Health-care Reform and Radiology: Introduction

imagingBiz | How the majority of provisions from the Patient Protection and Affordable Care Act (PPACA) will affect health care (in general) and radiology (in particular) remains to be seen; with the most sweeping changes still pending in the coming years, providers are holding their breaths.

Ed Gaines, chief compliance officer for Medical Management Professionals Inc (MMP), Atlanta, Georgia, says, “The uncertainty is what makes it scary. There are over a thousand references in the PPACA to the words ‘the secretary [of HHS] shall.’ Well, the secretary is pumping out regulations, but until those regulations are issued, it is probably too early to tell exactly what the impact will be.”

Gaines does warn, however, that radiology doubtlessly will be looking at major changes in quality requirements, payment, and (of course) referral base. Missy Lovell, compliance manager for MMP, adds that one provision that has already taken effect calls for stricter self-referral policies; though many in the imaging community feel that these policies are not sufficient to curb nonradiologists’ self-referral, they indicate that the topic of imaging utilization is on the congressional radar. “There is nothing black and white to it yet, but I would imagine we could see more tightening of self-referral rules by 2015,” she says.

Quality on the Table

Lovell bases this prediction, in part, on the PPACA’s endorsement of imaging demonstration projects: In the most recent project, five participants were just selected by CMS for two years of funding and support. This project will focus on the implementation and testing of clinical decision support, which has the potential to reduce inappropriate imaging without the burdensome time commitment of using radiology benefit management companies.

“They want to see how the use of decision-support systems will affect inappropriate imaging,” Lovell says. “In tandem with that, they want to know if it affects quality.”

Of course, as Lovell observes, “Measuring inappropriate imaging is one thing; measuring quality is another.” Though the ostensible aim of the PPACA is to increase quality and access while decreasing cost, “Quality can sometimes be in the eye of the beholder,” Gaines says. To underscore this, he points to some of the Physician Quality Reporting System (PQRS) indicators previously established by the DHHS. As the PPACA’s provisions kick in, these are likely to form the basis of future quality determinations.

“There are some who believe this kind of measurement of quality reduces medicine to a cookbook approach,” Gaines says. “One current PQRS measure for emergency-department physicians is prescribing a certain antibiotic for pneumonia, but does that really measure quality? Medicine is an art as much as a science, and that is not easily translated into a couple of CPT® codes.”

Payment in the Crosshairs

The stakes are higher than ever on the topic of how quality is determined because quality might soon play a much bigger role in reimbursement. Another set of CMS demonstration projects, which the PPACA legislation both endorsed and expanded, looks at bundling professional reimbursement with the hospital payment in several imaging-intensive areas, including emergency medicine, orthopedics, and cardiology.

“The notion is that you are going to incentivize the physicians for efficient and high-quality care,” Gaines says. “Instead of the perception, with some folks, that perhaps simply doing more service means higher reimbursement, you are going to coordinate care better under the bundled payment or episode groupers’ methodology being experimented with now in the demonstrations.”

One unintended result of this change, however, could be a reduction in the use of imaging simply for the purpose of cost savings. “It is definitely a concern that the program will result in decreased utilization of imaging,” Gaines says.

This concern is magnified by the fact that possible new payment models for hospital-based care, such as bundled payments or accountable-care organizations (ACOs), are still ill defined and might not be workable for many patient presentations—particularly for patients who are admitted through the emergency department. “My analogy is that an ACO is like a unicorn,” he observes. “We all know what it looks like, but we do not know what it is.”

If ACOs are to become the new norm, Gaines says, “There are some significant changes that will need to be made in current federal and state antitrust laws in order for an ACO to function the way it is being talked about—with sharing of price, charge, and cost data. A lot of different agencies will have to come together to create exceptions where the current law does not.”

Reimbursement will also be a concern under the ACO model, he predicts. “It is starting to sound like capitation: You will get so much money per case, and hospitals will decide how to divide the pie among various providers,” he says. “That is a concern not just to radiology, but across the care spectrum.”

Patient Base on the Rise

In 2014, mandates affecting payors’ ability to deny care will take effect, Medicaid coverage will be expanded, and state health-insurance exchanges will be launched. The individual requirement to have health insurance will also come into play, fining US citizens and legal residents who do not purchase qualifying coverage through a tax penalty. “I do not know how anybody, radiology included, is going to handle that kind of volume,” Lovell says. “They will have to struggle with how reimbursement can even begin to cover the costs they will be incurring.”

One avenue that many radiology groups are currently exploring is aligning themselves with a hospital through a joint-venture arrangement, enabling them to take advantage of potentially higher Hospital Outpatient Prospective Payment System reimbursement. “There is a lot of discussion, right now, about whether maintaining independence is a good thing,” Lovell says. “This potential revenue differential will probably erode, and if so, these groups will have moved from one entity to another with no realizable revenue to show for it.”

Recent months have seen the launch of several efforts to overturn the PPACA, including one from a Florida federal judge (who declared the bill’s individual mandate unconstitutional). Though these challenges to the legislation might create a modicum of hope that health-care reform will be reexamined or repealed, Gaines says that providers should continue to gird themselves for change.

“We are going to be living with the PPACA—good, bad, or indifferent—for several years before we even know if congressional repeal, or its being found unconstitutional by the US Supreme Court, is a possibility,” he concludes.


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