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Hirsch JA. Pulmonary Nodules As a Gateway to Value-Based Care. Acad Radiol 2019; 26:803-804. [PMID: 30904274 DOI: 10.1016/j.acra.2019.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Joshua A Hirsch
- Interventional Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114.
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2
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The pincer movement of cost and quality in neurointerventional care: resource management as an imperative. J Neurointerv Surg 2019; 11:323-325. [DOI: 10.1136/neurintsurg-2019-014871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2019] [Indexed: 11/03/2022]
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3
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Hirsch JA, Leslie-Mazwi T, Nicola GN, Milburn J, Kirsch C, Rosman DA, Gilligan C, Manchikanti L. Storm rising! The Obamacare exchanges will catalyze change: why physicians need to pay attention to the weather. J Neurointerv Surg 2018; 11:101-106. [DOI: 10.1136/neurintsurg-2018-014412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2018] [Indexed: 11/03/2022]
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Day of Week, Site of Service, and Patient Complexity Disparities in Musculoskeletal MRI Interpretations by Radiologists Versus Nonradiologists. AJR Am J Roentgenol 2018; 211:827-830. [PMID: 30063370 DOI: 10.2214/ajr.17.19438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Although most musculoskeletal MRI examinations are interpreted by radiologists, some nonradiologists provide interpretations as well. We aimed to study day of week (weekday vs weekend), site of service, and patient complexity differences between radiologists and nonradiologists interpreting lower extremity MRI examinations on Medicare beneficiaries. MATERIALS AND METHODS Using fee-for-service carrier claims for a 5% sample of Medicare beneficiaries nationally from 2012 through 2014, we identified all lower extremity joint MRI examinations. Services were classified by physician specialty, day of week, and site of service. Charlson comorbidity index (CCI) values were calculated for all patients. Chi-square statistical testing was performed. RESULTS Of all 125,800 billed lower extremity joint MRI examinations, 118,295 (94.0%) were performed on weekdays and 7505 (6.0%) on weekends. Of the weekday examinations, radiologists interpreted 85,991 (83.3%) and nonradiologists 17,260 (16.7%). Of the weekend examinations, radiologists interpreted 6212 (92.8%) and nonradiologists 485 (7.2%). Of examinations performed in inpatient hospital and emergency department settings, radiologists interpreted 6499 (99.2%) and nonradiologists 51 (0.8%). Of the examinations on the most clinically complex patients (CCI ≥ 3), radiologists interpreted 4228 (90.2%) and nonradiologists 461 (9.8%). All interspecialty differences were statistically significant (p < 0.001). CONCLUSION In the Medicare population, radiologists interpret most lower extremity joint MRI examinations. Compared with nonradiologists, radiologists disproportionately provide services on weekends, in the highest acuity settings, and on the most clinically complex patients. To promote patient access and minimize disparities, future pay-for-performance metrics should consider temporal, acuity, and complexity parameters.
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Spilberg G, Nicola GN, Rosenkrantz AB, Silva Iii E, Schirmer CM, Ghoshhajra BB, Choradia N, Do R, Hirsch JA. Understanding the impact of 'cost' under MACRA: a neurointerventional imperative! J Neurointerv Surg 2018; 10:1005-1011. [PMID: 30038063 DOI: 10.1136/neurintsurg-2018-013972] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/23/2018] [Accepted: 04/26/2018] [Indexed: 11/04/2022]
Abstract
The cost of providing healthcare in the United States continues to rise. The Affordable Care Act created systems to test value-based alternative payments models. Traditionally, procedure-based specialists such as neurointerventionalists have largely functioned in, and are thus familiar with, the traditional Fee for Service system. Administrative charge data would suggest that neurointerventional surgery is an expensive specialty. The Medicare Access and CHIP Reauthorization Act consolidated pre-existing federal performance programs in the Merit-based Incentive Payments System (MIPS), including a performance category called 'cost'. Understanding cost as a dimension that contributes to the value of care delivered is critical for succeeding in MIPS and offers a meaningful route for favorably bending the cost curve.
