INTRODUCTION. The Medicare Access and CHIP. Reauthorization Act (MACRA) of. 2015 [1] launched a new federal value-based
OPINION
Radiologists May Now Be Accountable for Containing Medicare Costs and Spending Under MACRA Andrew B. Rosenkrantz, MD, MPA, Joshua A. Hirsch, MD, Ezequiel Silva III, MD, Gregory N. Nicola, MD INTRODUCTION The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 [1] launched a new federal value-based payment program named the Quality Payment Program (QPP) [2] that seeks to improve quality of care while containing health care spending [3]. Under the QPP, most physicians will receive positive or negative payment adjustments according to the Merit-Based Incentive Payment System (MIPS) [4]. These payment adjustments will be based on a final score reflecting the weighted total of the individual scores in four separate performance categories: quality, cost, advancing care information, and improvement activities. Cost reflects the amount of physicians’ utilization of health care resources, consistent with an aim of MACRA to promote efficiency and reduce wasteful spending. Although all physicians are exempt from cost in the first MIPS payment adjustment year of 2019, cost will increase in its contribution to the final score in future years, reaching 30% by 2021 [4]. The QPP includes provisions to ensure that the measures and subsequent incentives remain based on factors under physicians’ control. These provisions exempt certain physicians from those individual measures
or overall performance categories that are typically not under their influence. Radiologists typically do not order imaging and procedural services, limiting radiology’s impact on cost. Thus, radiologists may assume that they will receive exemptions from the cost category, whether from specific cost measures or the entire cost category itself. However, it is possible that some diagnostic and interventional radiologists will be scored on cost. Accordingly, radiologists should be knowledgeable about the cost category and approaches for success.
THE COST CATEGORY The cost category includes measures that assess the extent of physicians’ utilization and spending on tests, therapies, hospitalizations, and other medical services [4]. The measures entail complex formulas that adjust for patient risk factors, geographic variation (eg, for local wage differences), and hospital structure (eg, for hospitals with teaching programs or larger volumes of uncompensated care). The cost measures use various methods for attributing individual Medicare beneficiaries and their costs during a specific hospitalization or episode of care to the responsible physician. The average spending
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levels for all of a physician’s attributed beneficiaries are compared against expected spending levels based on national data to determine the scores for the cost metrics. This standardization is intended to incentivize physicians to provide more efficient care in comparison with the expected benchmark spending levels. The QPP reduces the reporting burden for physicians with infrequent face-to-face patient encounters [4,5], referred to as “non-patient-facing” physicians. This designation lowers reporting requirements in the advancing care information and improvement activities performance categories, but not cost. A radiologist is still scored under cost if reaching a predefined attribution threshold regardless of patient-facing status. Indeed, CMS states in the 2016 MACRA final rule [4], “We did not propose to preclude non-patient facing MIPS eligible clinicians from receiving a score for the cost performance category..If non-patient facing MIPS eligible clinicians do in fact have sufficient case volume, however, they would be attributed measures.” The cost category includes three measures, two of which are unlikely to be attributed to radiologists or other physicians with infrequent face-toface patient interactions [4]: (1) total
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spending per capita and (2) episodebased measures. Total spending per capita includes spending for primary care services on the basis of a list of applicable Healthcare Common Procedure Coding System codes (eg, codes for office or outpatient visits for new or established patients), which radiologists generally do not provide. In comparison, the “episodebased” cost measure assesses resource utilization by specialist physicians during specific clinical episodes. The 10 episodes specified by CMS for the first MIPS performance year are all specialized invasive procedures (eg, mastectomy, coronary artery bypass graft, cholecystectomy, hip replacement, and transurethral replacement of the prostate) [4], which radiologists also generally do not perform. Thus, radiologists will not meet thresholds for total per capita costs or the first year’s episode-based measures and will be exempt from these cost measures.
MEDICARE SPENDING PER BENEFICIARY The third cost measure is Medicare spending per beneficiary (MSPB). Because radiologists will not receive sufficient attributes under the two previously described cost measures, the MSPB is significant. This single measure could determine radiologists’ entire cost score should radiologists reach MSPB thresholds and be the sole contributor to the 30% that cost contributes to a radiologist’s final score. MSPB focuses on resource utilization in the hospital setting, reflecting total spending for all Medicare Part A and Part B services during an inpatient hospital admission, as well as during the 3 days before and 30 days after the hospital admission. For each hospital admission, all applicable spending is attributed to the single 2
physician deemed most responsible for that patient’s management. By identifying one responsible physician, CMS seeks to encourage greater care coordination and responsibility, incentivizing physicians to partner with other providers within and beyond the hospital setting [4]. The accountable physician is designated to be the physician who bills for a plurality, or the greatest fraction, of the patient’s Medicare spending during the hospitalization [4]. Diagnostic and interventional radiologists could provide the greatest charges, thus being attributed patients and held accountable for their spending. For example, if a patient with trauma or transient ischemic attack were to have a brief admission during which multiple imaging studies and image-guided interventions are performed, but with no or limited services by other specialists, then a single radiologist who renders all such services may bill for more services than any other individual provider. MIPS allows physicians to report measures either as individuals or as part of a group. Many radiologists will choose to report as a group because there are practical benefits to doing so, including less expense, time, and administrative burden. Additionally, a wider range of measures are often available at the group than at the individual level. Despite the advantages of group reporting, there may be a downside with regard to cost. In MIPS, participants will be subject to evaluation by the MSPB measure, and thus the cost category, if attributed 35 or more beneficiaries in a given year. By definition, the MSPB measure attributes patients to individual physicians and not to groups. Individual radiologists are unlikely to reach the threshold of 35 attributed patients annually under MSPB. Such radiologists would thus be exempt
from cost when reporting as an individual. However, when reporting as a group, patients attributed to individual group members are summed across the entire group. This aggregate number of attributed patients at the group level increases a group’s risk of meeting the 35-beneficiary threshold. For example, if three members of a group each have 12 attributed beneficiaries, the group as a whole will be deemed eligible for MSPB evaluation (36 attributed beneficiaries total), even though no individual member of the group approaches the threshold.
