Medicare Cuts for Imaging Could Cut Access to Care

July 05, 2011

July 5, 2011 — A federal proposal to reduce Medicare physician reimbursement for multiple computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound scans (ie, those performed on the same patient on the same day in the same setting) could presage similar cutbacks for all imaging services, and even all diagnostic tests.

Consider, for example, a person injured in a car wreck who requires successive CT scans of the head, neck, abdomen, and pelvis. Under the new proposal, Medicare would pay the full fee for a radiologist's interpretation of the head exam, but only 50% of the fee for the rest of the exams.

The Centers for Medicare and Medicaid Services (CMS) floated this trial balloon in its proposed update, released July 1, of policies and rates for the Medicare Physician Fee Schedule for calendar year 2012. The update's biggest shocker, of course, is the 29.5% across-the-board reduction in physician pay that Medicare's sustainable growth rate formula will trigger on January 1, 2012. Organized medicine is counting on Congress to postpone this cut before year's end, as it has with other cuts going back to 2003.

However, the notion of deep cuts for the professional component of multiple imaging exams (ie, their interpretation) strikes radiologists and other specialists as catastrophic in its own right. A bipartisan group of 61 members of Congress calls the idea a "dangerous precedent for Medicare reimbursement policy."

"It's Blind Cost-Cutting," Says ACR Leader

The proposed policy for multiple procedure payment reduction (MPPR) originally stemmed from the decision by CMS years ago to reduce reimbursement by 50% for second and subsequent surgical procedures performed on the same patient on the same day. The agency reasoned that physicians engaged in such operations saved themselves work and expense in the process.

In 2006, that policy was extended to the technical component, representing the cost of equipment, supplies, and nonphysician personnel, of CT, MRI, and ultrasound. At first, the technical component reduction was 25%, but the Affordable Care Act raised it to 50%.

The proposed update for 2012 would extend the 50% fee reduction to the professional component of multiple CT, MRI, and ultrasound scans.

John Patti, MD, chair of the Board of Chancellors of the American College of Radiology, told Medscape Medical News that performing multiple same-day exams on a patient introduces some economies of scale, but not as much as CMS imagines. He pointed to published data showing that multiple procedures might reduce the professional component by 3% to 6%.

"CMS is recommending a 50% reduction, which is outrageous and capricious," said Dr. Patti. "It's based on no data whatsoever. It's blind cost-cutting."

Dr. Patti acknowledged that the CMS proposal cites a study by the Government Accountability Office that recommends a major fee reduction for interpreting multiple imaging exams, but he characterized the Government Accountability Office study as both limited in scope and flawed.

Dr. Patti contends that regardless of the number of exams ordered, radiologists are obliged to thoroughly review and interpret each image.

"The work of the physician is being severely undervalued," he said with regard to the CMS plan.

Dr. Patti and the American College of Radiology warn that the proposed reductions, together with previous ones for diagnostic imaging, would drive radiologists and outpatient imaging centers out of business, restrict access to care, and send more patients to higher-priced hospital radiology departments.

A similar prophecy comes in a letter that 61 members of Congress sent in May to the House Ways and Means Committee. Addressing the MPPR policy as first recommended by the Medicare Payment Advisory Commission, the lawmakers wrote that reducing reimbursement in these circumstances would not reduce use or increase efficiency, as radiologists rarely order the studies they are asked to interpret. In other words, physicians ordering the scans would have no economic motivation to limit their number, because they would not be the ones hit with the shrunken fees. The lawmakers also warned of independent radiologists abandoning the imaging business to hospitals.

The American Medical Association and 36 other medical societies, the vast majority in the specialty realm, also asked Congress in a letter to stop the proposed the MPPR policy in its tracks, calling the cuts "arbitrary."

CMS "Aggressively Looking" for More Efficiencies

In its proposed update, CMS stated that it will be "aggressively looking" for other efficiencies achievable with the MPPR principle, and invited comment on several ideas under consideration but not officially proposed for 2012. These include applying MPPR to:

  • the technical component of all imaging services, including fluoroscopy and X-ray, but excluding diagnostic and screening mammograms;

  • the professional component of all imaging services; and

  • the technical component of all diagnostic tests, such as electrocardiograms and hearing tests.

In each case, savings yielded by the reduced rates would be redistributed to other services reimbursed by Medicare.

CMS will accept public comments on its proposed update to the 2012 physician fee schedule through August 30, 2011. The draft regulations explain several ways to submit comments.

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