One-third to Nearly one-half of Radiologists’ Services are Not Good Candidates for Episodic Payment Models

Newswise — Reston, VA – A new Harvey L. Neiman Health Policy Institute study found that 33% to 46% of imaging studies interpreted by radiologists do not have any related imaging studies in the year following the index imaging event. As such, these ‘one-off events’ are not good candidates for reimbursement through episode-based payment models. This Current Problems in Diagnostic Radiology study was based on 42.3 million (2015-2019) diagnostic imaging studies for individuals covered by a large commercial payer insurer including commercial insurance and Medicare Advantage.

The researchers wanted to assess the opportunity for radiologists to participate in emerging payment models. “Given the growth of episode-based payments, we sought to determine how much of radiologists’ work cannot conceivably be reimbursed through such models. The data showed this was a substantial percentage – nearly one-half” stated Eric Christensen, PhD, Research Director at the Neiman Health Policy Institute. “One-and-done events—one-off events—may include injuries or other acute events, or ruling out a diagnosis for a symptomatic patient. These events that do not require patient follow-up imaging are not good candidates for episode-based payments as a mechanism to incentive higher-value care.”

“Episode-based alternative payment models ideally incentivize clinicians to reduce low-value care. Such payment models tend to work best for patient-facing clinicians, such as primary care, because these clinicians direct and coordinate much of the care a patient receives over the course of a chronic condition or health event” stated Lauren Nicola, MD, Chief Executive Officer, Triad Radiology Associates and Chair, ACR Commission on Ultrasound. “Radiologists, however, provide care for the largest number of Medicare beneficiaries of any specialty, but frequently do so in single or short care events. As a result, there are limited efficiencies to be gained when radiologists participate in alternative payment models as they have traditionally been defined .”

“For complex patients with substantial ongoing care, radiologists can add value by working with referring clinicians as integral members of the care team to improve quality, safety, and value of imaging. Radiologists may do this by helping to guide ordering clinicians in reducing the variation in their ordering patterns” stated Gregory Nicola, MD, Executive Leadership, Hackensack Radiology Group and Chair, ACR Economics Commission. “Conceivably, alternative payment models can be devised to incentivize this role for ongoing care, but for the one-third to one-half of radiologist workload that is not part of an ongoing episode of care, such payment models would not be effective. Therefore, some form of fee-for-service payment must remain for one-off events.”