HPC Corner: Hobson’s Choice

By Gaurang Shah, MD, FACR

The Patient Protection and Affordable Care Act (ACA) of 2010 had three primary goals: expand access to health insurance, protect patients against arbitrary actions by insurance companies, and reduce costs to accommodate the former goals. ACA was succeeded in a complex bipartisan trajectory by Medicare Access and Children’s Health and Insurance Program (CHIP) Reauthorization Act (MACRA) in 2015 which incentivized transition away from fee for service payments towards pay for performance. The Bipartisan Budget Act of 2018 was signed in to law in February 2018, which judiciously slowed down, but legislatively mandated, the previously ambitious timeline for the transition of the payment model.

The Medicaid expansion, individual mandates, insurance subsidies, health saving accounts and several other provisions in the ACA have undergone significant changes over the years due to political upheavals. However the intent to move away from fee-for-service to a value-driven payment system has remained unabated and has emerged as bipartisan consensus, which is not expected to change.

MACRA stabilized the physician part B Medicare payments and established new payment methods, which were implemented mainly through Merit based Incentive Payments System (MIPS). The payment adjustments for 2019, based on performance data entered in 2017, have just been announced and for the year cost performance category was weighted at 0% of the final score. For the 2017 performance year/2019 payment, quality accounts for 60% (for interventional neuroradiologists) or 85% (for most diagnostic neuroradiologists) of the final score. Improvement activities and promoting interoperability remain constant for all performance years at 15% and 25% of the final score, respectively, for 2018/2020 cost will account for 10% and for 2019/2021 cost is 15% of final score, then it goes up 5% per year until it reaches 30%. As cost escalates in weight, quality weight will go down.

During this first payment year of 2019, the can has already been kicked down the road to decrease the pain of transition in the reimbursement plan for the physicians. This year, only 5% of practices have received a negative payment adjustment and 93% have received a positive adjustment (not more than 4% and in reality, much less) as the threshold for negative adjustments was set very low; at <3 out of a possible 100 points. However, it is mandated in the law that by 2022, the threshold will be set as high as the median or mean of performers which may entail a performance threshold of 74-89 of a possible 100 points.  If one used the 2017 performance year data, this translates into up to 9% downside adjustments, and up to 37% upside adjustments of Medicare Part B allowed charges for a few high performers. The investment in time, efforts and resources towards diligently filing all the measures is a choice; but it’s also the predominate way of getting paid for radiology services. CMS lends help for small practices with several program level and performance category level exemptions and re-weightings, and there are many nuances and variations in finalized rules that even help radiologists in large groups. The ASNR economics team has kept their eyes on the ball, and offers multiple educational resources, to residents as well as practicing radiologists. ABR, ACGME and ACR offer multiple projects, tools and paid resources like National Radiology Data Registry (NRDR) to help us navigate through this complex maze. But as Henry Russell Sanders or later, Vince Lombardi might say, participating in this model is not the most important thing, it’s the only thing.

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