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Affiliation(s)
- Gabriela Spilberg
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | | | - Clemens M Schirmer
- Department of Neurosurgery, Neuroscience Institute, Geisinger, Wilkes-Barre, Pennsylvania, USA
| | - Brian B Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Rose Do
- Department of Cardiology and Cardiac Surgery, Veterans Affairs Medical Center, Long Beach, Kaiser Permanente of Southern California, Acumen, LLC, Long Beach, California, USA
| | - Joshua A Hirsch
- Interventional Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Golding LP, Nicola GN, Ansari SA, Rosenkrantz AB, Silva III E, Manchikanti L, Hirsch JA. MACRA 2.5: the legislation moves forward. J Neurointerv Surg 2018; 10:1224-1228. [DOI: 10.1136/neurintsurg-2018-013910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/08/2018] [Accepted: 06/09/2018] [Indexed: 11/04/2022]
Abstract
The Medicare and CHIP Reauthorization Act of 2015 remains the payment policy law of the land. 2017 was the first year in which performance reporting will tangibly impact future physician payments. The Centers for Medicare & Medicaid Services (CMS) considers 2017 and 2018 transitional years before full implementation in 2019. As such, 2018 increases the reporting requirements over 2017 in the form of a gradual phase-in while introducing several key changes and new elements. Indeed, it is the nature of the transition itself that led to the somewhat unique title of this manuscript, i.e., MACRA 2.5. Stakeholder feedback to the CMS regarding the program has ranged widely from the elimination of core components to expanding reporting to non-government payers. This article explores the potential impact on neurointerventional physicians.
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Albuquerque FC. Varied terrain. J Neurointerv Surg 2017; 9:1031-1032. [PMID: 29030461 DOI: 10.1136/neurintsurg-2017-013519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2017] [Indexed: 11/04/2022]
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8
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Hirsch JA, Rosenkrantz AB, Allen B, Nicola GN, Klucznik RP, Manchikanti L. AHCA meets BCRA; timeline, context, and future directions. J Neurointerv Surg 2017; 10:205-208. [DOI: 10.1136/neurintsurg-2017-013478] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2017] [Indexed: 11/03/2022]
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Wilson TA, Leslie-Mazwi T, Hirsch JA, Frey C, Kim TE, Spiotta AM, Leacy RD, Mocco J, Albuquerque FC, Ducruet AF, Cheema A, Arthur A, Srinivasan VM, Kan P, Mokin M, Dumont T, Rai A, Singh J, Wolfe SQ, Fargen KM. A multicenter study evaluating the frequency and time requirement of mechanical thrombectomy. J Neurointerv Surg 2017; 10:235-239. [DOI: 10.1136/neurintsurg-2017-013147] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 05/08/2017] [Indexed: 11/04/2022]
Abstract
IntroductionThere are few published data evaluating the incidence of mechanical thrombectomy among stroke centers or the times at which they occur.MethodsA multicenter retrospective study was performed to identify all patients undergoing emergent thrombectomy for acute ischemic stroke during a 3-month period (June through August 2016). Consultations that did not undergo thrombectomy were not included.ResultsTen institutions participated in the study. During the 92-day study period, a total of 189 patients underwent mechanical thrombectomy. The average number of procedures per hospital over the study period was 18.9 (average of 0.2 cases per day per or 75.6 cases per year). This ranged from 0.09 cases per day at the lowest volume center to 0.49 cases per day at the highest volume center. Procedures were more common on weekdays (p<0.001) and during non-work hours (p<0.001). The most common period for thrombectomy procedures was between 20:00 and 21:00 hours. The median time from notification to groin puncture was 84 min (IQR 56–145 min) and from puncture to closure was 57 min (IQR 33–80 min). The median time from imaging completion to procedural start was 52 min longer for non-work hours than during work hours (p<0.001). There were no differences in procedural length based on day of the week or time of day.ConclusionsThese findings indicate that the majority of mechanical thrombectomy cases occur during non-work hours, with associated off-hours delays, which has important operational implications for hospitals implementing stroke call coverage.
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Contextualizing the first-round failure of the AHCA: down but not out. J Neurointerv Surg 2017; 9:595-600. [DOI: 10.1136/neurintsurg-2017-013136] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 04/18/2017] [Indexed: 11/03/2022]
Abstract
On 8 November 2016 the American electorate voted Donald Trump into the Presidency and a majority of Republicans into both houses of Congress. Since many Republicans ran for elected office on the promise to ‘repeal and replace’ Obamacare, this election result came with an expectation that campaign rhetoric would result in legislative action on healthcare. The American Health Care Act (AHCA) represented the Republican effort to repeal and replace the Affordable Care Act (ACA). Key elements of the AHCA included modifications of Medicaid expansion, repeal of the individual mandate, replacement of ACA subsidies with tax credits, and a broadening of the opportunity to use healthcare savings accounts. Details of the bill and the political issues which ultimately impeded its passage are discussed here.
