The MACRA Survival Guide: How Radiologists Can Survive and Thrive

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 - Ezequiel “Zeke” Silva III, MD
Ezequiel “Zeke” Silva III, MD

It’s already Spring 2017, so if you're a clinician with a sizeable Medicare patient caseload, you're almost halfway through the first year in which you need to capture performance data to earn potentially big bonus dollars—or avoid increasingly painful deductions—starting in 2019. And if your specialty is radiology, be it diagnostic or interventional, you have some participation options unavailable to many other physicians.

Yes, CMS’s vigorous new Quality Payment Program (QPP), brought to life by the enactment of the Medicare Access and CHIP Reauthorization Act of 2015—aka MACRA—is upon us. Do you know where your quality measures are?

Covering the Basics

MACRA’s QPP replaces the Sustainable Growth Rate reimbursement formula. (Hence its nickname, the “Permanent Doc Fix.”) The QPP offers two avenues for participation: Advanced Alternative Payment Models (Advanced APMs) and the Merit-Based Incentive Payment System (MIPS). Most radiologists will be dealing with MIPS for now, making it the primary focus.

MIPS has four variously weighted performance categories that, together, incorporate and consolidate much of the alphabet soup of quality programs that made up MACRA’s forerunners. The Quality

category replaces the Physician Quality Reporting System (PQRS), while Advancing Care Information swallows Meaningful Use (MU) and Cost succeeds the Value-Based Modifier (VBM). A new category, clinical-practice Improvement Activities (IA) rounds out the program.

MIPS is open to any provider billing Medicare Part B more than $30,000 a year to care for more than 100 patients. Providers meeting those requirements still have until Oct. 2 to start collecting 2017 performance data, so it’s not too late to get started. CMS will need at least 90 days’ worth of data to make adjustments in 2019, and providers have until March 31, 2018, to officially submit that data.

Those are the rough contours of the quality-based payment landscape carved out by MACRA. For a guided tour of all the clearings and cliffs, the nooks and the crannies—including interactive, specialty-specific helps on choosing measures—providers can spend quality time at QPP.cms.gov, the user-friendly website developed by the Department of Health and Human Services.

The Freedom of Choice

Several aspects baked into MIPS make it less burdensome to work with than the legacy programs it replaces. For example, MIPS will require only six measures, where PQRS called for nine, and attesting providers no longer need to bother with National Quality Strategy domains.

Also, 2017 is a “pick your pace” transition year, demanding the reporting of only a single performance measure or practice-improvement activity, while 2018 picks up the pace some but still affords participants plenty of flexibility.

The objective is to give participants a chance to get to know the system before its payment adjustments become substantial. (And they will be quite substantial in just a few years. By payment year 2022, performance data from 2020 will either earn participants a 9-percent bonus or cost them a 9-percent deduction.)

 “We really wanted to tailor the first year in a way that allows for the real variation that reflects what we heard from clinicians in terms of readiness for this program,” says Kate Goodrich, MD, MHS, director and chief medical officer of CMS’s Center for Clinical Standards and Quality. “They can report on quality measures they’re familiar with and that are most relevant to their practice. They can look at the improvement activities category and see which ones make the most sense for their practice.”

Goodrich says her division drew from its close working relationships with the American College of Radiology (ACR) and the Society of Interventional Radiologists (SIR), holding face-to-face meetings and discussing comment letters referencing proposed rules to make sure radiology had a say in all the particulars of the program. She adds that fine-tuning the QPP to best suit each specialty remains an ongoing process, one that is unlikely to end any time soon.

That’s a good thing for specialists, as diagnostic radiology is essentially a “non-patient facing” specialty and needs provisions to comply. It gets such a break, not least in a weighting of 0 percent instead of 25 percent in the Advancing Care Information category. (This carries over from MU.) In addition, the requirement for Practice Improvement Activities, which considers broad healthcare-system aims such as care coordination and beneficiary engagement, is halved (20 points instead of 40). Diagnostic radiologists and other non-patient facers will make up the difference by having their Quality measures weighted at 85 percent instead of the traditional 60 percent figure that patient facers have for that category.

To help lighten the load for all providers, CMS has taken into account the reality that most initial measures in the Cost category are based on evaluation & management codes designed for primary care providers. That category is weighted at zero for the first year.

The Benefits of Reporting as a Group

For this first year, and probably for 2018 as well, radiologists in group practice would do well to report their MIPS performance as a group. That’s the studied opinion of Gregory Nicola, MD, vice president of Hackensack Radiology Group in New Jersey and chair of ACR’s committee on MACRA. Nicola is a co-author of a series of articles on the topic published in the Journal of the American College of Radiology. (“MACRA, MIPS and the New Medicare Quality Payment Program: An Update for Radiologists,” “The Proposed MACRA/MIPS Threshold for Patient-Facing Encounters: What It Means for Radiologists,” and so on.)

Group reporting for the first couple of years is “by far the best way to leverage data, mainly because you can consolidate measures across the group and lighten the reporting burden,” Nicola says. For example, a 40-radiologist group might submit six mammography measures even though only a few members of the group do mammography. In addition, the group could choose its best measure from among dozens it collected for a given clinical procedure as long as one member of the group is reporting on that procedure. Such an approach “allows you to collect a lot more measures and then tailor the measures to how well you performed,” Nicola says. 

