Get off the sidelines: A radiologist’s guide to surviving payment reform

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 - Giles Boland, MD
Giles Boland, MD

Value-based payments in radiology are here, and they are evolving fast. Nobody knows how they will morph, stretch, bend or otherwise play out in practice over the coming weeks, months and years. But there’s no more time to sit around waiting to find out before taking steps to adjust and prepare.

On that note, Giles Boland, MD, launched into a spirited session at the California Radiological Society’s annual meeting and leadership summit in October.

Boland, radiology professor at Harvard Medical School, vice chair of business development and director of network development and referral management at Massachusetts General Hospital, began by bemoaning the lack of residents in attendance.

“Where are our young people?” he asked. “This is their future. It’s the same at RSNA. People will flock to sessions on T2 weighted imaging or diffusion weighted imaging for masses. Well, that isn’t going to help us in this environment.”

He pointed out that, next year, 30% of CMS payments—and by 2018, 50%—are going to be in the form of alternative payment models (APMs). In the same time frame, 85% of fee-for-service payments will be tied to quality and safety in 2016, rising to 90% by 2018.

He drilled down into dollars at stake due to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Merit-based Incentive Payment System (MIPS). He noted CMS’s proposed goal to secure 25% of payments by APM in 2019 and 2020, 50% of payments by APM in 2021 and 22, and 75% of payments by APM as of 2023—“which shows how much they want to move away from fee-for-service payments.”

And he reminded attendees that, under HHS’s National Quality Strategy (NQS), there are six domains by which eligible professionals may report quality measures in order to avoid financial penalties—patient safety; person and caregiver-centered experience outcomes (formerly “patient and family engagement”); communication and care coordination; community, population and public health; efficiency and cost reduction in use of healthcare resources; and effective clinical care.

Participating practices must choose at least three of these, and two of them have to be outcome measures.

“All of this is relatively complicated,” Boland said. “But it is an absolute game changer in terms of how we are going to get paid. So how are we as radiologists going to engage in this process and do something about it?”

Today’s to-do’s

He began answering that question by ticking off eight things radiologists can do if they’re not doing them already:

  1. Understand the environment. “Be informed,” Boland urged. “If you’re not informed, if you’re not reading about this stuff [and attending sessions like this one], how can you do anything about” the evolution of payment reform?
  2. Provide leadership. “Without leadership, we are all doomed. You are all leaders here. That’s why you are here. I would propose that you two residents who [knew enough to attend] are going to be leaders one day.”
  3. Understand how and where value is created. “There are a whole slew of things by which we can show we add value. But, frankly, for all intents and purposes, for 90% plus of what we do, value is all about the radiology report.”
  4. Provide vision. “Unless we as radiologists are aligned with our hospital leadership—with the mission, vision, values and agenda of our overall organization—we are going to be in trouble.”
  5. Change thinking and mindset. “One thousand years from now, medicine will still be innovating and changing, so we have to take on the mindset that we [too] are always going to be changing. There is no reason to wait for perfection. We need to continuously innovate.”
  6. Build effective teams. “The key to all of this is building effective teams. Whether you have a small agenda or a large agenda, you can’t do this without teams and collaboration.”
  7. Measure outcomes that matter to patients. “The things we measure mean almost nothing to patients. This is changing because of payment reform, but [let’s acknowledge that] we have been measuring things that are important to us—not what is important to our customers.”
  8. Communicate to all stakeholders. “Many of you are doing great things, producing great results. But your CEO doesn’t know it. Communicate all of the good things you are doing” up and down your organization’s chain of command.

“Here we are in medicine, and I would propose it is the most important business on the planet,” Boland added. “It’s our health. We are dealing with people and families and children and moms and dads. And we don’t really know on a day-to-day basis how much good we are doing.”

Remain relevant, radiologist

Boland went on to describe his work as chair of ACR’s Economics Committee on Value-based Payment Models. The committee recently finished creating a series of itemized measures for each of nine “value activities” that, taken together, comprise the college’s forthcoming Value Based Payment Metric.

“Some of these we already do. Some of them we think we can do but we don’t. And some of them are kind of pie in the sky,” Boland said, adding that the value-activities measures include a number of outputs “that we can use to justify to payors that we actually are increasing value while reducing costs and waste. And if you do all of these, I would propose that all of the data that you need for APMs and for MIPS will already be there.”

Boland zeroed in on a value activity titled Examination Outcome. Its itemized metrics include:

  • Did the referring physicians find the information useful?
  • Did results of imaging change diagnosis or therapy?
  • Did use of imaging eliminate need for more invasive/expensive procedures?
  • Did use of imaging reduce length of stay?
  • Complications
  • Patient satisfaction
  • Referring physician satisfaction

Did the referring physician find the information useful after I generate a report? “I have no idea—seriously,” Boland said. “When I send a report and it goes off into the RIS, gets into the electronic medical record, I don’t know whether or not the referring physician found it useful. I’ve got no feedback.”

Do what it takes to close the loop and get the feedback, urged Boland.

Did the use of imaging eliminate the need for more invasive/expensive procedures? “This is a key metric. We have to get on top of it,” he said, “because, if we are displacing other more expensive tests, we are onto a winner. If we can demonstrate that time and time again we can mitigate many other downstream costs, we are off to the races.”

Did use of imaging reduce the length of stay? “I think it did,” he said. “But how do I know? I’m just guessing. If we can quantify that and put it into the length of stay financial algorithm, we have a game changer” of our own.

Ultimately, the radiologist’s job is to help improve patient outcomes. And that’s rightly what payment reform comes down to, Boland said.

“Imaging is critical to precision medicine, and we know that,” he concluded. “We have to find a way to measure it and demonstrate it to our stakeholders such that we can remain relevant and thrive in the evolving payment reform agenda.”