HIMSS14: CDS a process, not just a series of alerts | Health Imaging

Mostashari backs payment plan that replaces SGR | Vital Signs | The healthcare business blog from Modern Healthcare

Modern Healthcare

Article published February 10, 2014

Mostashari backs payment plan that replaces SGR

By Joseph Conn


Dr. Farzad Mostashari, the former head of the Office of the National Coordinator for Health Information Technology, is gung ho on a major change to the federal health IT incentive payment program incorporated in the proposed Medicare payment system for physicians to replace the sustainable growth-rate formula.

The legislation, unveiled Feb. 6 with bipartisan support, would eliminate penalties for noncompliance with Medicare meaningful-use criteria by 2017. The Medicare portion of the EHR incentive payment program, created under the American Recovery and Reinvestment Act, has already paid out about $4.1 billion to more than 218,000 physicians and other eligible professionals to adopt and meaningfully use EHRs.

“I think people need to really go down into a little bit of the details to appreciate what’s being proposed and, more importantly, what’s not being proposed,” said Mostashari, now a visiting fellow at the Brookings Institution, a New York-based think tank. Mostashari said Brookings has been tracking the legislation closely as it develops. “As far as I can see, this is all good,” he said. “The penalties are being phased out at the same time a value-based program is being started.” The timing, he said, is designed so there will be no gaps between old and new programs.

“What the Senate bill says, the determination of meaningful use will continue to be made by the Medicare program,” Mostashari said, with a strong push—and financial incentives of up to 10% of Medicare payments—toward alternative payment systems.

The way Mostashari sees it, financial incentives for meaningful use, which end in 2016 under the current Medicare portion of the EHR incentive payment program—will be baked into the proposed new Merit-Based Incentive Payment System, or MIPS.

“The carrots are renewed in a sense, because it’s part of the value-based purchasing model,” he said. Meanwhile, CMS will continue to determine meaningful use, which becomes a component of MIPS.

Another change contemplated by the legislation would induce providers to use a clinical decision support tool before ordering clinical images, such as CT scans, which Mostashari also likes.

“High-cost diagnostic imaging is a big and fast-growing item. The traditional approach to this on the part of payers is to put in place obstacles and prior authorization requirements. That drives doctors nuts.” A physician might spend an hour on the phone seeking prior approval from a payer’s representative who is “going through an opaque check list,” Mostashari said.

Mostashari noted that a study report, “A Technology Solution for the High-Tech Diagnostic Imaging Conundrum,” published in the August 2012 edition of the American Journal of Managed Care, showed promising results from a pilot project in Minnesota using an imaging CDS tool added to the EHRs of participating healthcare providers at four provider organizations.

The study showed orders that matched an appropriateness criteria increased from 79% to 89% after CDS implementation while overall orders for MRIs dropped 20% and CT scans fell 36%.

“The time to get approval went from an hour down to a second and it was just as effective as the manual operation in blunting excess utilization,” Mostashari said.

Reducing excess images is not only a cost-cutting measure, he said. “Inappropriate imaging is a safety hazard,” he said, noting estimates that 4% of all cancers are related to radiation exposure. The CDS proposal in the legislation is “a very sensible way to begin to implement decision support.”

Follow Joseph Conn on Twitter: @MHJConn

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ACR: Medical Imaging Provisions in SGR Bill Improve Quality, Preserve Resources and Make Medicare More Transparent

ACR: Medical Imaging Provisions in SGR Bill Improve Quality, Preserve Resources and Make Medicare More Transparent

Released: 2/6/2014 4:00 PM EST
Source Newsroom: American College of Radiology (ACR)

Contact InformationAvailable for logged-in reporters only

Newswise — Washington, DC (Feb. 6, 2014) – The American College of Radiology (ACR) strongly supports the bicameral, bipartisan legislation to replace the flawed sustainable growth rate (SGR) payment formula. The College particularly applauds inclusion of several ACR backed provisions that raise quality of care, make care more efficient and increase transparency in physician payment policy.

Foremost, the bill would require ordering providers to consult physician-developed appropriateness criteria when prescribing advanced medical imaging studies for Medicare patients. The legislation would direct the secretary of the U.S. Department of Health and Human Services to identify mechanisms, such as clinical decision support tools, by which ordering professionals could consult these criteria. Such ordering systems are shown to reduce duplicate and/or unnecessary scanning and associated costs.

