RBMA15: Reading the tea leaves on physician payment

 - RBMA2015
From left: Wendy Lomers, CPA, MBA, Keith Chew, MHA, CMPE, Jim Hamilton, MHA, CMM

Finding a path into the future is challenging in these times of change and uncertainty, but three Radiology Business Management Association (RBMA) board members did their best to shed light on one of the murkiest topics in radiology today: the future of physician payment.

Cindy Pittmon, RCC, chair of the program committee, moderated a panel discussion, “A View from the Top,” at the RBMA Spring Summit, on June 9, in Las Vegas, Nev. The panelists were Keith Chew, MHA, CMPE, president of the RBMA board of directors; Jim Hamilton, MHA, CMM, administrator, Medical Imaging Physicians, Dayton, Ohio, and board treasurer; and Wendy Lomers, CPA, MBA, immediate past-president of the RBMA board.

Chew predicted a higher volume of bundled payment moving forward. “As it stands now they are bundling services seen as episodes of care, like joint replacement, but they also are looking at things like PROMETHEUS Payment,” he said.

(PROMETHEUS Payment is an evidence-based methodology for packaging payment around a complete episode of medical care that covers all patient services related to a specific illness or condition, developed largely through the support of grants from the Robert Wood Johnson Foundation, as well as the Commonwealth Fund and several others.)

Just over the horizon, the Merit-based Payment Incentive System (MIPS), going into effect in 2019, is viewed by Chew as largely positive in that it will ultimately streamline reporting by combining multiple types of quality and performance data. Although the precise measures have not been selected, they are likely to include PQRS, MU and the Value-based Payment Modifier data.

“Under the MIPS program, we are going to be able to develop specialty-specific radiology metrics,” Chew said. “This is extremely exciting for radiology. We will get to the point where we as an industry can start to determine our own quality metrics.”

With a growing percentage of their income at risk, radiologists must embrace the quality movement, Lomers said: “Right now, they resent it.” Because their data will be posted on the Physician Compare web site, physicians will have more than income at risk.

The only way to sidestep the MIPS program is to participate in an alternative payment model. “If your practice is doing 25% or more in an alternative payment model, then you can avoid all of this,” she said.

State, private payor activity

Hamilton reported that Ohio is preparing to launch its own bundling pilot for the Medicaid program, called the State Innovation Model and funded through a CMS   Innovation Grant. Five episode of care have been identified—COPD, asthma, perinatal care, total joint replacement, acute/nonacute PCI—on which providers are currently receiving performance reports.

“Some of those don't have a whole lot of radiology involved, but there will be more,” Hamilton said. “This is just a beginning,” he said.

A second wave of episodes—upper respiratory infection, urinary tract infection, cholecystectomy, appendectomy, colonoscopy, upper GI endoscopy, and GI hemorrhage—has been identified for which providers will begin receiving performance reports in 2016, with the goal of rewarding the best providers.

Private payors already have introduced bundled payments in many of the markets where Chew works. He noters that radiologists will need to have a firm handle on resource-use in these situations. “They payor approaches the system and starts talking about the fact that they want to bundle the hip replacement, and then the system has to work with providers to find out how people get paid,” he said.

As a consultant with a practice management and business intelligence collaborative, Chew has access to analytics and a broad database of billing and utilization data. “Under CMS guidelines, four X-ray are the standard of care,” he said. “We went in and found out that as few as one and as many as nine were being done.” In that situation, the practice had to team with the organization to work with outliers.

Not only will resource use be scrutinized, it will be factored into future payment schemes, Lomers noted, including the MIPS computation.  

CDS, or else

The mandate to implement clinical decision support (CDS) is another situation in which resource use will impact reimbursement. Outlier physicians with the highest advanced-imaging resource use will begin to feel penalties in 2020.

“The law says it must be in place by 2017, but the rules are not in place yet,” Chew noted. One thing that is known, is that