the stairway to heavenly payments · described, the tip is seen fluoroscopically at the level of...
TRANSCRIPT
The Stairway to Heavenly Payments
Richard Duszak, MD, FACR, FSIR, FRBMA
Professor and Vice Chair for Health Policy and Practice
Department of Radiology and Imaging Sciences
Emory University School of Medicine
Research Support Acknowledgements
Harvey L. Neiman Health Policy Institute
Wallace H. Coulter Foundation
Woodruff Health Sciences Center
Financial Disclosures
Consultant, United States Department of Justice
Consultant, United States Department of Homeland Security
The Future
What is Value?
Value =Quality
Cost
Do You Want to Get Paid?
Medicare fee-for-service payments
• 85% tied to quality or value by 2016
• 90% tied to quality or value by 2018
All Medicare payments
• 30% through alternative payment models by 2016
• 50% through alternative payment models by 2018
Lower Cost
Hig
her
Qu
alit
y
Fee for
Service
Accountable
Episodes
Pay for
Performance
Lower Cost
Hig
her
Qu
alit
y
Fee for
Service
Accountable
Episodes
Pay for
Performance
Agenda
Take Advantage of Your Tools
Lower Cost
Hig
her
Qu
alit
y
Fee for
Service
Accountable
Episodes
Pay for
Performance
Lower Cost
Hig
her
Qu
alit
y
Fee for
Service
Accountable
Episodes
Pay for
Performance
What is Fee for Service?
FFS Paid on Best Practice Basis
$8.85
Fee for Service = Fee for Volume
$8.85
What if it Were Your $8.85?
Physician Reporting
CPT coding drives payment under FFS
As a general rule, payment for higher
complexity codes is higher than that for lower
intensity codes
Physician documentation drives code selection
Complete Abdominal US (76700)
1. Liver
2. Gallbladder
3. Common bile duct
4. Pancreas
5. Spleen
6. Kidneys
7. Upper abdominal aorta
8. Inferior vena cava
Limited Abdominal US (76705)
1. Liver
2. Gallbladder
3. Common bile duct
4. Pancreas
5. Spleen
6. Kidneys
7. Upper abdominal aorta
8. Inferior vena cava
Abdominal Ultrasound
76705 Limited
76700 Complete
39%
$28.24
$39.13
Ultrasound Documentation
336,062 abdominal US
reports
37 facilities
1,136 radiologists
Incomplete documentation
7 or fewer elements on
complete examinations
9.3% to 20.2% of reports
2.5% to 5.5% lost
revenue
Duszak R, et al. JACR 2012; 9: 403-408.
Lower Cost
Hig
her
Qu
alit
y
Fee for
Service
Accountable
Episodes
Pay for
Performance
Lower Cost
Hig
her
Qu
alit
y
Fee for
Service
Accountable
Episodes
Pay for
Performance
The Devil’s in the Details
Value =Quality
Cost
PQRS: Common Radiology Metrics
All process based (i.e., not outcomes based)
Specific metrics: CT or MR for stroke: Documentation of hemorrhage, mass,
infarct
Carotid duplex for stroke: Stenosis reported in reference to distal ICA diameter
Fluoroscopy: Documentation of radiation dose or exposure time
Central lines: Documentation of maximal sterile barrier technique
Mammography: Screening mammograms reported as “probably benign”
Bone scan: Documentation of correlation with relevant imaging
PQRS Documentation
CLINICAL HISTORY
Chronic renal failure, with failed dialysis fistula, and hyperkalemia. Central venous access was requested for
urgent hemodialysis.
PROCEDURE
The procedure, options, and risks were reviewed. Maximal sterile barrier technique was utilized. After local
anesthesia with 1% lidocaine, using real-time sonographic guidance, 21 gauge single-wall needle access was
easily achieved into the right internal jugular vein using an anterior approach. The tract was converted with a
micropuncture set to allowing introduction of a J wire down into the inferior vena cava under fluoroscopic control.
The tract was dilated to allow introduction of 16 cm long triple lumen hemodialysis catheter. The catheter was
sutured to the skin with silk suture. Catheter care was provided by the hospital staff. There were no immediate
complications. Total fluoroscopy time was 0.4 minutes.
COMMENT
The right jugular vein is patent and easily compressible. After placement of the central venous catheter, as
described, the tip is seen fluoroscopically at the level of the right atrial and superior vena cava junction.
Fluoroscopy demonstrates no evidence for pneumothorax. Permanent images were obtained.
IMPRESSION
Uncomplicated imaging guided placement of temporary hemodialysis catheter.
PQRS: Early National Results
Mean DR bonus in 2010: $2,811.39
Qualified for bonuses:
23.7% of radiologists
16.3% of non-radiologists
Registry reporting better than claims-based
Odds ratio 4.40 (95% CI 4.03-4.80)
Duszak R, et al. JACR 2013; 10: 114-121.
PQRS: Financial Projections
Duszak R, et al. JACR 2013; 10: 114-121.
