How the shift to value-based reimbursements could transform cardiology

"I think we really need our cardiologist community to understand the changes that are happening with value-based payment. By 2030, every dollar that Medicare pays is going to be tied to a value-based payment model, which is really going to transform how care is delivered, and also potentially really change our reimbursement," Sandhu explained. 

Traditionally, healthcare providers received payment based on the volume of services rendered—a model known as fee-for-service. In contrast, value-based payment models recalibrate reimbursements to reflect the quality and efficiency of care delivered. This shift aims to incentivize improvements in patient outcomes while curbing excessive healthcare spending.

Sandhu said the most common value-based program now in place is the merit based incentive payment system (MIPS). He said many cardiologists are already participating under this model, but it can lead to up to 9% in penalties if a cardiologist fails to follow through. 

"I think it is really important to know that this is not some sort of voluntary engagement, that everybody needs to know exactly what program they're participating in, what measures they're reporting, what measures they're being evaluated on, because of the significant payment implications, and also because it's changing quite rapidly. This is not something where I think the cardiology community, especially cardiologists that aren't working in large healthcare systems but are in smaller practices, can assume that their practice administrator alone is taken care of. I think they really need to understand what's being evaluated and how that's impacting your reimbursement," Sandhu said.

As the Centers for Medicare and Medicaid Services (CMS) move entirely toward value-based payment models, he said cardiologists must adapt to these evolving frameworks, wherein payments are contingent upon achieving predetermined cost and quality targets.

CMS plans to replace the current MIPS program

MIPS has been criticized by many medical specialities, including cardiology, because of its complexity and many variables that even experts knowledge of the program's details say can be hard to factor accurately with every patient case. 

"MIPS is complex and I think Medicare has heard that, and there are efforts to try to streamline MIPS and make it simpler," Sandhu said. 

For example, he said the program has been transitioning over time to the MIPS value pathways or MVPs. Instead of having hundreds of measures to select from, Sandhu said, you tell CMS you are a cardiologist and they give you a narrow set of measures that are relevant. That said, he said it is still quite complex, and that is why ACC is hosting in-depth business sessions at its annual meeting to address these challenges.

Sandhu said resources and support mechanisms exist to help navigate reimbursements. ACC and MedAxiom offer educational resources and guidance to empower clinicians in understanding reimbursement methodologies and optimizing practice operations.

"This is only going to expand and continue to transform not only how we're paid, but to transform all of the administration and groups around us, how they end up interacting with us ,as clinicians. So I think the big takeaway is really just to get involved and improve your understanding because this is going to transform how care is delivered," Sandhu explained.