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Hirsch JA, Rosenkrantz AB, Allen B, Manchikanti L, Nicola GN. Foundational Changes Critical to Payments for Radiology Services. J Am Coll Radiol 2017; 14:875-881. [PMID: 28242063 DOI: 10.1016/j.jacr.2016.12.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 11/04/2016] [Accepted: 12/23/2016] [Indexed: 10/20/2022]
Abstract
In early 2015, Sylvia Burwell, Secretary of the Department of Health and Human Services, described the federal administration's goals for delivery of health care in the United States. Prominently featured was a conversion from volume to value through the incorporation of Alternative Payment Models. The Department of Health and Human Services laid the framework, but recognized significant knowledge gaps in how providers and institutions would develop Alternative Payment Models. To that end, the Health Care Payment Learning and Action Network was conceived. On March 25, 2015, the Health Care Payment Learning and Action Network held its first meeting, which included a broad swath of industry participants. This collaboration was considered mission critical to achieving success in the goals of advancing Alternative Payment Models. This article highlights the Health Care Payment Learning and Action Network and the framework it is proposing for Alternative Payment Models that would have meaningful implications for radiologists.
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Affiliation(s)
- Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Bibb Allen
- Department of Radiology, Grandview Medical Center, Birmingham, Alabama
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Rosenkrantz AB, Nicola GN, Allen B, Hughes DR, Hirsch JA. MACRA, Alternative Payment Models, and the Physician-Focused Payment Model: Implications for Radiology. J Am Coll Radiol 2017; 14:744-751. [PMID: 28132819 DOI: 10.1016/j.jacr.2016.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/29/2016] [Accepted: 12/05/2016] [Indexed: 10/20/2022]
Abstract
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 describes alternative payment models (APMs) as new approaches to health care payment that incentivize higher quality and value. MACRA incentivizes increasing APM participation by all physician specialties over the coming years. Some APMs will be deemed Advanced APMs; clinicians who are a Qualifying Participant in an Advanced APM will receive substantial benefits under MACRA including an automatic 5% payment bonus, regardless of their performance and savings within the APM, and a larger payment rate increase beginning in 2026. Existing APMs are most relevant to primary care physicians, and opportunities for radiologists to participate in Advanced APMs fulfilling Qualified Participant requirements are limited. Physician-Focused Payment Models (PFPMs), as described in MACRA, are APMs that target physicians' Medicare payments based on quality and cost of physician services. PFPMs must address a new issue or specialty compared with existing APMs and will thus foster a more diverse range of APMs encompassing a wider range of specialties. The PFPM Technical Advisory Committee is a new independent agency that will review proposals for new PFPMs and provide recommendations to CMS regarding their approval. The PFPM Technical Advisory Committee comprises largely primary care physicians and health policy experts and is not required to consult clinical experts when reviewing new specialist-proposed PFPMs. As PFPMs provide a compelling opportunity for radiologists to demonstrate and be rewarded for their unique contributions toward patient care, radiologists should embrace this new model and actively partner with other stakeholders in developing radiology-relevant PFPMs.
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Affiliation(s)
| | | | - Bibb Allen
- Department of Radiology, Grandview Medical Center, Birmingham, Alabama
| | - Danny R Hughes
- Harvey L. Neiman Health Policy Institute, Reston, Virginia; Department of Health Administration and Policy, George Mason University, Fairfax, Virginia
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Rosenkrantz AB, Nicola GN, Hirsch JA. Anticipated Impact of the 2016 Federal Election on Federal Health Care Legislation. J Am Coll Radiol 2017; 14:490-493. [PMID: 28082158 DOI: 10.1016/j.jacr.2016.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 12/15/2016] [Accepted: 12/15/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Hirsch JA, Rosenkrantz AB, Liu RW, Manchikanti L, Nicola GN. The episode, the PTAC, cost, and the neurointerventionalist. J Neurointerv Surg 2016; 9:1146-1148. [PMID: 27934634 DOI: 10.1136/neurintsurg-2016-012885] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2016] [Indexed: 11/04/2022]
Abstract
Episodic care forms a payment methodology of increasing relevance to neurointerventional specialists and other providers. Episodic care payment models are currently recognized in both payment paths described by the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act (MACRA): the Merit-Based Incentive Payment System and Advanced Alternative Payment Models. Understanding the cost of care, as well as how such costs are shaped in the context of episodic care, will be critical to success in both of these paths.
