Value in Radiology

I'm super energized by an outstanding, informative and incredibly important lecture at Los Angles Radiologic Society Meeting by  Richard Heller titled "Quality Metrics, Value Based Payment and Radiology: The Long and Winding Road."

The modern era of medicine forces us to show value because value is being tied to reimbursement. For radiology, these are a few things to know:

• Value has to be measured. If it's not quantified, then it would be difficult to show value. Data. Data. Data. 
• There has to be objective measure. It's not about how we feel or think which may not be accurate.  For radiology, here are a few objective measures:
• accuracy:  improve diagnosis (i.e. reduce errors) by creating an environment that will foster learning from mistakes. 



Fig. 1: RAD PEER categories.

• in Radiology, we have RAD PEER, but there is problem with the system. RAD PEER stratifies error into different categories (Fig. 1).
• Unfortunately, few radiologists rarely marks 2b and above. This results in poor accuracy to reflect errors. In reality, the error rate is higher but this information is not accurately collected.

Value-Based Payment

• Definition of Value = Quality/ Cost 
• MIPS: Merit Based Incentive Payment System
• 4 performance category: 0-100 score is given per category.
• Quality
• Cost
• Advanced Care Information based on Meaningful Use
• Improvement Activities
• this information will be public.
• financial incentive for MD based on scores for each category. 
• Implementation to start in 2019-2022.
• There will be up to -9 to 9% difference in physician salary based on scores
• It's meant to be budget neutral. The losers pay the winners.
• MACRA: an attempt to curb cost in healthcare, metrics will be use to measure performance.
• Quality metrics in Radiology that will possibly regulated using three tiers.
• Structural: ACR accreditation, ABR certification 
• Process: Turn-Around-Time (TAT); ACR Appropriateness
• Outcome: Peer Review (ACR RadPeer), Patient and Provider Satisfaction score
• probability the most important parameter but the most difficult to measure because health is a team sport. 
• the goal is improve outcome for patient; Radiology is part of the team.  Independent of the team (hospital and the multidisciplinary team), there are Radiology-specific parameters that should be measured that follow certain guidelines:
• metrics that impact patient care and outcome
• metrics that can be realistically measured
• metrics that are under direct control
• Merit-based Incentive Payment System (MIPS) Quality Measures
• issue: 
• confusing rules
• asymmetric field of play: there is one pie and it has to be split into different sub specialities
• Gamesmanship: the speciality that shows the most impact will take the biggest slice of the pie
• Size matters: small practices will not have the resources to show quality.
• Advanced Alternative Payment Method (advanced APM) status
• This is an alternative to MIPS which is being developed.
• CMS is offering 5% yearly bonus to encourage practices to adopt Advanced APM status from 2019-2024
• 3 Measures:
• use of EMR
• Metric measures
• Dollars impact
• What models are advanced APMs?
• most of the APM models are primary care oriented. 
• has neglected Radiology by CMS but it's been acknowledged and is under development
• Physician Focused Payment Model (PFPM):
• PFPM Model impact on Radiology (https://www.ncbi.nlm.nih.gov/pubmed/28132819)
• Goals
• Improves quality without raising costs; lowers costs w/o reducing quality; improves quality and lowers cost
• payment methodology support of PFPM goals
• Broaden scope: Of APMS or specialities involved (providing meaningful contribution to the team)
• Value over Volume
• PFPM committee decides which speciality to designate as APM
• currently, there is a GI and Surgery APM
• no Radiology PFPM yet proposed
• Health Policy Institute:  Inpatient Cost Evaluation Toot (ICE-T)
• Online tool to learn Bundle payment, DRG and bundle
• Currently, we use MIPS but the future is in Advanced APM. 
• What is ACR doing? Where do we need to go?
• best practices: 
• provide follow up recommendation
• give specific recommendation 
• Examples: Incidental Thyroid Nodules
• Thyroid Nodule recommendation
• measured baseline and after implementation: there is decreased in ultrasound evaluation and decrease variability over time.
• clinical accuracy: how to improve accuracy?
• clinical conferences to present misses
• call doctors with findings that need follow; most importantly, implement a program to ENSURE follow up is made if not done by PMD and primary team.
• program development
• quality program started January 1, 2017
• programs to improve quality

Take Home: Value Care Payment is here and the young radiologists will be most impacted. Radiologists will need to have an active participation with patients and providers during clinical practice;  we need to use data-driven approaches to scientifically quantify our value; and we need to be participate in advocacy to ensure our speciality stays ahead of the movement.