Neiman Institute’s Hughes: Post-MACRA, ‘where else can radiology take a leadership role in driving care quality and adding value?’

When it comes to adapting to U.S. healthcare’s transition from volume- to value-based reimbursement, radiology is “leading the charge for non-patient-facing providers in a world that’s geared almost entirely around the direct patient-facing experience.”

The quote is from Danny R. Hughes, PhD, senior director of health policy research at the Harvey L. Neiman Health Policy Institute. Hughes spoke with Health Imaging after the July 14 publication, in the Journal of the American College of Radiology, of a two-part Neiman report aimed at helping radiologists achieve business and compliance success in the wake of the Medicare Access and CHIP Reauthorization Act of 2015.

The first article puts the series in context by reviewing how our healthcare system got to MACRA. The thrust of the second is tipped by its title: “Alternative Payment Models in Radiology: The Legislative and Regulatory Roadmap for Reform.” Hughes was a co-author of both. Here are excerpts from the interview.

Health Imaging: While the particulars of the new payment models are being hammered out for radiology, what can individual practices be doing to keep from falling behind in the coming months and years? 

Danny R. Hughes, PhD: Some practices at the forefront are already participating in bundled payments. Most aren’t doing so yet, and what they really ought to be doing right now is making sure their house is in order for at least the existing conventional Physician Quality Reporting System (PQRS) metrics. The initial period that ushers in the Merit-Based Incentive Payment System (MIPS) in 2019 with its various incentives and penalties will actually be looking at 2017 data—data that started [accruing] six months ago.

On many PQRS metrics, radiologists are leading the way. But if you’re a radiologist who hasn’t paid serious attention to how you fit in with the metrics that now exist, even though the final MIPS metrics are going to change, you need to get your house in order now. The final MIPS metrics are going to be applied to this work you’ve already done as MIPS is folding PQRS inside.

So the strongest thing radiology practices can do right now is keep their ear to the ground to follow the rule changes and ensure they’re participating to the fullest extent they can within the existing quality-based programs. By doing that, they should be positioning themselves well for when the final rules come out within MIPS.

How do you feel about the timeline vis-à-vis the readiness of the profession—too slow, too fast or just right?—and what have you been hearing about this aspect from radiologists at large?

I think it’s too fast, only because the timeline is geared for primary care. This is what we’re constantly pushing back on. Because CMS is on an aggressive timeline, they’re going where they perceive the big payoff is, which is primary care. It leaves radiology on the sidelines yet subject to the same aggressive timeline that, quite frankly, even primary care providers are going to have difficulty meeting.

Unfortunately, the timeline is driven by a desire to see immediate savings and quickly make the transition from fee-for-service. It’s not driven by the time it really takes to re-engineer a system and include all the providers at the table, giving them the due diligence they deserve.

And ACR, along with the Neiman Institute and others, continues to push for exemptions or extensions to try to buy a little more time for radiology, correct?

Yes, that is in the works. Part of what we’re examining now is how some of the rules hinge on whether a provider is classified as patient-facing versus non-patient-facing. There’s no hard definition of those terms. We’re actually doing an internal project now, where we’re looking at what it means to be patient-facing and, if you’re exempt, what does it mean to be under that exemption?

It certainly can’t mean you’re going to stay fee-for-service forever. But it might provide an exception from some of the requirements—particularly certain metrics that are coming under MIPS that are going to be difficult to meet if you’re not really patient-facing.

In the press release Neiman sent out to publicize the JACR papers, there’s an expression of hope that these papers will help “prompt the creation of a research agenda to inform new payment model discussions.” What sorts of research projects do you and your fellow authors hope to spur, and what kinds of questions do you hope these inquiries will answer?

The key questions involve APMs: Where can radiology best participate? For example, the Neiman Institute has been developing a mammography bundled payment model where radiologists can drive the episode of care. Where else can radiology take a leadership role in driving care quality and adding value? That’s something that really needs research.

Some of the answers that radiology practices need are in the tiny details. For example: Great—we’ve got bundled payments. We’re going to have a benchmark regional rate for the Comprehensive Care for Joint Replacement Model that’s mandated by CMS. But it turns out that the data is notoriously skewed in healthcare. Nothing is a nice, normal bell curve. So if you’re a small practice, what’s the right patient panel size to adequately manage the risk? Does a patient panel size even exist that’s going to make sense for that small practice? Someone has to look into that. And if there’s not a patient panel size that works, how do you help a smaller practice face more risk? Do you build risk-mitigation models that go with the bundled payments? Do you adjust the payment rates for them?

These are all areas for research, because, if you ask CMS, the answer becomes, We don’t really know. What happens if someone changes providers within a bundle? Can someone model that and see what the leakage rate would look like and how that’s ultimately going to influence the incentives or the penalties? These are all questions with no answers. It was easy for CMS to issue a rule saying they’ll pay for this with a bundled payment and not have a rule for what happens to the leakage out of the bundle. 

So researchers have a lot of unanswered questions that are, quite frankly, policy-relevant. Without research, the answers will be entirely arbitrary decisions. You really don’t want to have arbitrary rules coming out in advance of real knowledge and data. Unfortunately, because of the aggressive timeline, that’s the world we’re in.

It’s easy to have this broad legislation, but a lot of research has to be done to inform the details. And hopefully it will be done before some of these details are set in stone, as opposed to after the rules are set in stone—when the research indicates that some of the details didn’t really make sense in the first place.