CMS Quality Measures and Their Impact on Radiology
The Physician Quality Reporting System (PQRS) was initiated by the U.S. Centers for Medicare and Medicaid Services (CMS) in 2007 to establish a standard of reporting quality metrics to promote patient outcomes and quality treatment.
Initially a voluntary program offering bonus payments paid to participating physicians, PQRS became mandatory as part of the Patient Protection and Affordable Care Act of 2010. As of Jan.1, 2015, physicians who fail to participate will incur penalties of 1.5% on reimbursements for Medicare/Medicaid patients.
Data can be submitted through a claims-based method, in which measures are tied to reimbursement claims for CPT codes, or through registry reporting. In May 2014, the ACR National Radiology Data Registry (NRDR) was recognized by CMS as a Qualified Clinical Data Registry. The ACR lists on its website (www.acr.org/Quality-Safety/Quality-Measurement/PQRS/Measures) 34 measurement specifications applicable to radiologists: nine for diagnostic radiology, one for nuclear medicine, 11 for interventional radiology, and 13 for radiation oncology.
Will PQRS result in measurable improvement of patient care and treatment value in radiology?
In the view of Saurabh Jha, MD, this remains an open question.
“Value is very nebulous,” said Dr. Jha, an assistant professor of radiology at the Hospital of the University of Pennsylvania in Philadelphia, PA. “There are many elements of radiology that represent value. Radiologists know what they are, but defining value precisely is problematic. Value is defined as quality divided by cost. Being able to accurately compare quality includes many things that cannot be measured. And if measurement isn’t possible, how can you precisely compare quality?”
Dr. Jha, who has a scholarly interest in the value of radiology, has established a website on value: www.valueofimaging.com. This educational repository, underwritten from an education grant from the RSNA, focuses on the economics of diagnostic imaging and the value of information. Dr. Jha will discuss CMS quality measures and their impact on radiology in a presentation at an evening event at this year’s RSNA meeting in Chicago.
The PQRS requirements represent quality measures that physicians and their representing organizations believe are important. From radiology’s perspective, Dr. Jha said, this includes items that are reasonably easy quality metrics to procure, including radiation dose, patient exposure time in fluoroscopic-guided procedures, providing a reminder system for screening mammograms, and reporting the percentage of final reports for screening mammograms that are classified as “probably benign.”
But are the measurements relevant, and how appropriate are they?
According to Dr. Jha, reporting radiation dose so that that it falls within the range of acceptable doses of the specific procedures does not necessarily reflect quality of clinical judgment or risk to the patient unless it is put into context of a clinical need, patient’s medical condition and age – i.e., neither the risk of radiation nor the benefits of the diagnostic test are captured by reporting the dose.
Dr. Jha pointed out that performing a cardiac CT angiography on a patient presenting to the ED with chest pain represents value, because appropriate treatment decisions can be made very rapidly. But what if a patient presents to the ED on a regular basis and has repeat (negative) CTs to rule out pulmonary embolism? He may have a low single radiation dose but a high cumulative dose and, more importantly, unwarranted studies.
Monitoring radiation dose can be a value proposition, particularly if it encourages a tailoring of the protocol and application of clinical nuance, and for a patient close to reaching the threshold of radiation, substitution with a test with less or no ionizing radiation.
“Radiologists must deepen their understanding of PQRS metrics for other clinicians, and see if imaging can help clinicians reach their metrics — something for which we will be appreciated,” he said.
“The PQRS program is well-meaning, and it may stimulate more awareness of the need to provide valuable services to patients and ordering physicians,” Dr. Jha continued, “but it is largely of uncertain value, because the metrics that are easy to report and easy to acquire need to be placed in greater context.”
“Radiologists need to comply—there is no point in shooting the messenger that is trying to improve our compliance with PQRS, but we need to step beyond PQRS,” he said. “Utilization management is not a formal part of this program, but that is where radiologists can make a great contribution.”
Dr. Jha believes all radiologists should act on behalf of patients in managing imaging utilization so that patients get the appropriate study— and not an unnecessary investigation. Dr. Jha trained in the United Kingdom at a time when imaging was a scarce commodity in the National Health Service.
“To get through the gate for approval on a patient’s CT exam, clinicians had to be at the top of their game,” he said. “To triage effectively, radiologists had to think like the referring physicians. Both sides pushed each other, resulting in clinical acumen improvements for both. This has not been part of the culture in the United States, and it should be, for the sake of resources and patients, and for the sake of radiologists.”
In the U.S., Dr. Jha argues, radiologists traditionally have not wanted to question a referring physician. While that has been financially rewarding and led to job security for radiologists, the U.S. healthcare system is undergoing seismic changes. The American College of Radiology Imaging 3.0 initiative includes use of its appropriateness criteria.
“In my experience, guidelines help but are not enough,” Dr. Jha said. “I am a strong advocate of radiologists getting personally involved in clinical medicine beyond the film reading. They must aggressively but constructively consult with referring physicians.”
“We need to be proactive clinicians,” he said. “We can make a huge impact with primary care physicians who would benefit from our knowledge about what exams to order, and the risk of overdiagnosis when ordering a test for reassurance sake, and also by our producing unambiguous, informative reports. We need to develop clinical-imaging conferences, act as imaging consultants, and conduct imaging rounds. Benchmarks need to be established to define an acceptable proportion of negative studies,” he emphasized.
It’s also the radiologist’s job to educate and reassure, Dr. Jha said, noting that media focus on the dangers of radiation exposure from imaging must be put into context.
“Quality is when a radiologist evaluates the need to expose a patient to radiation based on the patient’s condition, the patient’s age, and the value of the imaging procedure,” he said. “No patient should be put in the position of not being given an imaging procedure that could reach a serious diagnosis based on fears of unknown risks of radiation-induced cancer at low doses, and it is very important that a radiologist be a patient advocate, whether fighting for a needed exam or denying an inappropriate one. To do this effectively, radiologists need to develop extensive knowledge of clinical medicine.”
PQRS gathers metrics that determine value at the federal level, but radiologists should also be sure to articulate activities associated with value at the local level.
“Quality and value are a blank slate,” he said. “The blankness of the slate is a huge opportunity for radiologists to fill what we think is measurable and of value. If we don’t articulate, someone else will do so for us.”
Dr. Jha said that considering the changing reimbursement landscape, if radiologists’ value is restricted to film reading, they face the very real risk of commoditization.
“And when that happens we will be judged by how fast we read, how many we read and how low we charge for our reads — the cheapest hamster on the fastest wheel will win,” he concluded.
Per University of Pennsylvania Conflict of Interest Policy, Dr. Jha discloses that he has received speaking fees and travel reimbursement from Toshiba America Medical Systems.