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Affiliation(s)
- Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Raymond W Liu
- Department of Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, Kentucky, USA.,Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
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Hirsch JA, Leslie-Mazwi TM, Nicola GN, Bhargavan-Chatfield M, Seidenwurm DJ, Silva E, Manchikanti L. PQRS and the MACRA: Value-Based Payments Have Moved from Concept to Reality. AJNR Am J Neuroradiol 2016; 37:2195-2200. [PMID: 27659194 DOI: 10.3174/ajnr.a4936] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- J A Hirsch
- From the Departments of Neuroendovascular Imaging (J.A.H., T.M.L.-M.)
- Radiology (J.A.H.)
| | - T M Leslie-Mazwi
- From the Departments of Neuroendovascular Imaging (J.A.H., T.M.L.-M.)
- Neurology (T.M.L.-M.), Massachusetts General Hospital, Boston, Massachusetts
| | - G N Nicola
- Hackensack Radiology Group (G.N.N.), River Edge, New Jersey
| | | | - D J Seidenwurm
- Department of Radiology (D.J.S.), Sutter Medical Group, Sacramento, California
| | - E Silva
- South Texas Radiology Group (E.S.), San Antonio, Texas
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Hirsch JA, Harvey HB, Barr RM, Donovan WD, Duszak R, Nicola GN, Schaefer PW, Manchikanti L. Sustainable Growth Rate Repealed, MACRA Revealed: Historical Context and Analysis of Recent Changes in Medicare Physician Payment Methodologies. AJNR Am J Neuroradiol 2015; 37:210-4. [PMID: 26585253 DOI: 10.3174/ajnr.a4522] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- J A Hirsch
- From the Department of Radiology (J.A.H., H.B.H., P.W.S.), Massachusetts General Hospital, Boston, Massachusetts Harvard Medical School (J.A.H., H.B.H., P.W.S.), Boston, Massachusetts
| | - H B Harvey
- From the Department of Radiology (J.A.H., H.B.H., P.W.S.), Massachusetts General Hospital, Boston, Massachusetts Harvard Medical School (J.A.H., H.B.H., P.W.S.), Boston, Massachusetts
| | - R M Barr
- Mecklenburg Radiology Associates P.A. (R.M.B.), Charlotte, North Carolina
| | - W D Donovan
- Norwich Diagnostic Imaging Associates (W.D.D.), Norwich, Connecticut
| | - R Duszak
- Department of Radiology and Imaging Sciences (R.D.), Emory University, Atlanta, Georgia Harvey L. Neiman Health Policy Institute (R.D.), Reston, Virginia
| | - G N Nicola
- Hackensack University Medical Center (G.N.N.), Hackensack, New Jersey
| | - P W Schaefer
- From the Department of Radiology (J.A.H., H.B.H., P.W.S.), Massachusetts General Hospital, Boston, Massachusetts Harvard Medical School (J.A.H., H.B.H., P.W.S.), Boston, Massachusetts
| | - L Manchikanti
- Pain Management Center of Paducah (L.M.), Paducah, Kentucky Department of Anesthesiology and Perioperative Medicine (L.M.), University of Louisville, Louisville, Kentucky
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Hirsch JA, Leslie-Mazwi TM, Patel AB, Rabinov JD, Gonzalez RG, Barr RM, Nicola GN, Klucznik RP, Prestigiacomo CJ, Manchikanti L. MACRA: background, opportunities and challenges for the neurointerventional specialist. J Neurointerv Surg 2015. [DOI: 10.1136/neurintsurg-2015-011952] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The legislative branch of government took many by surprise when it announced the Medicare Access and CHIP Reauthorization Act of 2015. Once the Act was passed, President Obama quickly signed this bipartisan, bicameral effort into law. A foundational element of this legislation was the permanent repeal of the sustainable growth rate formula. Physicians and their patients were appropriately enthusiastic about this development. The Medicare Access and CHIP Reauthorization Act of 2015 included additional elements of considerable interest to neurointerventional specialists.
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