Medicare reimbursement in the U.S. is rapidly changing under the Medicare Access and CHIP Authorization Act (MACRA). Several alternate payment models (APMs) are being rolled out, including bundling, Merit-based Incentive Payment System (MIPS) and the Accountable Care Organization (ACO) Shared Savings Program (SSP). Danny Hughes, PhD, Senior Director of the Harvey L. Neiman Health Policy Institute in Reston, Virginia, spoke to Radiology Business about radiology’s role in SSPs, as well as future roles for imaging in these new reimbursement models.
Radiology Business: How has the Shared Savings Payment (SSP) model worked so far?
Danny Hughes: They haven’t been overly successful overall in the realm of generating real broad savings for providers. Practices and health systems are dropping out, and those that are continuing are moving to the next generation ACO model, which is a different way of managing two-sided risk and savings benchmarks.
Why aren’t they as successful as they could be?
It comes down to the cost benchmarks. The benchmarks are too aggressive, and once you’re in the program, you’re expected to have continued decreases in cost. For example, Dartmouth Medical Systems dropped out of ACOs a couple weeks ago, simply because they couldn’t manage to generate savings, because they were already a low-cost provider. The majority of ACO savings are almost entirely from better management of post-acute care. Moving to skilled nursing versus home health, managing readmission better—that’s where the lion’s share of ACO savings are coming from. But, if you’ve mastered post-acute care, it’s hard to generate consistent savings. In addition, the vast majority of ACOs that are generating savings are integrated health systems. Imagine if you’re Kaiser or Cleveland Clinic and you’ve already got a managed care component—why wouldn’t you participate in an SSP?
How does radiology fit into the equation?
Well, imaging has very little involvement in post-acute care, so when you’re thinking about savings, there’s little reason to expect reimbursements to come back to the radiologists. So how to radiologists participate in an ACO? Basically, not in an SSP.
It’s not that there’s no participation for them, but SSPs are really not designed for specialty providers. They’re designed for hospitals and integrated health systems. Primary care physicians have a role—no special provisions—but they can make decisions that guide care a bit more proactively than a specialist like a radiologist or an anesthesiologist. It can be difficult for radiologists to have a voice, which gives hospitals very little incentive to incorporate them into the program. Even when they do, radiologists get a tiny portion of the reimbursement, because post-acute care is where the savings are greatest.
In spite of the limitations, what should a radiologist do to participate in an ACO?
I think for most practices, the key is trying to find solid participation in Merit-based Incentive Payment System (MIPS). Registry reporting becomes an easy way to meet MIPS criteria. In addition, we are working on a special dispensation allowed for practices that are deemed “non patient-facing.” They haven’t codified what it means to be patient-facing, but if radiologists fall underneath the exemption it becomes easier to be reimbursed under MIPS.
The wonderful part about radiology is that it is already outperforming most specialties in Physician Quality Reporting System participation. The fact that we’re able to leverage things like registries to provide quality input is nice; it doesn’t require onerous EMR or IT systems to try to push these quality metrics out. Claims data is already being collected by CMS.
I think any practice that chooses to be proactive, get their data together and push out the quality data that’s already in existence, they’re all going to be fine. Under the MIPS framework, there’s plenty of room for radiologists to be leaders.