ACR Update Overview Darlene Metter MD FACR Professor

ACR Update Overview Darlene Metter, MD, FACR Professor of Radiology & Family and Community Medicine, UT Health San Antonio Eastern Radiological Society April 24 , 2017

Welcome to San Antonio & Fiesta!

ACR Key Facts § Founded 1923; 38, 000 members § 300+ staff in these locations § Headquarters, Reston, VA § Government Relations, Washington, DC § ACR Center for Research and Innovation™, Philadelphia, PA § American Institute for Radiologic Pathology, Silver Spring, MD ACR Headquarters | Reston, VA 3

ACR Is Led by Members § 1, 850 members volunteer their time and talents together on commissions and committees to promote excellent patient care and professionalism in radiology James A. Brink, MD, FACR, of Boston, MA, was elected by the ACR Board of Chancellors to serve as Chair from April 2016 to April 2018 William T. Herrington, MD, FACR, of Athens, GA, was elected by the ACR Council to serve as Council Speaker from May 2015 to May 2017 4 Geraldine B. Mc. Ginty, MD, MBA, FACR, of New York, NY, was elected by the ACR Board of Chancellors to serve as Vice Chair from April 2016 to April 2018 Timothy L. Swan, MD, FACR, of Marshfield, WI, was elected by the ACR Council to serve as Council Vice Speaker from May 2015 to May 2017

ACR Core Purpose and Values § Core Purpose of the ACR § To serve patients and society by empowering members to advance the practice, science and professions of radiological care § ACR Core Values § Leadership § Integrity § Quality § Innovation 5

ACR ― The Voice of Radiology: a leader § Leader in advancing the practice, science and professions of radiological care § Recognized within the House of Medicine and by patient advocacy groups as a leader in shaping the future of health care 6

ACR ― The Voice of Radiology § A leader and an established global voice of quality, safety and best practices, government decision makers look to the ACR for solutions § Fosters a sense of community among radiologists both locally and nationally 7

ACR Supports Members and Patients § Helps you participate in new practice and payment models that promote high value, patient-centered radiological care § Provides you with the tools to adapt and thrive in the future of health care Ezequiel Silva III, MD FACR Chair, ACR Commission on Economics 8

ACR Supports Members and Patients § Protects and supports your work through advocacy, economics, leadership, quality and safety, and innovation § Making connections with dedicated professionals to shape radiology and to ensure that radiology will remain key to the future of health care 9

ACR Core Areas § Membership: acr. org/membership § Advocacy: acr. org/advocacy § Economics: acr. org/economics § Quality and Safety: acr. org/quality-safety § Education: acr. org/education § Research: acr. org/research § Informatics: acr. org/advocacy/informatics 10

ACR Is The Voice of Radiology § As The Voice of Radiology at local, state and federal levels, ACR advocates for positive change in regulations and legislation § ACR advocacy efforts lead to important changes, such as physician payment reform, imaging utilization research, and patient access to diagnostic and screening services 11

ACR Advocacy § ACR has a proactive approach in representing and advancing radiology before U. S. Congress, state legislatures and federal agencies § ACR website: Advocacy in Action e. News gives updates 12

ACR Advocacy § ACR supports these and other important issues: § Transition to value-based models § Imaging appropriateness § Patient- and family-centered care § Quality Payment Program (APMs/MIPS) § Regulatory affairs and research policy § Evidence-based justification for covered services § To learn more, visit acr. org/success 13

ACR Advocacy Communication § Legislative and regulatory communication goals § Ongoing, frequent and concise updates § Keep members more informed and engaged § Maintain ACR as the clear Voice of Radiology § Tactics § Weekly e-newsletter: ACR Advocacy in Action § Practice management tools § Webinars & podcasts § Voice of Radiology Blog & Web content § Social media § Capitol Hill meetings/events 14

ACR Advocacy: Recent Victories § H. R. 2029: Consolidated Appropriations Act of 2016 § Delayed 2015 draft United States Preventive Services Task Force (USPSTF) mammography screening recommendations for 2 years (2015 -2017) 15

2015 USPSTF Mammography Screening Recommendations § § 50 -74 yrs: biennial screening (Category B) < 50 yrs: an individual decision (Category C) 75 and older: Insufficient data (Category I) All women: Rec “against teaching breast selfexamination (BSE)” (Category D) § B: Rec; high certainty of moderate benefits § C: Selective rec; moderate certainty, benefit small § D: Rec against this service

