RSNA: Payment models disregard radiology, need overhaul

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When deciding which technologies would best suit your hospital and patients, analyzing quality metrics is helpful, but radiology is often left out of the national coverage equation, James V. Rawson, MD, chairman of radiology at the Medical College of Georgia in Augusta, said during a presentation Nov. 30 at the 96th annual meeting of the Radiological Society of North America (RSNA).

Part of the How Payment Policy Will Impact Technology Development in the 21st Century session centered around the importance of collecting quality metrics, which can help hospitals evaluate the need for certain technology.

“In this very complex healthcare environment, we are going to need a lot of coordination, a lot of good communication and a lot of data to show the effectiveness of our technologies and how they are impacting clinical outcomes,” Rawson offered.

While currently many stakeholders are collecting hospital and physician data to outline individual performance to compare their own to others in the community, radiology is often excluded from the process. “Shouldn’t we [radiology] be collecting data also?” Rawson asked.

While the American College of Radiology (ACR) collects data from multiple registries to outline the efficacy of hospitals and practices, quality metrics measured by the Centers for Medicare & Medicaid Services (CMS) under CMS 24 does not incorporate radiology metrics.

In 2002, the CMS began measuring 24 quality metrics of core measures pertaining to pneumonia patients, heart failure patients and surgical metrics, among others, but none are specific to radiology. The situation concerns Rawson as radiologists often take part in the post-operative care of heart attack and pneumonia patients with imaging.

“We are involved in the diagnosis [of these patients] but yet none of the metrics reflect the value that we [radiologists] bring to the system,” Rawson noted.

Radiology does not appear in the top 10 diagnosis-related groups (DRGs) for Medicare patients either, despite the fact that radiologists play a large part in treating patients with conditions like pneumonia, TIA and stroke, he said. These top 10 DRGs account for 30 percent of hospital admissions, and Rawson said that effective management could have a positive impact on the hospital.

Hospital payments for Medicare are determined by the outpatient prospective payment system (OPPS) where data is pooled and averaged—this number is what hospitals are paid for their outpatient services, Rawson offered. The system is based on DRGs and the ambulatory payment classifications system creates fixed payment amounts for outpatient encounters or services.

These data are centered around volumes; however, Rawson said the system may be flawed, particularly for uncommon procedures like MR-guided focused ultrasound to treat fibroids, which is highly unlikely to occur in the Medicare population. These small data still set the national standard for reimbursement.

In addition, Rawson said, “As we look at academic centers and the role they may play … we may see a paradigm shift from the end of the ‘build it and they will come era’ to one where you will really need to demonstrate the value of new technology not just to one customer, but to multiple constituencies."

The challenge, he said, will be determining what metrics a hospital will use to determine how to market these new technologies. While some stakeholders, like patients, will benefit from looking at the outcomes of new technology, other stakeholders may be more interested in examining costs or lengths of stay.

“If you were a hospital administrator and you had extra money, where would you invest that money? Would you buy the greatest and latest in modalities or put it towards an area in hopes to reach meaningful use criteria? These are all questions that you must think about,” said Rawson.

When assessing new technology, you must show the benefit to the hospital and link it to something that makes it more efficient and lowers cost, he continued.

“Diagnostic imaging does have an effect on lower mortality but also length of stay,” said Rawson. “When trying to match your imaging and new technology needs to multiple customers you have to understand individual needs and have to have data to support those,” he concluded.

Hospitals, physicians and other consumer stakeholders have all been collecting quality metrics data to outline the benefits of procedures and devices to patients, but Rawson offered that