Quality: The ACR Perspective

Geraldine McGinty, MD, MBA, chair of the ACR® Commission on Economics, explores the difference between ACR and payor positions on quality. RBJ: Do employers, insurers, and patients agree with the radiology specialty, when it comes to the definition of quality? McGinty: There are some basic quality measures that we, at the ACR, consider to be a bottom line and an absolute requisite, such as ACR accreditation. There are enhancements—such as participation in the various quality measures, the Physician Quality Reporting System measurement set, and things like dose registries—that we consider to be additional measures of quality. Payors vary in the degree to which they recognize any additional measures. ACR accreditation is a fairly widespread concept that many payors have recognized and acknowledged. In many cases, our perception is that cost is more important than quality to them. The payors would probably tell you otherwise. There are programs where patients are offered rebates to choose a cheaper facility, without really being told that it is not the facility that their physicians requested they go to; this suggests that there is more of an emphasis on reducing the cost of the service, as opposed to respecting the relationships the referring physicians might have with the imaging providers they chose. I wrote an article¹ for the ACR Bulletin on this topic. Anthem in New Hampshire has a program called Smart Shopper. There are other programs where there are rebates to patients for choosing a cheaper facility. Believe me, we are certainly committed to patients getting the best value, but patients aren’t necessarily getting all the information they need about the fact that this might not be the imaging facility that their referring physician felt was the most appropriate. If I work with a clinician, and we’ve developed a relationship, there is an ability to communicate. There is an understanding. I get comfortable with the level of concern that the physician has, and he or she gets comfortable with my readings. Clinicians also are comfortable with calling me to ask, “Is this the right test?” rather than ordering a test that might not be the most appropriate. That’s what we see lacking when patients are steered solely based on cost, and that’s when the insurance companies don’t value what we do. RBJ: How much are payors willing to sacrifice for lower prices? McGinty: It is difficult to speak about payors as a homogenous group. When we see programs where patients are steered to other providers after their referring physicians have recommended an imaging facility, we have to wonder whether the value of that consultative relationship is something that the payors also value. I would have to assume they are willing to sacrifice that relationship. RBJ: What is the consequence of such a sacrifice? McGinty: The sacrifice is potentially not getting the right image the first time. If you send patients for a follow-up study, and they go to a different facility, it’s possible that the second facility may not have, or may not get, the prior imaging, and so the reading might not be as accurate. It’s not that they are not doing a good job; it’s just that they would not have the history and the prior exams to compare. Obviously, if (as a payor) you are just sending a patient to a cheaper facility, you might be prepared to sacrifice that quality. I would very much hesitate to include every payor in that scenario, however. RBJ: Whom do payors trust? McGinty: The ACR has been a leader in the development of appropriateness criteria. That process has been a significant collaborative effort of radiologists and other specialties—because obviously, some of our tests are performed by other specialists as well. We believe the appropriateness criteria are the very best way to manage appropriate utilization. Many payors use RBMs. It’s our position and our belief that the potential savings offered by those RBMs are not real savings. They just transfer costs onto referring providers, who then must spend a lot of time getting authorizations. They make care difficult for patients. Of the tests that they deny, the large majority meet their own medical-necessity criteria, so we believe that having physicians consult with physicians about appropriate testing is the best way to make sure patients get the right tests. RBJ: Payors want a lot from radiologists, and it seems that they want it for less and less. Is there a fundamental disconnect between what payors will pay and what radiologists believe that they are worth? McGinty: There are business decisions that payors make about what they are prepared to pay for care. I think radiologists are an extremely valuable and integral part of the delivery of high-quality and high-value care. We are the very best medical professionals to help referring physicians and patients navigate through the very complex array of tests out there. We know, better than anybody, which test fits which clinical scenario, and we are a very valuable part of the care team. RBJ: Do nonradiologist physicians feel the same way? McGinty: When physicians are asked what the key medical innovations over the past decades are, CT and MRI are way at the top. Radiology, imaging, and radiologists have contributed a huge amount to the health-care field, and utilization has flattened. Further cuts would seem absolutely unfair and unwarranted. Utilization is back to the levels where it was in the early 2000s. I think radiologists provide a very high-value service in the delivery of integrated care. These are life-saving tests. These are tests that can keep people out of the hospital. These tests can pick up cancer while it’s still extremely treatable and curable. RBJ: Where do payors want reimbursement levels to be in the future—and where do you think they will be? McGinty: Certainly, radiology and radiologists have been hit with successive cuts, from the DRA to the various Multiple Procedure Payment Reductions (MPPRs). Most recently, we have seen the really egregious professional-component MPPR of 25% when two physicians read studies on the same patient on the same day. We are continuing to fight back on that because it’s a flawed policy. The recent proposed application of it across group practices is even more specious. We certainly think radiology has been unfairly targeted, in the recent past, as being a significant contributor to the growth in health-care costs. The administration and CMS have made it very clear that they want to improve reimbursement for primary-care physicians, and this is a way to take funds away from one specialty and give them to another. Their rationale for the 25% MPPR is that there are efficiencies when the same physician provides two services, and that there are efficiencies when different physicians in the same group provide two services. We published a paper² last summer demonstrating that those efficiencies—if, indeed, they exist at all—are negligible. If I were a patient, I would want both of my studies to be read at 100% by the physicians, not by one at 25% less. When two separate physicians provide separate services, it is really hard for me to understand how they can rationalize the MPPR.