ACR Advocacy: Recent Victories § H. R. 2029: Consolidated Appropriations Act of 2016 § Lowered PC multiple procedure payment reduction from 25% to 5%, effective Jan 2017 17

ACR Advocacy: Recent Victories § USPSTF assigns CT colonography and other colorectal cancer screening exams an “A” grade* for use in adults ages 50− 75, mandating private insurance coverage with no patient cost-sharing under the Affordable Care Act * Grade A: USPSTF recommends the service. There is high certainty that the net benefit is substantial. 18

H. R. 1151/S. 1151: USPSTF Transparency and Accountability Act* § ACR GR advanced legislation considerably § Bill garnered 73 House cosponsors (60 R, 13 D) § Nov. 30, 2016: House Energy and Commerce Health Subcommittee hearing on H. R. 1151 § Despite support in House, bill viewed by Democrats as another attack on the Affordable Care Act (ACA) * USPSTF be transparent in their review, establish a system for grading preventive care, solicit public comment to include a stakeholder board to provide feedback, and a GAO report listing recommendations, a comparative review and impact. 19

H. R. 1151/S. 1151: USPSTF Transparency and Accountability Act § Senate bill struggled to gain cosponsors because Sen. Vitter announced retirement and bill introduced without a lead Democrat § Bill died in Congress § New House Bill, H. R. 539, introduced on Jan. 13, 2017 § Sens. Bill Cassidy, MD (R-LA) and Heidi Heitkamp (D -ND) interested in introducing bill in 115 th Congress § Effort to pass bill next Congress must be balanced with changing political climate 20

H. R. 1151/S. 1151: USPSTF Transparency and Accountability Act § Senate bill struggled to gain cosponsors because Sen. Vitter announced retirement and bill introduced without a lead Democrat § Bill died in Congress § New House Bill, H. R. 539, introduced on Jan. 13, 2017 § Sens. Bill Cassidy, MD (R-LA) and Heidi Heitkamp (D -ND) interested in introducing bill in 115 th Congress § Effort to pass bill next Congress must be balanced with changing political climate 21

115 th Congress Legislative Forecast § Results of the 2016 election have altered the political landscape § Republicans retained control of the House and Senate, and captured the White House § The Major Republican & White House priority: repeal and replace the Affordable Care Act 22

115 th Congress Legislative Forecast § A few new faces in Senate leadership and on key House Committees: § New Senate Minority Leader: Charles Schumer (D-NY) § New Energy and Commerce Committee Chair: Rep. Greg Walden (R-OR) § New Energy and Commerce Health Subcommittee Chair: Rep. Michael Burgess, MD (R-TX) § New Ways and Means Committee Ranking Member: Rep. Richie Neal (D-MA) § New Ways and Means Health Subcommittee Ranking Member: Sander Levin (D-MI) 23

ACA Repeal and Replace § Although Republicans control the Senate, they do not have a filibuster (60 vote) proof majority § As a result, Republicans are forced to utilize “budget reconciliation*” to repeal the ACA or enact any other controversial legislative effort * “Budget reconciliation” allows the Senate to consider a budget bill with debate limited to 20 hours. 24

ACA Repeal and Replace § In the Senate, Budget Reconciliation/expedited consideration means: § Bill cannot be filibustered § Debate is limited to 20 hours § Only germane amendments (i. e. must deal with “spending”) per the “Byrd Rule” § After 20 hours of debate, germane amendments subject to immediate consideration (“vote-a-rama”) § Final passage only requires a simple majority (including the Senate) 25

3 Phase Republican American Health Care Act § Speaker Ryan developed a 3 -phase plan: § 1 st Phase- Repeal and Replace as much of the ACA as possible through a new reconciliation bill § 2 nd Phase- Lean on HHS Secretary Tom Price, MD to make additional ACA changes through regulations § 3 rd Phase- Try and pass other bills to undo ACA, but these bills would require a 60 vote threshold in the Senate 26

