Original articleHealth services research and policyMACRA, Alternative Payment Models, and the Physician-Focused Payment Model: Implications for Radiology
Introduction
The US Department of Health and Human Services has an overarching vision for health care in the United States that focuses on “better care, smarter spending, and healthier people” [1], seeking to link 90% of Medicare payments to the quality of care by 2018, in stark contrast with the current fee-for-service system 2, 3. These goals serve as guiding policy principles in the bicameral, bipartisan Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 [4]. MACRA seeks to achieve these aims through significant changes in how care is delivered to incentivize quality and value over quantity as well as through more efficient clinical decision making 5, 6. If successful, the legislation will catalyze innovative patient-centered delivery approaches that are meaningful, flexible, resource-effective, and operationally feasible, thereby improving health outcomes and care experience for the American public [1]. MACRA will first begin to impact physicians’ Medicare Part B payments in 2019. For the overwhelming majority of physicians, such changes in payments will initially be determined by the Merit-Based Incentive Payment System (MIPS), which has been the focus of numerous separate works 7, 8, 9, 10. Under MIPS, physicians will be required to report a large array of performance metrics in multiple categories, which in turn will form the basis of positive, neutral, or negative payment adjustments to their traditional fee-for-service payments. However, a small fraction of physicians will instead initially receive Medicare payments under MACRA through Advanced Alternative Payment Models (APMs), which achieve a larger transformation in how physicians deliver care and get reimbursed. Participation in Advanced APMs offers numerous benefits compared with participation in MIPS and is expected to increase considerably over time. Although a diverse range of APMs have been piloted through the years, MACRA introduces a new particular form of APM termed the Physician-Focused Payment Model (PFPM) that specifically targets the quality and cost of physician services. Recognizing historic low participation rates by specialists, MACRA legislates that CMS must establish pathways for participation in PFPMs, not only by primary care physicians but also by specialty providers, and establishes a new PFPM Technical Advisory Committee (PTAC) to accept and review proposals for new PFPMs from specialties and other stakeholders. Despite that, real barriers remain for radiologists to participate in PFPMs. This article summarizes key aspects of Alternative APMs, PFPMs, and the PTAC, including relevant considerations for radiologists (Table 1).
Section snippets
APMs, Advanced APMs, and Their Incentives
MACRA describes an APM as any new approach to paying for medical care that incentivizes higher quality and value [4]. However, the legislation also provides three strict criteria that an APM must fulfill for its participants to be exempt from the MIPS reporting requirements and to receive the complete benefits of being in an APM [1]. These CMS-designated Advanced APMs must (1) require use of certified electronic health record technology, (2) base payment on quality measures that are comparable
Physician-Focused Payment Models
The MACRA legislation requires that a process be established to provide physician specialties and other stakeholders the flexibility to participate in the design and implementation of new PFPMs [4]. In its subsequent proposed ruling, CMS defined PFPMs as an APM that includes Medicare as a payer and a physician group practice or individual physician (rather than a facility, nurse, or other allied health practitioner) as the APM entity and that targets the quality and costs of physician services,
Implications for Radiologists
An important consideration for radiologists and other specialists in CMS’s APM proposal is the disparity in physician payment between the MIPS and Advanced APMs. As previously noted, a QP participating in an Advanced APM will receive a 5% bonus in the initial 5 years of the program and a 3-fold higher annual adjustment in subsequent years than the typical MIPS-eligible clinician, all without any budget neutral payment adjustments [1]. Robust opportunities for Advanced APM participation will be
Take-Home Points
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The MACRA legislation of 2015 describes alternative payment models (APMs) as new approaches to paying for medical care that incentivize higher quality and value; MACRA incentivizes increasing participation in APMs by all physician specialties over the coming years.
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A fraction of APMs will meet criteria to be deemed an Advanced APM; clinicians who are a Qualifying Professional in an Advanced APM will receive substantial benefits under MACRA, including an automatic 5% payment bonus regardless of
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2020, Journal of the American College of RadiologyCitation Excerpt :Of note, MIPS introduces an entirely new participation mechanism through Alternative Payment Models (APMs) [6,7], which was not considered in prior works [2,3]. Other prior works discussed how providers meeting participation thresholds for a subset of APMs deemed advanced APMs could be excluded from MIPS participation [8]. However, providers in an advanced APM but below that threshold, or in an APM that is not an advanced APM, may participate in MIPS through a novel MIPS APM pathway that has, to date, received little attention in the radiology literature.
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2019, Journal of the American College of RadiologyCitation Excerpt :These non-RVU-generating activities are time consuming and have been previously reported to range from to 19% to 42% of an academic radiologist’s work day [2-4]. In the current era of rising health care expenditures and legislative responses such as the Medicare Access and CHIP Reauthorization Act of 2015, there is mounting pressure to decrease volume-based, fee-for-service payments in favor of value-based, pay-for-performance remuneration [5-7]. In general, this poses a challenge for radiology practices, in which compensation systems and individual radiologist salaries are currently based on practice revenue driven through the accumulation of clinical RVUs [8].
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Dr Rosenkrantz is supported by a research grant from the Harvey L. Neiman Health Policy Institute. Dr Hirsch has received fees unrelated to the present work from Medtronic, Carefusion, and Codman Neurovascular. The authors have no conflicts of interest related to the material discussed in this article.