Without physician, practice, or program changes…
over 75% of radiologists may face mean penalties…
of at least $2,654 in 2016…
totaling an estimated $111,393,067 for the entire profession!
Success Depends on the Metric
Rosenkrantz AB, et al. JACR 2016; 13:243-248
What Measures Matter?
Let’s Measure Stuff that Matters
Dose Matters…To Us!
Flug J, et al. JACR 2016.
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Radiologists Non-Radiologists
Medicare abdominal computed tomography “double scan” rates by specialty group.
MIPS: It’s All About Your Composite Score
25%
15%
10%
50%
2019
25%
15%
30%
30%
2021
Quality (Old PQRS)
Resource Use (Old VBPM)
Advancing Care Information (Old MU)
Clinical Practice Improvement
$80
$85
$90
$95
$100
$105
$110
$115
2017 2018 2019 2020 2021 2022
MIPS: It’s A Zero Sum Game
+19.8%
Leverage Emerging Tools
Lower Cost
Hig
her
Qu
alit
y
Fee for
Service
Accountable
Episodes
Pay for
Performance
Lower Cost
Hig
her
Qu
alit
y
Fee for
Service
Accountable
Episodes
Pay for
Performance
The Inpatient Hospital Episode
Focus of most “episode of care” bundled
payment interest
Metrics du jour have focused on hospitals
Length of stay
Readmissions
Physicians have still been paid under FFS
Inpatient Spending Distribution
Graphic from Komisar HL, et al. “Bundling” Payment. Center for American Progress, 2011.
Most spending in
hospitals is for
hospital services
Physicians don’t
matter much, right?
Physicians Matter a Lot!
Many policy makers miss the real
cost (and value) of physicians
Yes, they don’t directly cost a lot, but…
They’re calling day to day health care
shots!
Physicians Matter a Lot!
Many policy makers miss the real
cost (and value) of physicians
Yes, they don’t directly cost a lot, but…
They’re calling day to day health care
shots!
Who has control over…
Use of hospital services?
Involvement of other physicians?
Likelihood of readmission?
Appropriate use of post-acute care?
Physicians!
Perspectives on Slicing the Pie
Just the physician piece?
Or, the whole pie?
14%
Total Health Care Spending
Physician
Other
?
Perspectives on Slicing the Pie
Just the physician piece?
Or, the whole pie?
They’re not separate!
14%
Total Health Care Spending
Physician
Other
Re-slicing the Pie
What if we could cut waste and
inefficiencies by 15%?
12%
15%
Total Health Care Spending
PhysicianSavingsOther
Re-slicing the Pie
Opportunities for savings
12%
Total Health Care Spending
PhysicianSavingsHospital
The Future is Here Now
How Will Bundles Play Out?
Hospital CEO convenes meeting of physicians
Everyone thinks his group is entitled to 90%
How About This Approach?
One specialist presents robust national data
Based on nearly one billion Medicare claims
Descending frequency order by DRG
Range of services by his specialty
Specific CPT codes
Percentage of total physician spending
Asks for…
90% of national mean specialty payment per DRG
Plus, 25% of hospital savings on technical costs
controlled by specialty
How To Lead Data and Information!
But Where are the Tools?
www.neimanhpi.org
ICE-T: DRG Ranking Tool
ICE-T: Medicare Cost Estimator
ICE-T: Professional Share Estimator
Armed with Information
Geography Matters
What About Me?
Neiman Almanac at www.neimanhpi.org
The Extremes
Neiman Almanac at www.neimanhpi.org
Florida
Ohio
But What About Me?
Smaller is Better (Information)
Rosenkrantz AB, et al. Unpublished data.
County level variation in Medicare medical imaging events per 1,000 beneficiaries.
Green = less than national average, red = greater than national average.
Don’t Forget Variations in Turf
Rosman DA, et al. AJR 2015; 204: 1042-1048.
Big Spending Means Big Opportunities
Main T & Slywotzky A. The Volume to Value Revolution, 2012.
CareMore approach to Medicare Advantage population health management
Spiraling Savings
Focus on Top Tier
Focus on Lower Tier
Focus on Yet Lower Tier
Resources Savings
$
$ProfitReinvestment
$
And So On…
Quality
Co
st Low Quality
High CostHigh Quality
High Cost
Low QualityLow Cost
High QualityLow Cost
Accountability is Key
• Appropriateness
• Safety
• Efficiency
• Satisfaction
Quality Safeguards are Critical
Process driven
Accreditation
Procedures
Reporting
Outcomes driven
Immediate
Short-term
Long-term
Transparency
To payers
To consumers
Report Cards
You may not be getting them yet…
But, you will increasingly be graded
My Report Card: Physician Compare
How Do Radiologists Compare?
Physician Evaluate Thyself
Those who proactively self assess
themselves—and define ways to assess
themselves—are less likely to be surprised
Leverage existing processes! Accreditation
PQRS
MOC
Information about quality is essential to
demonstrate value
Payment Systems are Evolving
It is not the strongest
of physicians that
survives, nor the most
intelligent, but the one
most responsive to
change.