CONCLUSION: MSPB, COST, AND RADIOLOGISTS Radiology practices should assess their likelihood of meeting the 35beneficiary threshold for the MSPB measure to result in scoring in the cost category. To accomplish this, practices may assess the semiannual feedback reports that will be provided under the QPP [4]. These reports will include data for all MIPS performance categories, thereby providing radiologists’ number of attributed beneficiaries for the cost measures. Receiving such information at an early stage will allow individual radiologists and radiology groups to prepare and adjust their practice patterns. Moreover, in the spirit of MACRA’s goals, radiologists should take cost and resource utilization seriously and consider how they can contribute to more efficient and coordinated care. Admittedly, it may be unrealistic for a radiologist interpreting the imaging for an inpatient to substantially alter overall spending during a period from 3 days before to 30 days after that admission. However, it may be possible for the radiology practice as a whole to pursue initiatives that contribute to
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decreased utilization. Such actions may include partnering with other specialties in their health system or network and collaborating in initiatives such as clinical decision support that achieve more appropriate utilization. Moreover, radiologists will stand to do better in cost if the system in which they practice has achieved coordinated efficient care. The Radiology Support, Communication, and Alignment Network [6] and the Emergency Quality Network [7] are examples of two national initiatives that foster multidisciplinary collaboration to improve care efficiency, among other end points. Such
programs provide models of how radiologists stand to improve resource utilization in their systems.
REFERENCES 1. US Congress. H.R. 2—Medicare Access and CHIP Reauthorization Act of 2015. Available at: https://www.congress.gov/bill/114thcongress/house-bill/2/text. Accessed August 20, 2016. 2. Centers for Medicare and Medicaid Services. Quality Payment Program. Available at: https:// qpp.cms.gov. Accessed January 19, 2017. 3. Rosenkrantz AB, Nicola GN, Allen B Jr, Hughes DR, Hirsch JA. MACRA, MIPS, and the new Medicare Quality Payment Program: an update for radiologists. J Am Coll Radiol 2017;14:316-23. 4. Centers for Medicare and Medicaid Services. 42 CFR parts 414 and 495. Medicare program;
Merit-Based Incentive Payment System (MIPS) and alternative payment model (APM) incentive under the Physician Fee Schedule, and criteria for physician-focused payment models. Final rule. Available at: https://s3. amazonaws.com/public-inspection.federal register.gov/2016-25240.pdf. Accessed October 27, 2016. 5. Rosenkrantz AB, Hirsch JA, Allen B Jr, Wang W, Hughes DR, Nicola GN. The proposed MACRA/MIPS threshold for patient-facing encounters: what it means for radiologists. J Am Coll Radiol 2017;14:308-15. 6. American College of Radiology. Radiology Support, Communication, and Alignment Network (R-SCAN). Available at: http://www. acr.org/Advocacy/Economics-Health-Policy/ Imaging-3/PQI-Initiative. Accessed September 8, 2016. 7. American College of Emergency Physicians. Emergency Quality Network (E-QUAL). Available at: https://www.acep.org/equal/. Accessed January 19, 2017.
Andrew B. Rosenkrantz, MD, MPA, is from the Department of Radiology, NYU Langone Medical Center, New York, New York. Joshua A. Hirsch, MD, is from the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. Ezequiel Silva III, MD, is from South Texas Radiology Group, San Antonio, Texas; and the Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Gregory N. Nicola, MD, is from Hackensack Radiology Group, PA, River Edge, New Jersey. Dr Rosenkrantz is supported by a research grant from the Harvey L. Neiman Health Policy Institute. Dr Hirsch has received fees unrelated to the present work from Medtronic, Carefusion, Globus, and Codman Neurovascular. All other authors have no conflicts of interest related to the material discussed in this article. Andrew B. Rosenkrantz, MD, MPA: Department of Radiology, Center for Biomedical Imaging, NYU School of Medicine, NYU Langone Medical Center, 660 First Avenue, 3rd Floor, New York, NY 10016; e-mail:
[email protected].
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