in which we need to go, but like a lot of bold initiatives, the devil is in the details.

And what I mean by that is that while we all can agree that our payments should be value-based as much as possible, the operational dilemma in getting us to that point is that the metrics that currently exist as a means of measuring value are not—in a lot of cases—ready for prime time, particularly as they apply to some subspecialty services, and I include radiology in that group.

One of the dilemmas that we have as radiologists is that measuring outcomes related to radiology can be quite difficult because there are so many downstream things that happen after we render our services—and over which we have no contol—that impact outcomes.

One of the examples I like to use is the case of appendicitis. I may be on clinical duty and see a teenager with a very subtle case of appendicitis where I pat myself on the back for making this really fantastic, subtle call. I do everything right. I pick up the phone, track down the referring physician, call him or her, and say I think your patient has really early appendicitis.  I basically did everything possible as a radiologist to impact care in that case.

But what if that family practitioner refers that patient to a general surgeon who has the worst performance track record, the highest incidence of complications, and the worst bedside manner. And then the patient is asked through some type of satisfaction survey to [evaluate] the encounter? A lot of that will reflect upon the surgeon, but I was part of the "team"of care there and I can get pulled into a potentially less than favorable outcomes score.

So how does one measure the value of my services?  If you ask that referring family physician he or she would say I was great, but if you look at the whole encounter I can potentially get lost in the process.

That being said, I think it's great CMS is putting forth these bold initiatives for us to move into value-based payment systems. The goals are awfully ambitious, particularly if they are they are intended to be applied on a general basis rather than in certain niches, because the goals and the timetables are more ambitious than the level of evidence and the ability to measure a value as it currently stands.