Failure of AHCA Illustrates Many Things § Despite Republican control of Congress and White House, House GOP would not support AHCA. Bill withdrawn 03/24/2017. Why? 1 Independence of individual members of Congress 4 Individual members of Congress have become more willing to act independently of their party’s leadership 2 Heightened influence of well-funded outside groups There has been a transfer of influence from political parties to well-funded outside groups that are willing to support Republican representatives who take stances on issues that align with the group 3 27 Less reliance on party infrastructure Many members of Congress now depend less on the party’s financial assistance and support. An example of this was the Koch network’s willingness to support those who buck party leadership 5 Polarized sources of money in politics It is now easier than ever for members of Congress to connect with small donors throughout the country. Small and individual donors tend to be the most ideologically polarized, which further empowers extreme wings of the parties Reduced importance of congressional committee assignments Committees did not play a central role in crafting the AHCA. Now, committee assignments are less necessary for PR and fundraising purposes, meaning less leverage for leadership 6 Impact of elimination of earmarks The elimination of earmarks has stripped a tool that party leaders could have used to entice members to support certain legislation

Other Key Issues in 115 th Congress § ACR will also be working to: § Continue to protect access to preventive screens in any ACA rollback bills § Continue to put legislative pressure on CMS to properly implement the imaging Appropriate Use Criteria policy § Stop any retrospective site neutral payment policies (i. e. Medicare reimbursing hospitals at the same rate as physician offices) 28

Other Key Issues in 115 th Congress § ACR will also be working to: § Promote legislation to mandate Medicare coverage of CTC § Extend the moratorium on implementing the 2015 USPSTF mammography screening recommendations § Pursue changes to USPSTF within the context of broader ACA reforms 29

ACR Economics & Health Policy § Focusing on coding, payment policy, national and local coverage policy, regulation, as well as private and public payer relations, the ACR: § Provides evidence for communications with Centers for Medicare and Medicaid Services (CMS), policy makers and medical insurers § Fights against CMS edits that place incorrect payment restrictions on particular CPT® codes 30

ACR Economics & Health Policy § The ACR: § Works to ensure ACR members are reimbursed fairly by government and private payers § Aims for successful implementation of Clinical Decision Support systems § Helps to adopt value-based payments and alternative payment models 31

CPT Editorial Panel § 2016 cycle ― completed Feb. 2015 to include new Category 1 codes (61), deleted codes (31) and revised codes (19) § Majority of work at Current Procedural Terminology (CPT®) Editorial Panel for all specialties related to “bundling” (combining existing CPT codes into new bundled codes); meet 3/yr; up-to-date; >100 societies; Mark Alson; 2019 coding cycle § Extensive coding education for ACR members § Clinical Examples in Radiology § ACR Radiology Coding Source™ newsletter § Coding guides ― Ultrasound, Nuclear Medicine § Coding update ― Interventional Radiology § Learn more at www. acr. org/billingcoding 32

Clinical Decision Support Final Rule § 2017 final rule w/ possible implementation date of 01/01/2018, encouraged providers to get ready § Final rule outlined requirements for clinical decision support mechanisms (CDSMs) § CMS will announce the approved qualified CDS systems 06/30/2017 § CMS finalized list of 8 priority* clinical areas to determine physician outliers § ACR comments led to changes in final list, including addition of several MSK indications * CAD, suspect PE, HA, hip pain, LBP, shoulder pain, lung CA, cervical/neck pain 33

Medicare Access and CHIP Reauthorization Act § Key Payment Policy Provisions § MACRA repeals Sustainable Growth Rate formula but in return sets up 2 -track payment system to encourage physicians into risk-based payment models § Merit-Based Incentive Payment System (MIPS) § Alternative Payment Models (APMs) § June 2015 − December 2019: All physicians get 0. 5% annual update § January 2020 − December 2025: Reimbursement rates frozen at 2019 levels with possibility of earning additional reimbursement through participation in MIPS or APMs 34

Imaging 3. 0 § Raising awareness and communicating change § Grassroots ACR members: Case studies § ACR Bulletin, JACR® § Medical imaging community and health care partners § Develop, deploy and promote Imaging 3. 0 tools § Most Valuable Radiology Practice: living document to help you advance Imaging 3. 0 solutions in your practice § ACR Diagnostic Imaging Center of Excellence™ (DICOE) § National Radiology Database Registry (NRDR®) § Radiology Support, Communication and Alignment Network (R-SCAN™) § ACR Select® and Patient Portal § Actionable reporting and image sharing § Learn more at acr. org/imaging 3 * Positioning radiologists as expert consultants to HC providers & systems. 35

