Linking Payment and Quality

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Judy Burleson continued the ACR’s economic update this afternoon, beginning with a discussion of existing strategies and tools HHS and CMS use to get at quality: public reporting and data sharing, incentive-based programs, regulatory means, coverage decisions, and, of course, demonstrations/pilots/research. “These will inform CMS and HHS on how to move forward with certain initiatives,” she said.

Burleson then moved to the Affordable Care Act’s national strategy for quality improvement. The legislation requires CMS and HHS to develop priorities for quality initiatives as well as a transparent and collaborative process. The statute requires that CMS measure development and review the measures in use every few years to either improve upon them or implement new ones, and must use an “entity”—i.e. the National Quality Forum—as a consultant prior to rulemaking. “One of the major criticisms of the legislation is that it didn’t go far enough to control future costs,” Burleson noted. “That being said, the CMS Center for Innovation was created to work through some of the new, innovative payment and delivery arrangements, and funding was included in the legislation to test these new models.” These models could include patient-centered models, ACOs, or shared savings programs (i.e. capitation or payments bundled based on episode of care).

As far as linking quality with payment, a few ACA initiatives support this goal. The hospital-based value purchasing program will be transitioning to a performance-based program, and “the achievement of incentive will be based on attainment of a certain standard against the measures, whether it’s improvement or reaching a certain score,” Burleson said. In 2013, quality measures will become part of the program, and in 2014 some as-yet-defined efficiency measures will be added in as well. “There aren’t currently any imaging-related measures, but traditionally efficiency measures are related to imaging,” Burleson said.

2008’s MIPPA implemented the Physician Feedback Program, which so far has mostly been primary-care based. “The professionals receive a confidential feedback report comparing their use of resources to others in their geographic area,” Burleson said. “CMS must eventually include quality measures, and they state that they will continue to implement it with different specialties until every applicable physician receives a feedback report. For consultant-based specialties like radiology, how is that going to look? We’re not sure how that will play out.”

In 2013, CMS will begin implementing the value-based payment modifier, and will extend it to specialties in 2015. Congress says CMS will need to enhance its measures and methods, do some analysis and research, refine their reports and get input on the process prior to implementation. Meanwhile, in happier news, a 1.5% PQRI bonus is available this year, which will gradually shrink until 2015, when reductions for not reporting will kick in. “The legislation also requires that CMS provide timely interim feedback reports,” Burleson noted, “as well as an appeals process.” Participation in a board’s maintenance of certification program as well as PQRI will result in another bonus for physicians through 2014.

In terms of regulatory changes, in the MPFS 2011 proposed rule, the PQRI sample size for reporting has been reduced to 50%. A new measure for radiology, “Reminder System for Mammograms,” was proposed, as was expanding the group practice reporting option (although Burleson says it’s unlikely radiology will be able to participate). CMS is also proposing to add 12 ARRA Meaningful Use measures to PQRI. In the HOPPS 2011 proposed rule, there is some discussion of changes to the quality reporting program, including the addition of four imaging-related efficiency measures to the existing four. Two have to do with cardiac imaging and two have to do with neuro. In 2012, CMS is proposing to add an additional imaging measure involving door-to-interpretation time for head CT. “The current specs only include CT, but it’s likely it will also include MRI,” Burleson added.

Burleson moved on to discuss meaningful use, including an outline of the three stages. “Probably 90% of radiologists would be eligible for the incentive program,” she said. “You’re stating that you’re using certified EHR technology, so you find a system that has been through the ONC certification process. There are two paths for what an EHR is: a complete system or a modular program.