The U.S. healthcare industry was rocketed into the 21st century with the passage of the Patient Protection and Affordable Care Act (ACA) in 2010. The legislation and its focus on reducing healthcare costs while expanding insurance coverage has generated a great deal of controversy in the four years since, and an expert panel in a special session at the 2014 Radiological Society of North America (RSNA) meeting warned radiologists to brace themselves for more changes in 2015.
Rewriting the Code
For physicians and radiologists, the ACA largely represents a fundamental shift in how its services will be evaluated and paid for. The industry is moving away from a fee-for-service model — where patients are charged for each visit, procedure or examination — and toward a more value-based payment system.
This raises the question of how the value of healthcare, particularly radiology, is determined. One of the primary mechanisms being used thus far is the American Medical Association’s (AMA) system of Current Procedural Terminology (CPT) codes used by the Centers for Medicare and Medicaid Services (CMS) to identify various medical procedures and services for administrative, financial and analytical purposes. According to Ezequiel Silva, M.D., FACR, RCC, vice-chair of the American College of Radiology (ACR) Commission on Economics, the AMA’s Relativity Assessment Workgroup (RAW) has been making its way through the CPT codes to identify those that may be misvalued and are in need of addition or deletion. Silva said that to date, nearly 1,800 codes have been identified by the workgroup, 434 of which are related to radiology. The end goal of this process is to bundle services together wherever possible to minimize the number of times patients have to pay a hospital or physician.
CMS released a final rule in late October on code changes for radiation oncology, giving a taste of what may be to come for other specialties. The changes included new codes for intensity-modulated radiation treatment (IMRT) delivery and image-guided radiation therapy (IGRT) services, as the latter will be bundled into the former. In addition, 14 codes for ultrasound guidance and radiation treatment delivery were deleted.
With so many code changes, CMS announced that it would delay valuation of the new codes until 2016, implementing a series of Level II Healthcare Common Procedure Coding System (HCPCS) to describe the affected procedures for 2015.
Quality Over Quantity
Transitioning to a value-based payment system is a sound theory, but it begs the question of what constitutes quality in radiology. Silva admitted that the definition is still a bit of a moving target, with CMS providing tools such as Quality and Resource Use Reports (QRUR).
At the same time, Silva highlighted two quality assurance measures that are scheduled to expand in 2015. The Physician Quality Reporting System (PQRS), established in 2011, incentivizes eligible professionals (EPs) to report on their performance against quality standards with increased Medicare reimbursements for good reports. The nature of the system will shift in 2015, however, adding a payment penalty for EPs that don’t report or meet quality standards. According to Silva, that penalty — which is based on physician performance from two years prior — will be somewhere around -1.5 percent for 2015.
Silva also highlighted the expansion of the value-based payment modifier that will take effect in 2015 per CMS. This mechanism provides Medicare payment incentives for physicians and radiologists who provide high-quality care at low cost to Medicare patients. On the flip side, EPs who don’t meet quality standards will face payment reductions.
Between these two measures, penalties related to Stage 2 Meaningful Use of electronic health records (EHRs) and the most recent deficit reduction sequestration, radiologists and other EPs could be facing Medicare reimbursement penalties up to 5.5 percent for poor performance in 2015. According to Silva, total penalties could reach as much as 13 percent by 2019.
Winds of Change?
The November 2014 midterm elections saw Republicans wrest control of the Senate from the Democrats, leading to speculation as to the future of the ACA. However, Thomas J. Greeson, former general counsel for the ACR, doesn’t anticipate any serious challenge to the legislation as President Obama would ultimately be able to veto any repeal attempts.
Greeson does see opportunities for small changes to the framework, such as:
* A reduction to the employer mandate, scheduled to kick in this year, stating that all businesses with 50 or more full-time equivalent (FTE) employees must provide health insurance or pay a monthly premium;
* Repeal of the 2.3 percent medical device excise tax; and
* Repeal of the Independent Payment Advisory Board (IPAB).
The IPAB looks to be a particularly sticky issue. Established by the ACA, it is a 15-member board of presidential appointees charged with keeping Medicare spending in check without impacting overall coverage or quality. Congress can only veto an IPAB decision through a supermajority vote, which raises concerns that radiologists and physicians would have less of a voice in policy changes, according to Cynthia Moran, ACR executive vice president for government relations, economics and health policy. While funding has been set aside for the board, and they are expected to begin operation in 2015, President Obama has yet to name any appointees.
Ultimately, Moran sees the potential for bipartisan cooperation in 2015, saying that both parties agree the fee-for-service payment model needs to change. “There’s a lot of pent-up frustration,” she said of the ACA’s opponents. “As long as there’s at least one vote to repeal the act, once they get that out of their system then I think you’ll see some sanity.”
Get on Board
All of these changes together illuminate a shifting landscape for radiology, said Greeson. With the expansion of the healthcare insurance marketplace fully underway, the proliferation of new insurance exchanges has actually narrowed the size of each available network. As a result, he said, radiologists need to make sure they are working to secure contracts and be active participants in every single network in their community. The key is to recognize the value of their relationship to hospitals and other imaging suppliers, which he believes is as innovators in the use of technology to improve the quality and reduce the cost of healthcare.
“It’s incumbent on you to demonstrate your value to them,” he concluded. “You want them to be your ally when you’re at the negotiating table and working on those bundled payments.”
The end goal of the ACA, said Greeson, is to move toward a patient-centered continuum of care with high transparency regarding price and quality of care. While the ACA has been the impetus behind these individual changes, all three panelists agreed they would have happened with or without the legislation. It’s now up to radiologists to continue evolving with the rest of the industry.