From the October 2015 issue of HealthCare Business News magazine
The types of tools needed to do well in a value or risk-based payment system is something that imaging service providers know well: appropriate use criteria and patient safety protocols. Appropriate Use Criteria that are evidence- based and developed by physician-led organizations, such as the American College of Radiology and the American College of Cardiology, can help clinicians to order the right scan at the right time, and lower the need for additional imaging services or for expensive imaging tests to be ordered, when an ultrasound or X-ray test is just as, or more, appropriate.
With Medicare moving forward to adopt Appropriate Use Criteria for the ordering and rendering of imaging services reimbursed under Medicare’s fee for service payment system, it seems only natural that the Centers for Medicare and Medicaid Services (CMS) would encourage its use in all of its risk-based demonstration projects, such as Accountable Care Organizations, and provide access to these tools to those providers.
Similarly, patient safety protocols where central venous access or the placement of a tap or a needle is done under ultrasound guidance have been studied and shown to prevent several costly complications. Uniform adherence to such protocols would save the health care system and the patient money, but more importantly ensure higher quality patient care.
Another theme in this hearing revolved around competition. Members of Congress expressed concerns at the hearing about hospitals buying physician practices to then being able to charge the higher facility payment rates for services under the hospital outpatient department payment system. As discussed previously in this column, such a practice has led policy makers to the topic of “site neutral” payments for certain services, including some imaging services. In fact, it would primarily be the least expensive imaging services, such as ultrasound and X-ray, which would be negatively impacted by these types of site neutral policies.
This is because in some instances these services are “conditionally packaged,” which means that hospitals do not always get the cost of the service on the patient’s claim because the service is not, in that circumstance, paid separately. This incomplete data submission means that the overall payment by Medicare for the hospital outpatient department can go down, as hospital outpatient payment rates are set based on the charges submitted to Medicare by the hospital, if the charges do not get reported on the claim.
