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Quality improvement column

05-18-2017 15:50

Interview with Ammar Sarwar, MD, on cost analysis in interventional radiology

Spring 2017

In December 2016, SIR Foundation held a research consensus panel (RCP) on cost analysis in interventional radiology. The RCP, which was made up of physicians and representatives of federal agencies, industry, and other sectors, was led by Ammar Sarwar, MD. Dr. Sarwar is an assistant professor of radiology at Harvard Medical School and a staff radiologist in the vascular and interventional radiology and informatics divisions at Beth Israel Deaconess Medical Center. IRQ recently sat down with Dr. Sarwar to discuss the RCP.

What prompted SIR Foundation to pursue an RCP on this topic?

Sarwar: The fact that IR offers better value and better or equivalent efficacy compared to medical or surgical alternatives has been ignored in cost-agnostic delivery systems. Due to their unsustainable nature, rising costs of health care delivery have pushed cost measurement to the forefront of the U.S. health policy agenda. This paradigm shift crystallized with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which firmly established costs of care as a metric for comparing physician performance. SIR Foundation recognized that it was an ideal opportunity to promote the cost advantage that IR services provide to patients, providers and payers. This RCP is the first step in promoting the research agenda that will help interventional radiology be recognized for its low-cost, high-value services.

How did you determine the participants in the panel?

Sarwar: The easiest task in creating the panel was determining the interventional radiology participants. I was extremely fortunate to have Dr. Fil Banovac, chair of SIR Foundation, assigned as the RCP’s moderator. Based on an exhaustive literature review, I identified key researchers who have worked on costs of care in interventional radiology. The SIR health policy and economics staff had excellent insights on experts in the development of alternative payment models from other specialties, who were extremely collaborative and eager to participate. As a member of the CMS Clinical Committee on Resource Use Measurement, I have had several conversations with Dr. Ted Long, the CMS administrator who leads that committee. He is passionate about measuring and reducing wasted health care dollars and quickly agreed to participate. And, finally, SIR Executive Director Sue Holzer helped recruit a national leader in health care economics. So, as you can see, with such a large, complex and important topic it was truly a team effort that helped us create a stellar panel.

2016 RCP panelists

What did you find to be the biggest challenge in preparing for this RCP?

Sarwar: The breadth of IR procedures presented the biggest challenge. As experts in image-guided therapies, interventional radiologists treat a wide range of disease processes and anatomical regions in a range of health care settings. Measuring costs is a very nuanced endeavor and should ideally be tailored to each procedure or disease process. The challenge was for the panel to have a broad discussion that would cover all major IR procedures, while simultaneously having enough granularity to generate meaningful next steps.

Were you surprised by any of the discussion points at the meeting?

Sarwar: Yes. Going into the panel, I feared that IR was behind in thinking about costs and creating alternative payment models (APMs) compared to other specialties. However, the panel discussions clearly showed how all providers are struggling with howthis concept will be operationalized. It was also encouraging to see that the economists and other specialists on the panel thought that interventional radiology services had a clear advantage over other specialties in a cost-conscious world.

What variables are involved in cost analysis in IR?

Sarwar: This is a complex question. Briefly, the variables include an assessment of the patient’s condition (risk-adjustment), costs of health care provided (direct and indirect costs), access to meaningful cost data (price transparency), appropriate analyses of cost comparison or cost savings, and insights on how best to use this information (cost constituent perspective).

How will MACRA affect cost analysis in IR?

Sarwar: MACRA will have a tremendous effect on cost analysis for all health care delivery, including IR, in Medicare patients. CMS has recognized the complexity of this endeavor and excluded cost measurement from the composite score of physician performance for 2017. However, eventually cost measurement (along with quality) will form the largest share of the composite score in the Merit-based Incentive Payment System (MIPS) program and will be an essential component of APMs. Therefore, from a practical standpoint, the most acute affect of MACRA will be an acceleration in the need for IRs to understand the costs of the care they provide with an aim to reduce the cost of wasted services.

How can physicians, federal agencies, industry and other institutions work together to improve cost analysis?

Sarwar: In my opinion, the only way for all stakeholders, with competing financial interests, to collaborate effectively on health care costs is to adopt a patient-centric perspective. As long as the patient (and his or her outcome) is the key arbiter of health care delivery success, I’m certain the health care marketplace will find a solution to rising health care costs. More specifically, I think price transparency, benchmarking and analyses based on disease conditions rather than heterogeneous populations will form the foundation for meaningful collaboration.

What do you feel the RCP accomplished?

Sarwar: I think the RCP was an important first step in planning the research agenda that will allow IRs to drive home their advantage in providing cost-effective care. I think several concepts that were discussed in the panel such as episodes-of-care, out-of-pocket costs, time-driven activity based costing, and bundled payments needed to be explored further from the interventional radiologists perspective. The details of these discussions will be published soon in the form of a white paper that I hope is crucial in driving a structured, meaningful research agenda. I anticipate that the RCP will be helpful for IRs in practice leadership to determine their institutional costs for care delivery and for IR policymakers to help develop new APMs.

What are the next steps?

Sarwar: As I mentioned above, the panel members are currently drafting a white paper, which will share our findings with the IR, policy and industry stakeholders who will be affected by this new paradigm. In addition, I intend to work with panel members to see how we can help create APMs for several of the key conditions that IRs treat such as interventional oncology, end-stage renal disease and peripheral arterial disease.

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