However, he adds, there are select scenarios in which individual reporting makes more sense. These include situations involving a small group whose members vary markedly in their proficiency, for instance. If one of the radiologists is such a poor performer that he or she could tank the group’s scores down the road—meaning in subsequent years when multiple measures will be required—that group probably would be better off going with individual reporting, Nicola says.

“The members who do really well would get positive income adjustments and the one who did poorly would get a negative income adjustment—but it wouldn’t hurt the whole group’s income,” he says.

Registries at the Ready

MIPS is open to four mechanisms for reporting performance measures: claims data, qualified traditional registries, qualified clinical data registries (QCDRs) and electronic health records. The latter is a non-starter for radiologists for the time being, and experts seem to agree that QCDRs are the best option going forward.

QCDRs allow participants to report all traditional measures plus some innovative, specialty-specific measures that have never been reported by any other mechanism before. These new types of measures are typically designed by the registry operator working with members of the specialty, who work through their representative society or association.

In the case of radiology, that description points to ACR’s National Radiology Data Registry (NRDR) which recently added a sub-registry specifically for interventional radiologists. Nicola gives the NRDR a full-on endorsement, calling it “the most diverse and robust QCDR available.” He likes it for its attention to radiation dose control, incorporation of subspecialty-specific registries and inclusion of both process and outcomes measures.

“It gives you access to high-priority measures, for which you can receive bonus points that are harder to get with a qualified registry or claims database,” Nicola says.

Like most, if not all, registry operators, ACR charges fees for reporting performance measures to CMS.

“We have heard from a lot of clinicians who are paying these registries to report on their behalf that [the service] is, for the most part, well worth the cost,” Goodrich says. “It’s not exorbitant, and I think that’s partly why we are seeing such an increase in group reporting and less individual reporting over time.”

Stiff Penalties and Big Bonuses

Over time, participation in MACRA/MIPS becomes significantly more rewarding than its predecessors and doesn’t take long to get there. Where MU, PQRS and VBM each had adjustments in the 0.5 to 5 percent range in their early years, this all-encompassing QPP hits 9 percent as soon as reporting year 2020. The penalties will hurt, and the bonuses can quickly reach well into the double digits—potentially topping 30 percent for exceptional performers by as early as 2021.

That’s because the system is, by mandate, budget-neutral. It grades participants on a scale, and the poor performers’ penalties help fund the best performers’ bonuses. Plus the program allocates $500 million per year specifically for exceptional performers.

And who will these winners be? 

 “The physicians and practices that really dig into the rules and regulations really understand the reporting mechanisms and really understand the individual measures under which they are going to be judged,” says Ezequiel “Zeke” Silva III, MD, chair of ACR’s economics commission.

“The rules are complex,” adds Silva, who practices with South Texas Radiology Group, a 67-radiologist provider based out of San Antonio. “The rules are changing. It takes more than a cursory overview of the rules to become proficient” in applying their intent to improving patient care as well as leveraging participation to greatest financial advantage. 

According to Silva, getting there requires contemplating your mission and vision as a radiologist.

“You have to have a philosophical commitment to do this in order to reach the high end of the [bonus] spectrum,” he says. “You just do. Otherwise, to do it just for the money makes it more unpleasant than it has to be. And it runs the risk of putting a whole bunch of processes into place that don’t make any difference for patient care.”

Benefits Abound, So Why Wait?

Silva urges radiologists who are on the proverbial fence, mulling participation, to question themselves on goals, aspirations and desired reputation.

“When you look at all the details, it’s not hard to find yourself overwhelmed with the overall scoring system, the individual measures, how things are weighted, all the terminology,” he says. “It’s easy to become so overwhelmed that you just say ‘I give up.’”

He says opting out or doing the bare minimum early on may, in fact, be a valid and legitimate route for some QPP-eligible radiologists and group practices. At the same time, however, he points to the many helps, outreaches and resources available from ACR, SIR and CMS itself as both reasons to go “all in” and levers by which to do so.

“I am committed in my position with the ACR to help ensure the organization does its job to have the measures out there for radiologists,” says Silva, who presented on the subject at RSNA 2016 as part of ACR’s ongoing efforts to translate and disseminate usable information to the radiology community.

“The stronger we are together as a specialty, both locally and nationally, the more sure we are to remain relevant in healthcare long term,” he says. “And that is not a given.”

Looking beyond MIPS to episode-based care, such as that put forward by advanced APMs, radiology “is really going to have to prove its worth and prove its contribution,” Silva notes. “I think we are well-positioned to do so in current and future payment models.

It’s just going to take a deep philosophical and purposeful commitment.”

Not surprisingly, these present and future payment models have their detractors. In an opinion piece written for Medpage Today, internal medicine physician Caroline Poplin, MD, writes: “MIPS is just a transition to the ideal system, the Advanced Alternative Payment Model, where patients are cared for inside a vertically integrated healthcare delivery system managed by highly-paid corporate executives, reimbursed by capitation, at financial risk for profit and loss: an Accountable Care Organization accountable to payers, not patients.”1

Silva has a different take on it. MIPS and Advanced APMs, he says, offer participating clinicians and practices a good way to make meaningful strides toward improving not only their bottom line but also their operations and their standing within their communities and institutions.

 

“These steps are really driven by doctors’ desire,” he says, “to do their best for their practices, their facilities and their patients.”