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Optimization

Bundled Payments and Radiology

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With an intensified focus on providing cost effective care, payors are searching for new ways to manage cost. One such effort is the Centers for Medicare and Medicaid Services’ (CMS) Bundled Payments for Care Improvement (BPCI) initiative.

The ACR’s recent publication “A Radiologist’s Primer on Bundles and Care Episodes” provides a brief overview of the expected changes in bundled health care payments and the impact on radiology services. Bundled payments provide a financial incentive to reduce costs and improve coordination of care. This is achieved by setting a price for an episode of care to cover the range of services, including imaging, needed to treat a patient for a particular diagnosis. The price set for an episode of care is based on the diagnosis. A list of CMS defined episodes of care can be found here. We anticipate radiology-only bundles to be developed to cover episodes which rely primarily on imaging services. Seidenwurm and Lexa provide mammography screenings as an example of a potential radiology-only bundle.1 This bundle could include the initial mammography screening, recall diagnostic imaging, and follow up.

Bundled Payments
“Expect payments to reflect an average or lower than average utilization of imaging studies.”

Payment models vary on the definition of an episode of care and may cover the initial inpatient stay to post-acute period.2 The models also vary in how payments are provided, retrospectively or prospectively.  Bundled payments will require hospitals to determine how the payments are distributed among the different departments providing services.

With bundled payments, radiology departments would receive a portion of the payment for an episode of care. Determining the proportion of the payment for imaging services can be based different factors, such as:

  • Average utilization trends per diagnosis.
  • Guidelines and evidence-based recommendations for imaging required per episode.
  • Imaging results requiring follow up, such as in cancer diagnoses.

Since the goal is to curb costs associated with over-utilization of inappropriate imaging studies, expect payments to reflect an average or lower than average utilization of imaging studies.1

How Can CareSelect Imaging™ Help?

CareSelect Imaging™ incorporates the American College of Radiology’s guidelines into the existing provider workflow to drive the appropriate selection of imaging studies. Clinicians are able to determine the right diagnostic test for their patient at the time of ordering, thereby reducing the number of inappropriate tests.

Next step: Implement relative cost information with CareSelect Imaging™ to promote the use of appropriate diagnostic studies.

With tight reimbursement rates, it is important to help inform your providers about the cost of the studies they order. CareSelect Imaging™ provides an easy to interpret summary about the relative costs of diagnostic tests and promotes the selection of cost-effective imaging studies.

Next step: Customize the CareSelect Imaging™ workflow to alert providers to orders associated with bundled payments.

The CareSelect™ Reporting & Analytics tool provides a focused look at trends and ordering practices. The reporting package provides information on the frequency of an imaging study by a variety of characteristics including by diagnosis or provider.  These features help identify areas of opportunity and interventions can be tailored to specific orders.

Next Step: Use the CareSelect™ Reporting & Analytics tool to focus on ordering trends for diagnostic tests when payment bundles have narrow profit margins.

 

1. Seidenwurm D and Lexa FJ. A Radiologist’s Primer on Bundles and Care Episodes. J Am Coll Radiol 2016;13:1029-1031.
2. Centers for Medicare and Medicaid Services. Bundled Payments for Care Improvement (BPCI) initiative: general information. https://innovation.cms.gov/initiatives/bundled-payments/. Accessed October 11, 2016.

Pain in the Neck

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Low Appropriateness of Imaging Orders for Lower Back and Neck Pain

Back and neck pain can make day-to-day activities challenging and miserable. Medical attention is commonly sought in clinics, urgent care centers, and emergency rooms in pursuit of relief from back and neck pain. Imaging studies can help clinicians rule out high risk medical conditions, determine a diagnosis, and provide evidence to proceed with an appropriate treatment plan or further evaluation measures. However, imaging can also be used inappropriately, which can lead to variation of patient care as well as increased healthcare costs and resource utilization in organizations. Imaging studies can increase patient exposure to radiation, and there can be adverse events associated with imaging modalities. Furthermore, findings on an initial imaging can lead to obtaining additional diagnostic studies to further explore abnormal results.

The Journal of the American College of Radiology (ACR)’s recent publication “ACR Appropriateness Criteria Low Back Pain” advises that “imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags raising suspicion for serious underlying conditions…”¹ Six months of recent imaging order data from three CareSelect Imaging customers and revealed 93% of imaging orders for the indication of low back pain with low ACR appropriateness scores included the reason for exam as “Low back pain, <6 weeks, no red flags.” This suggests there is significant potential to reduce unnecessary imaging orders for low back pain and that enhanced clinical education on current guidelines may be beneficial.

“Neck pain” was among the top three indications listed as a reason for exam for imaging orders with low ACR appropriateness scores placed at these organizations. For one customer, “neck pain” accounted for 17% of the imaging orders placed with low ACR appropriateness scores. There is opportunity to identify clinical scenarios that can lead to imaging orders that may not be necessary, to assess imaging ordering practices, determine drivers of inappropriate imaging order placement, and to plan for improvements. Study findings published in the JACR’s “Screening Cervical Spine CT in the Emergency Department, Phase 3: Increasing Effectiveness of Imaging” depicted that “a clinical education initiative resulted in improved adherence to ACR Appropriateness Criteria and improved clinical effectiveness of the studies by increasing fracture detection rate.” ²

How Can CareSelect Imaging help?

CareSelect Imaging assists clinicians to determine the appropriateness of diagnostic tests for their patients and provides useful information about imaging modalities at the time of order placement. Imaging appropriateness scores from the American College of Radiology’s ACR Select™ Criteria for the chosen reason for exam, cost, and relative radiation level can help clinicians to proceed with determining plans for patient care.

CareSelect Imaging is a decision support tool that healthcare providers can utilize to decide if imaging is clinically indicated and which type of imaging modality is appropriate to pursue for a particular medical condition. In addition, CareSelect Reporting & Analytics tools enable full data collection and analysis of the decision support process, which enables sites to provide continuous education for their clinicians and trainees and to advocate for quality improvement programs.

Next Steps

Appropriate use of diagnostic imaging studies is essential for providing optimal patient care and for reduction of unnecessary costs. Several approaches can be taken in this effort:

  • Implement CareSelect Imaging with ACR Select™ to provide enhanced information to clinicians at the point of order, including the appropriateness scores for imaging in relation to the reason for exam, cost, and relative radiation exposure
  • Utilize CareSelect Reporting & Analytics tools to identify areas of opportunity, drivers of inappropriate imaging order placements, solutions, and improvement interventions at organizations
  • Educate clinicians and clinicians in-training about ACR guidelines for imaging orders and current evidence-based diagnostic guidelines for common medical conditions
  • Encourage reassessment of habitual ordering practice amongst healthcare providers

Interested in improving your organization’s quality of patient care while reducing costs from inappropriate imaging?

Reach Out Today

¹Patel N, Broderick D, Burns J, Deshmukh T, Fries I, Harvey B, et al. ACR Appropriateness Criteria Low Back Pain. J Am Coll Radiol 2016;13:1069-1078.
²Griffith B, Vallee P, Kupp S, Jung M, Slezak M, Nagarwala J, et al. Screening Cervical Spine CT in the Emergency Department, Phase 3: Increasing Effectiveness of Imaging. J Am Coll Radiol 2014;11:139-144.