“The imaging appropriateness criteria provisions in this SGR bill will help ensure that patients get the right exam for the right condition and avoid care they may not need. This will raise quality of care and help preserve resources without interfering in the doctor-patient relationship or affecting access to care. We applaud Congress for taking this groundbreaking step,” said Paul H. Ellenbogen, M.D., FACR, chair of the American College of Radiology Board of Chancellors.

The ACR also supports provisions in the bill which would provide a positive payment update of .5 percent to physicians each year through 2018 and require that any specific cuts to medical services greater than 20 percent be phased in over two years.

“Repeated imaging cuts have forced many facilities to close or cut services. According to the FDA, there are now roughly 150 fewer mammography facilities and nearly 600 fewer mammography units available than in 2007. This “dampening” policy would help prevent such massive impact on patient access to care and is a step toward sensible imaging reimbursement policies,” said Ellenbogen.

Another ACR backed provision would require the Centers for Medicare and Medicaid Services (CMS) to produce data used to justify a 2012 policy that implemented a 25 percent multiple procedure payment reduction to certain medical imaging procedures provided to the same patient, on the same day, in the same session.

“A 2012 JACR study proves that this multiple procedure payment reduction has no basis in fact. CMS has never provided any basis for this destructive policy that affects care for the most sick and injured patients. We look forward to a legislative policy that will force Medicare to justify this cut, which has negatively impacted so many providers,” said Ellenbogen.

To arrange an interview with an ACR spokesperson, please contact Shawn Farley at 703-648-8936 or PR@acr.org.

DOTmed.com – ACOs are evolving, where will imaging fit in?

ACOs are evolving, where will imaging fit in?

by Loren Bonner, DOTmed News Online Editor
For the past couple of years, the ACR Future Trends Committee has been tasked with developing strategies and tools to help radiologists become part of accountable care organizations — one of the shared savings programs written into the Affordable Care Actthat’s intended to improve care for patients.

Fast forward to today, and many radiologists are still unsure how they fit in to ACOs. Nonetheless, many are technically a part of an ACO, although imaging as a whole has still not been written into the ACO structure.

“There aren’t 300 examples of radiologists being in a comprehensive ACO and behaving as if they are in one, where all their work is now at risk,” Dr. Frank Lexa, a professor in the department of radiologic sciences at Drexel University in Philadelphia, told DOTmed News.

While the ACA has created interest in, and opened the door for, ACOs in the private sector, it specifically created an ACO program in the public sector: the Medicare Shared Savings Program (MSSP). There is also the Pioneer ACO program that’s a part of Medicare, but designed to be more flexible in nature. A recent study in the journal Health Affairs found that hospitals were participating in slightly less than half of the initial group of the public sector ACOs.

According to national figures, there are roughly 300 private ACOs, and roughly the same number of Medicare ACOs across the country. Many hospital systems — like Kaiser Permanente or even Montefiore Medical Center in New York — already functioned like an ACO even before the term was coined. These institutions have an integrated delivery system with technology built in to coordinate patient care, as well as a payment arrangement with health plans that includes financial accountability and performance incentives.

“To borrow someone else’s quip: Many radiologists didn’t even know they were in an ACO because nothing changed,” said Lexa.

That might be seen as a good thing for some who are happy to know radiologists are in the mix, but a disappointment to others who feel radiologists need to be more involved.

Lexa said that the flexible nature of the private ACOs, and that fact that they are still evolving, is an opportunity for radiologists to do just that — get involved.

“The biggest message from ACO diversity so far is that they’re an opportunity to craft your own contract or your own relationship and consider ways that you might make an offer,” said Lexa.

He hopes radiologists will go beyond working as contractors in ACOs that only provide imaging services.

“Ultimately, your pay in the future is going to be a part of this,” said Lexa.

While ACOs will likely be tweaked through the years — especially the federal ones — returning to the days of fee-for-service is unlikely, according to Lexa.

“Whether you like ACOs or not, it’s kind of a kick to get you to wake up, to figure out how we can get paid for value and can do a better job measuring outcomes,” he said.

NOTE FROM EDITOR: Are you a part of an ACO or do you have experience with one? If so, please let us know below. I’ll write a follow up story based on your responses.

Radiologist Takes Appropriateness Message to the Community

Published on Diagnostic Imaging (http://www.diagnosticimaging.com)
Home > Radiologist Takes Appropriateness Message to the Community

January 30, 2014

One radiologist is taking a proactive approach to encourage appropriate image ordering by educating his fellow referring physicians. Here’s why he’s doing it, and why other radiologists should, too.

