Quality and Imaging: Be at the Table or on the Table

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This article is second in a four-part series on health-care reform and radiology. To read the first article in the series, click here. Ed GainesMissy LovellAs specifics of how health-care reform’s provisions will be executed increasingly come into focus, the radiology industry awaits word on how it will be required to demonstrate quality under the new order. “By 2015, physician payments can be reduced by 1.5% if physicians are not reporting under the Physician Quality Reporting System (PQRS),” according to Ed Gaines, chief compliance officer for Medical Management Professionals, Inc (MMP), Atlanta, Georgia. He says, “We are moving from a pay-for-reporting to a pay-for-performance mentality and payment system.” Missy Lovell, compliance manager at MMP, adds that the stakes are higher than ever, when it comes to quality, because quality is poised to play a significant role in future reimbursement. While CMS reimbursement will already take a 1.5% hit by 2015 for lack of successful quality reporting, if private payors join the federal agency in linking payment to quality, the ability to demonstrate quality could affect an even larger proportion of a physician’s bottom line. Reporting on quality, at the same time, is only becoming more complex. “In terms of the PQRS, the measures on which radiology has to report have grown; for 2011, the ACR® has identified approximately 13 measures that are relevant to the specialty of radiology (to include interventional radiology),” Lovell says. “I think that the number of measures relevant to the specialty will grow; in the future, you will see retention of some past measures, new measures added, and revisions added.” Pay for Reporting to Pay for Performance Gaines notes that in order to ease physicians into using the PQRS, CMS has allowed them to report quality via claims-based options before moving to registry-based reporting. In 2009, 32% of eligible radiology professionals participated in the program, almost all of whom presumably submitted their data through claims-based reporting; participating radiologists received an average potential incentive payment of $2,772, while participating interventional radiologists received a potential $3,707, on average. “Based on these numbers, radiology professionals are very slowly warming up to the idea of quality reporting, even though the number of applicable measures is expanding,” Lovell says. She notes, however, that more than 90% of eligible professionals who reported through a registry received an incentive, while only 50% of those who reported through claims did—a discrepancy that is probably owed to errors in claims-based reporting. “There is little payout for a big effort,” she observes. “Many do not go to registries because they do not understand them, and because there are costs associated with their use, thereby reducing what little incentive was obtained.” Lovell adds that inability to obtain incentive payments is the result, in many cases, of errors made in submitting claims, not of failure to take quality-promoting action in the areas covered by the PQRS. “Therefore, many practices have not bought into doing it yet,” she says. Although a date has not been set for physicians to move over to pay for performance, Lovell notes, the physician side is generally two to three years behind the hospital side, which will make the change in 2013. “It is probably in the offing,” she says. Quality Transparency As pay for performance takes hold, physician reporting data will be posted to Medicare’s Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), the partner site of Hospital Compare (www.hospitalcompare.hhs.gov), where hospitals’ quality data are accessible to the public. Gaines notes that these websites are not without their flaws. “The Physician Compare website is up, but the data have not been populated, and there are a lot of issues with the accuracy of information there,” he says. “At Physician Compare, they sometimes have old hospitals where providers are no longer working. We are trying to figure out where they are deriving the data, but once they get the wrinkles worked out, needless to say, pay for performance will no longer be just reporting.” The next question, Gaines predicts, is how important these data will prove to be to the financial health of physician practices. “We have certainly already seen hospitals advertising how they have scored,” he says. “That is the offensive version. It will be interesting to see what happens on the physician side.” Possibilities, he says, include local media picking up on low scores and hospital boards using radiology groups’ scores to evaluate them for contracts. “There is a healthy debate as to how important this information will be to the public, but a local hospital board member may take issue with physicians with lower-than-benchmark scores,” he says. ACOs and Quality Lovell predicts that radiologists will see an increasing number of PQRS measures relevant to their specialty in the future. At least, currently, the successful-reporting requirements have been held relatively constant (and have even been eased a bit, with the lowering of the claims-based reporting threshold this year). Gaines notes, however, that the recently released proposed rule for accountable-care organizations (ACOs) includes 65 measures just for emergency medicine. “The ACO proposed rule is quality reporting on steroids,” he says. “If you are a hospital-based physician, your number of measures for reporting through that ACO may be multiplied by many times. One of the big concerns is how all of that will get done in a cost-effective way.” Another key issue, Gaines and Lovell say, is how payment under the ACO program will affect radiology utilization. By giving hospitals incentives to lower the cost of each episode of care, ACO regulations might also encourage them to cut corners on higher-cost procedures (such as imaging). “It is definitely possible that appropriate imaging will be curbed,” Gaines notes. “In the Medicare Acute Care Episode (ACE) demonstration project, the focus is on 30 to 40 Medicare Severity DRGs (MS-DRGs), including some that are imaging intensive—such as cardiac, valve-replacement, and pacemaker MS-DRGs. The question is how Medicare defines the baseline. What is considered appropriate imaging for the Medicare patient with a hip fracture, and how is the hospital in the ACE project measuring against that baseline?” In the example of the hip-replacement patient, for instance, Gaines points to an MRI procedure that can assess whether a hip replacement needs to be revised. “There was not a compelling need for this before this massive recall of artificial hips,” he says. “With medical technology racing forward, you have to wonder whether a beneficial diagnostic study that may be helpful to the patient and provider will now be withheld because it will bump up the total case costs, and the ACO could incur higher-than-benchmark costs.” The best thing that radiology can do now, he says, is inject itself into the discussion—before it is too late. “The message we would send to radiologists is that they need to get involved in the discussion and say, ‘I have a role here. If you are telling me a baseline patient will now receive 10% less diagnostic imaging than in the past, how do I know we are at the medically appropriate level of study?’” As Gaines says, “You are either at the table or you are on the table.” Cat Vasko is editor of ImagingBiz.com and associate editor of Radiology Business Journal.