Imaging 3. 0 § Raising awareness and communicating change § Grassroots ACR members: Case studies § ACR Bulletin, JACR® § Medical imaging community and health care partners § Develop, deploy and promote Imaging 3. 0 tools § Most Valuable Radiology Practice: living document to help you advance Imaging 3. 0 solutions in your practice § ACR Diagnostic Imaging Center of Excellence™ (DICOE) § National Radiology Database Registry (NRDR®) § Radiology Support, Communication and Alignment Network (R-SCAN™) § ACR Select® and Patient Portal § Actionable reporting and image sharing § Learn more at acr. org/imaging 3 * Positioning radiologists as expert consultants to HC providers & systems. 36

Radiology Support, Communication and Alignment Network (R-SCAN) § One of ten Support and Alignment Network organizations nationally to be awarded the Transforming Clinical Practice Initiative grant § ACR receiving ~$3 M over 4 years from CMS to support health payment systems transition from volume-driven to value-based § Sign up to participate at rscan. org 37

What Is R-SCAN? § An Improvement Activity that engages radiologists and referring clinicians to optimize imaging care § Shows radiology’s value to patients, referring clinicians and hospital administration; fosters care coordination § Features imaging exams of Choosing Wisely® initiative § Highlights benefits of clinical decision support systems 38 § April 27, 2017 8: 00 pm (EDT) JACR tweet chat on R-scan

R-Scan Topics § CT for renal colic § CTA in asymptomatic, low risk pt for CAD § Admission or pre-op CXR § CTA for PE § Adnexal cyst F/U § Advanced imaging for early prostate CA staging § Imaging for LBP § CT for uncomplicated rhinosinusitis § Imaging uncomplicated HA § CT for minor pediatric or adult head injury § Advanced imaging for febrile seizures

Benefits of R-SCAN Participation § Obtain MOC Part IV Credit and free CME activities § MOC Credit currently available for radiologists and internal medicine physicians § Participation positions providers for future of value-based health care through TCPi* activities * TCPi – Transforming Clinical Practice Initiative 40

Benefits of R-SCAN Participation § An easy (and free) way to try out clinical decision support (CDS) § Prepare for Protecting Access to Medicare Act (PAMA) implementation, effective 01/01/2018: Requires ordering providers to consult AUC before ordering advanced imaging (CT, MR, NM, PET) for Medicare patients. No pay if not done. Needs to be done by ordering provider. Imaging providers can refuse the undocumented imaging referrals. § CMS funded R-SCAN: Sign up and get referring providers, too; get familiar with CDS/AUC; get MOC Part IV credit, free CME 41

ACR Quality and Safety § § § § § 42 Accreditation in 10 modalities ACR Practice Parameters and Technical Standards ACR Appropriateness Criteria® ACR Diagnostic Imaging Center of Excellence™ Breast Imaging Center of Excellence ACR Designated Lung Cancer Screening Center™ Image Wisely® and Image Gently® ACR BI-RADS® Atlas Fifth Edition RADPEER® and e-RADPEER® Learn more at acr. org/Quality-Safety

ACR Q&S Tools for Patient Care Provide quality patient care with ACR: § § § Liver Imaging Reporting and Data System (LI-RADS®) Prostate Imaging Reporting and Data System (PI-RADS™) CT Colonography Reporting and Data System (C-RADS™) Thyroid Imaging Reporting and Data System (TI-RADS™) ACR National Radiology Data Registry (NRDR®) * § Lung Cancer Screening Registry § Early 2017: Interventional Radiology Registry, a collaboration between the ACR and Society for Interventional Radiology * MOC IV activity: Active participation in submitting data to a national registry. 43

Lung Cancer Screening Activities § ACR Lung Cancer Screening Center designation; learn more at acr. org/lungcancerscreening § Reporting and management system based on BI -RADS® ― Lung-RADS™ Version 1. 0 available at acr. org/lungrads § ACR Lung Cancer Screening Registry; learn more at acr. org/lcsregistry § Appropriateness Criterion under development 44

Helping Improve the Patient Experience § Patient-and-Family-Centered Care on acr. org: § Helps radiologists better understand the value of patient- and family-centered radiologic care and apply such principles to their practices § Supports radiology participation in emerging alternative payment models § Learn more at: acr. org/patient-experience 45