As the campaign to encourage the right imaging tests at the right time continues to gather momentum in the medical community, one radiologist is taking an active approach to promoting appropriateness. Austin radiologist Robert M. Milman, MD, who has been giving presentations on imaging to primary care providers for many years, recently turned his attention to educating referring physicians on appropriate image ordering.

While it might appear at first glance that a radiologist instructing referring physicians to be more judicious about ordering imaging studies would be doing financial harm to himself and his group, Milman has the broader picture in mind. He embraces the ACR’s Imaging 3.0 initiative to provide better care at lower cost by helping providers determine the most appropriate tests to order.

Milman is with Austin Radiological Association, a 90-physicain private practice radiology group that provides services to almost all of the hospitals in the Austin area and operates 16 imaging centers. Diagnostic Imaging spoke with Milman about his efforts to ensure the appropriate use of imaging in his community, and how you might do the same where you practice.

Where are you giving these presentations, and to whom?

I go to different venues. I speak at meetings of state-wide organizations like the Texas Academy of Family Physicians when they meet in Austin and to local primary care groups. I also give the talks at the University of Texas School of Nursing for advanced nurse practitioner graduate students and at Texas A&M University to medical students.

What do you typically cover in your talk?

The main focus of the presentation is about appropriate imaging or “what to order when.” I go over what different types of studies can and can’t do and discuss the level of radiation exposure to patients — what’s involved in a CT scan versus a plain X-ray, for example, or that there is no radiation exposure at all with ultrasound or MRI. I also cover how to decide on appropriate follow-up studies and some of the lesser discussed risks involved with imaging like false positives and incidentalomas, both of which can cause patients unexpected anxiety.

What do you think draws primary care physician and nurse practitioners to these talks?

Imaging is now involved in the care of so many patients that our referring community really wants to learn about how to order the right study at the right time for the right reason. As radiologists, we can provide information to help doctors get the answers they need in the most efficient and most cost-effective way possible. They appreciate learning how to get from point A to point B when they’re trying to make the right diagnosis for a patient. The feedback has been positive. Also, my group has the ability to offer CME credit for some of the talks, so that helps.

What’s the level of engagement in the part of your audience members?

They’re very attentive and stay with me and stay on topic. For them it’s a picture show because radiology is so visual. No one is interested in dull material, but if you can provide something of worth, people will attend.

One issue that often comes up is related to patient demand. People have access to a lot of medical information today and if they have low back pain they know there is this thing called an MRI machine out there and they think they need that scan. Referring physicians spend a lot of time trying to help patients understand what’s appropriate when it comes to imaging, so I touch on that in my presentations.

What has surprised you since you’ve been offering these presentations?

Mostly that even though the American College of Radiology’s appropriateness criteria program has been out there for quite a while that many primary care physicians are still not aware of it. The traditional method of picking up the phone and calling a radiologist when they have a question is fine — and our group does a lot of that and is happy to do it — but primary care doctors could save a lot of time by using the information that the ACR has available. With a few clicks on the computer they can usually get an answer about what test to order.

How does the practice of so-called “defensive medicine” come into play related to appropriate imaging?

Some doctors order more than others or sooner than others because they don’t want to miss anything, and that’s understandable. But the appropriateness criteria are actually a benefit to physicians because if they follow the guidelines and document what they’re doing, they’re acting reasonably. That’s protective from a medical-legal standpoint.

What do you see as the future for radiology groups given the push for referring physicians to follow appropriateness guidelines?

Most radiologists are becoming aware that the world is changing from a volume driven, fee-for-service model to a value driven, patient-centered model. At the end of the day you want to do the most appropriate test and be as efficient as possible. It’s about making the right diagnosis and treating the patient appropriately. This is a culture change, but resources are not unlimited and costs need to be contained.

Is your group supportive of your efforts to educate healthcare providers?

Yes. There are about 90 radiologists in our group and many of us give CME presentations. I’m the primary one in the group doing talks on imaging appropriateness right now. I’m planning to branch out and start giving presentations about appropriateness specifically related to screening studies such as the latest in breast imaging, lung cancer screening, and the use of virtual colonoscopy.

What advice do you have for a radiologist who is reading this and thinking about offering similar presentations in their community?

Get energized about the topic and put effort into giving the talks. They could contact some of their local primary care groups and offer to come in and make a presentation or they could work through their local hospitals or medical society to get the ball rolling. Groups always appreciate having interesting speakers come in.