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High health care costs driving shift to value-based care

February 13, 2017
From the January 2017 issue of HealthCare Business News magazine

By Menashe Benjamin

The existing fee-for-service model of health care delivery in the U.S. has created an unsustainable spiral of rising costs, often accompanied by poor performance based on quality indicators. Unfortunately, this payment model rewards providers who increase the volume of services they deliver, but does not offer financial incentives that are tied to patient health outcomes. As a result, employers, health plans and government purchasers of health care are advocating a transition to value-based payment models. The objective is to create an environment that lowers costs while simultaneously aligning bonuses or penalties for physicians, hospitals and other care providers based on cost, quality and patient health outcomes.

U.S. health care spending is estimated to reach almost $4.5 trillion by 2021, which represents an estimated 19 percent of the nation’s gross domestic product (GDP). This level of spending is unsupportable and the aging of the population is compounding the problem. When Medicare began in 1965, the ratio of Medicare taxpayers to beneficiaries was 4.6 to 1. That ratio is currently 3.1 to 1 and is projected to reach 2.3 to 1 by 2030. Several recently enacted laws amending Medicare reflect concerns about costs and goals for better value.

MACRA (Medicare Access and CHIP Reauthorization Act) of 2015 encourages health care providers, including radiologists, to participate in one of two models for reimbursement: a Merit-Based Incentive Payment System (MIPS); or an Advanced Alternative Payment Model (AAPM), including Accountable Care Organizations (ACOs), which use shared savings/risk payment models and pilots for bundled payments.

MIPS is designed to consolidate existing quality-based payment policies. MIPS’ goals include a set of evidence-based, specialty-specific standards as well as practice-based activities for improved quality and use of resources; advanced care information through the use of certified EHR technology; and practice-based improvement objectives. Examples of MIPS measures that are applicable to radiology include:

• Appropriateness standards for ordering imaging studies. This includes use of decision support systems for ordering advanced imaging studies, such as CT, PET and MRI exams.

• Avoidance of overuse of CT for sinusitis, head trauma in children, bone scans in low-risk patients with prostate cancer and cardiac stress testing in low-risk surgery patients. Standards related to radiation dose management and monitoring, including reporting fluoroscopy exposure time. Workflow and radiology reporting standards include documentation regarding prophylaxis for patients with fractures or findings suggesting osteoporosis, as well as appropriate follow-up recommendations for conditions such as incidental abdominal lesions on CT, thyroid nodules in CT or MRI and pulmonary nodules. These standards promote the use of imaging analytics and natural language processing. Workflow will also involve image and medical data sharing within and between provider organizations, including the use of patient portals.

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