Helping Improve the Patient Experience § JACR® Special Issue: Patient- and Family -Centered Care § Original articles provide valuable insights to help radiologists provide more patientcentered care § Focuses on increasing patient involvement in their own health and health care 46

Education § Your one-stop education, training & leadership shop: § ACR Education Center — one of the most technologically advanced and interactive training facilities in the world § Radiology Leadership Institute® — unparalleled program to develop your leadership skills § American Institute for Radiologic Pathology — radiologic-pathologic correlation courses 47

Education § Your one-stop education, training and leadership shop § Continuous Professional Improvement (CPI) — one of ACR’s most popular self-assessment programs providing current, quality clinical content ® § ACR RADAR — Comprehensive knowledge, selfassessment and benchmarking tool, interactive elearning in 11 subspecialty areas (8 CME, 8 SA-CME) § Comprehensive, individualized ACR e-Learning activities address your needs at your own pace § Learn more at acr. org/education 48

The Crossroads of Radiology® 2017 Annual Meeting of the American College of Radiology SAVE THE DATE! May 21− 25, 2017 Marriott Wardman Park Hotel Washington, DC Advocacy ● Economics ● Education ● Governance acr. org/annual-meeting 49

ACR Center for Research and Innovation § State-of-the-art facility in central Philadelphia § World-class core laboratory: Advanced imaging processing tools and workstations; cloud-based image management, quality assessment and interpretation; site and modality qualification; reader study training § Expert clinical trial support: Protocol design; data management; statistical analysis and results reporting § Network of research leaders: Experts in specific diseases, modalities, trial design § Network of qualified sites: Demonstrated competence to perform advanced imaging § Fully regulatory-compliant research environment 50

Harvey L. Neiman Health Policy Institute® § Studies value and role of radiology and radiologists in evolving health care payment and delivery models § Scientific deliverables § 48 scientific papers since 2013 § 2015 Impact Factor: 4. 66 § Provides web-based data tools to help practices succeed! Neiman Almanac Learn more at neimanhpi. org 51 ICE-T

Advancing the treatment of traumatic brain injury (TBI) through the application of diagnostic imaging. § Research: Facilitating and organizing research efforts that will lead to improvements in care for patients with TBI § Awarded $1 million funding to create a Normative Neuroimaging Library § Awarded funding from U. S. Navy for neuroimaging of "breachers" ― people trained to use explosives for entering buildings and exposed to repeated blasts 52

ACR Informatics Systems and Tools § ACR is at the forefront of advancing imaging informatics, applying technological advances to practical medical use: § ACR Assist™: Structured CDS framework that incorporates content into radiology workflow, real time CDS § ACR Common™: Compilation of radiology terms and semantic structures to facilitate interaction with ACR products/services § ACR Connect™: Communication platform that manages flow of information between ACR and health care community (e. g. , registries, RADPEER) § TRIAD®: Software application providing secure and efficient transmission of electronic images and data § DART: Data warehouse and analytic platform (Data Archive & Research Toolkit), a gateway to browse & query data for research and clinical studies § Learn more at: acr. org/advocacy/informatics/systems-and-tools 53

Member Services § The ACR supports 38, 000 members by: § Ensuring that radiology's voice is heard on Capitol Hill § Maintaining the highest standards while pushing the frontiers of education and clinical research § Offering complimentary membership to residents and discounted rates to young and early career physicians § Providing career resources and tools for skill development § Watch ACR membership video about ACR member benefits and how the College works for you § Learn more at: acr. org/membership 54

ACR Member Benefits § Complimentary subscriptions to leading publications: 1. Journal of the American College of Radiology® 2. ACR Bulletin 3. ACR Radiology Coding Source™ § Free and discounted CME/MOC activities covering subspecialties across the radiology specialties: § Daily Case in Point § Image Wisely Radiation Safety Cases § JACR® journal-based CME activities § Deep discounts on premier programming, including courses at ACR Education Center and Radiology Leadership Institute® 55

Fiesta – All week- Enjoy! § Cavalier River Parade: Monday 7 -9 pm § Night in Old San Antonio (NIOSA): Tues - Fri 5: 30 -10: 30 pm § Battle of the Flowers Parade: Friday 11: 30 am § https: //www. fiesta-sa. org

Enjoy San Antonio! and Cascarones!