How Radiologists Can Join an Advanced Alternative Payment Model

February 07, 2017 - Radiologists may want to look to the physician-focused payment model path in MACRA to develop specialty-specific Advanced Alternative Payment Models (APM), suggested a recent Journal of the American College of Radiology report.

Harvey L. Neiman Health Policy Institute researchers stated that most approved Advanced APMs in the Quality Payment Program are mainly focused on primary care providers and opportunities for radiologists are lacking.

“Given the major role of imaging to potentially achieve better quality and cost savings through the rendering of an early diagnosis, the ACR [American College of Radiology] recognizes the importance of ensuring that radiologists have reasonable opportunity to participate in APMs,” wrote researchers. “However, such opportunity is clearly lacking in the current state based on an insufficient number of disease-based or episode-based APMs.”

Radiologists that qualify as eligible clinicians in MACRA can either participate in the Merit-Based Incentive Payment System (MIPS) or an Advanced APM.

However, the report advises radiologists to consider an Advanced APM because qualifying participants will receive a 5 percent incentive payment based on Medicare Part B reimbursements from 2019 to 2024 regardless of quality performance or healthcare savings.

READ MORE: CMS Timelines for Stage 3 Meaningful Use, MACRA Implementation

After 2024, Advanced APM qualifying participants will receive a greater fee schedule conversion factor rate than MIPS eligible clinicians. The rate will be 0.75 percent for qualifying participants versus 0.25 percent for MIPS eligible clinicians.

Qualifying participants will also be exempt from MIPS reporting and the budget neutral upward or downward Medicare payment adjustments, which cap out at 4 percent in 2019. MIPS reporting may be problematic for radiologists because the quality measures are more generic and not specialty-specific.

To participate in the Advanced APM track, though, eligible clinicians must join an approved model or partake in a model that meets specific criteria. The most up-to-date list of approved Advanced APMs for 2017 participation according to CMS is:

• Comprehensive End-Stage Renal Disease Care Model (two-sided financial risk track only)

• Comprehensive Primary Care Plus

READ MORE: Understanding the Value-Based Reimbursement Model Landscape

• Next Generation Accountable Care Organization (ACO) Model

• Medicare Shared Savings Program Tracks 2 and 3

• Oncology Care Model (two-sided financial risk track only)

• Comprehensive Care for Joint Replacement Model (certified EHR use track only)

• Vermont Medicare ACO initiative (part of the Vermont All-Payer ACO model)

READ MORE: Key Ways to Succeed Under MACRA’s Quality Payment Program

Researchers pointed out that the current list of 2017 Advanced APMs focuses almost entirely on primary care providers and the only specialty model deals with oncology, leaving limited opportunities for radiologists to earn maximum incentive payments.

Although, the Comprehensive Joint Replacement Model and some recently announced 2018 Advanced APM options may include radiologists. In December 2016, CMS unveiled several new approved models, including the Cardiac Rehabilitation Incentive Program and an updated Comprehensive Joint Replacement model.

The two Advanced APMs could potentially be relevant to radiologists because of the imaging role in joint replacements and cardiac rehabilitation. But the models do not target radiologists, researchers mentioned.

Without specific Advanced APMs available, researchers recommended radiologists to focus on the physician-focused payment model track for 2018 Quality Payment Program participation. The final MACRA implementation rule established a process that allows physician specialties and other healthcare stakeholders to create alternative payment models for potential Advanced APM qualification.

The models must have Medicare as a payer, contain a physician group practice or individual physician as the APM entity, and focus on physician care quality and costs.

Physician-focused payment models can also become an Advanced APM if they require certified EHR technology use, determine reimbursement based on quality measures similar to those used in the MIPS quality performance category, and mandate that participants “bear more than nominal” financial risk.

“By encouraging innovation by physician specialties in the design of new delivery and payment models of relevance to their practice, PFPMs [physician-focused payment models] are intended to allow participation of a broader range of physician specialties in the Advanced APM path, with physician payments associated with PFPMs anticipated to begin in 2018,” the report stated.

Researchers added that the physician-focused payment model track will probably “represent the dominant pathway through which stakeholders will introduce new Advanced APMs,” especially for radiology-specific models.

Radiologists and stakeholders may want to start developing the specialty-specific physician-focused payment model by modifying the Medicare Bundled Payment for Care Initiative. The initiative includes multiple services performed in a single episode of care, making it relevant to radiologists who oftentimes provide imaging services.

CMS did not approve the Bundled Payment for Care Initiative for Advanced APM status because the model does not include MIPS-comparable quality measures and certified EHR use requirements. But researchers suggested that specialists use the episodes of care in the initiative and develop quality measures and EHR use criteria for Advanced APM qualification.

Similarly, radiologists and stakeholders may want to look to a recently proposed breast cancer screening model that contains financial risk. By developing appropriate quality measures and certified EHR use mandates, the model could be considered an Advanced APM.

Other lung cancer and cancer staging and follow-up models should also be developed for radiology.

However, the road to radiology-specific physician-focused payment models may not be smooth, the report continued.

First, CMS should clarify how it plans to attribute patient outcomes and healthcare costs to specialists in the models. Radiologists are faced with many factors beyond their control that affect patient outcomes and costs, especially since some are only primarily responsible for image interpretation.

“In addition, the savings relating to quality imaging may involve reductions in downstream tests and interventions that cannot be immediately captured,” stated researchers. “Thus, defining radiologists’ impact in a meaningful fashion and properly accounting for their specific role in patient care is difficult.”

The role imaging plays with downstream outcomes and costs may also make it difficult to submit appropriate information to the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which reviews and approves models. Without data connecting imaging to other outcomes and costs, radiologists may face troubles gathering enough data to present the physician-focused payment model.

Second, the PTAC will review and approve models, but the committee does not contain many specialty representatives.

“Physician representation on the PTAC is primarily from primary care physicians and policy experts, with only two specialties represented (both non-radiologists),” the report added. “Therefore, it is unclear whether the PTAC has the medical knowledge and technical expertise to appropriately evaluate specialty APMs.”

Radiologists can lessen the burden of physician-focused payment model development by working with stakeholders and accepting APM participation, the report concluded.

“Radiologists should welcome this new model and actively partner with CMS, the public, and other stakeholders in designing radiology-relevant PFPMs,” wrote researchers. “By embracing the transformations in care delivery afforded by APMs, and PFPMs in particular, radiologists will be positioned to contribute to higher-quality care, cost savings, and improved population health.”