Imaging Services -- On the Medicare Chopping Block

Roxanne Nelson

March 01, 2012

March 1, 2012 — Medical imaging is an important component of cancer care, and continuing reductions in Medicare reimbursement for imaging procedures will jeopardize patient care, radiologists and industry experts warn.

Since 2007, when the spending cuts initiated by the Deficit Reduction Act of 2005 (DRA) went into effect, reimbursement for advanced imaging services has suffered several sharp cuts. The final blow was a proposed rule last July, which suggested slashing payment for interpretation of imaging by 50% for multiple scans performed on a patient during the same visit.

In its proposed rule for 2012, the Centers for Medicare and Medicaid Services (CMS) called for a multiple procedure payment reduction (MPPR) of 50% for the "professional component" of computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound services administered to the same patient on the same day in the same setting. This would sharply cut reimbursement for radiologists who interpret the images and make a diagnosis. Previously, payment cuts have only applied to the "technical component," which represents the cost of equipment, supplies, and nonphysician personnel.

The technical component reduction was originally 25%, but was raised to 50% under the Affordable Care Act.

Even though CMS revised the MPPR from 50% to 25%, the 25% cut "is still unfounded and potentially dangerous," according to the American College of Radiology (ACR).

"They proposed 50% and then lowered it to 25%, but you can hardly characterize that as a win," said Bibb Allen Jr., MD, chair of the ACR Commission on Economics. "It's hard for us as radiologists to conceptually understand that there are big efficiencies when we are providing 2 or more scans on the same patient."

For example, if a patient was having 2 scans on the same day — one on his knee and the other on his shoulder — interpreting them would be the same as interpreting scans from "2 different people," but the reimbursement would be less, Dr. Bibb explained to Medscape Medical News. "If the knee scan was done on Wednesday and the shoulder scan on Thursday, then it would be full reimbursement."

Flawed Data?

The Government Accountability Office (GAO) recommended a major fee reduction for interpreting multiple imaging exams, and suggested a systematic MPPR to the physician component, which could be as high as 25%. The GAO conducted its own analysis using the Resource-Based Relative Value Scale Data Manager, and determined that there are efficiencies in professional work when physician services are performed by the same provider for the same patient in the same setting. However, an expert panel of radiologists found the GAO study limited in scope and flawed (J Am Coll Radiol. 2011;8:610-616).

Potential efficiencies in physician work can occur when multiple services are provided to the same patient in the same setting, but they are highly variable and considerably less than has previously been estimated, they conclude. Rather than the "single systematic 25% reduction proposed by the GAO," the analysis found that the estimated maximum professional-component relative-value unit ranged from a mean of 2.96% for CT scans to 5.45% for ultrasound.

The CMS final rule expanded this reduction to include multiple providers within the same group practice. This unanticipated action, according to the ACR, "violates the spirit of the rulemaking process and indicates that the CMS fundamentally misunderstands the practice of medicine." The extension of the MPPR to include physicians within the same group practice was not specifically included in the 2012 Medicare Physician Fee Schedule proposed rule.

That provision has been rescinded, at least for now, explained Dr. Allen. But the ACR is still concerned that the rationale for this decision was based solely on administrative and operational burdens that the CMS contractors would have had to deal with to implement this policy in a tight timeframe.

In a letter submitted to the CMS during the final rule comment period, the ACR reiterated many of their concerns. Of note, they pointed out that radiologists operating in small practices or rural hospitals and imaging facilities will be more affected by the MPPR policy than those in larger practices. In rural locations, they write, there is frequently only enough volume to support a single radiologist, and in "small practices, there will be instances where patients have multiple advanced imaging services that are in clinically separate sessions, but interpreted by the same radiologist."

Heading Up the Hill

Radiologists and other groups have taken the fight to Capitol Hill, and are backing the passage of the Diagnostic Imaging Services Access Protection Act of 2011 (H.R. 3269). The bipartisan bill, introduced by 2 members of Congress — Pete Olson (R-Texas) and Betty McCollum (D-Minnesota) — has already amassed 196 cosponsors.

The bill would effectively prohibit the Secretary of Health and Human Services from "applying a multiple procedure payment reduction policy to the professional component of imaging services furnished," either this year or in the future, unless data from a study completed by an expert panel of radiologists can justify further reductions in reimbursement.

"There is no question that we have to make some decisions on cost," said Dr. Allen, "and find a more permanent solution to the whole issue of Medicare reimbursement."

He is hopeful that it will be passed either as a standalone bill or part of other legislation, and that a similar bill will be introduced in the Senate.

"This multiple procedure reduction will affect the most vulnerable of Medicare beneficiaries: people suffering from multiple trauma, stroke patients, and those with widespread cancer — all of whom often require multiple imaging scans to survive serious illness and injury, the interpretation of which can often require the expertise of several different radiologists," said John A. Patti, MD, chair of the ACR Board of Chancellors, in a statement.

On the Chopping Block

Since 2007, Medicare funding for imaging scans has been cut by $5 billion, and the Obama administration has recommended slashing another $1.3 billion.

"Imaging continues to be targeted as the place where there is too much spending, but we are spending the same amount that was spent in 2003 or 2004, so we have not increased the burden on Medicare, dollar-wise," Dr. Allen pointed out.

From 1999 to 2005, imaging spending grew by about 10% to 15% each year, according to Dr. Allen. "But during this time, we had the absolute maturation of CT technology, and MR imaging came into maturity as well. As these technologies became mainstream practices, you'd have to expect that there'd be some growth."

The use of imaging increased because it was valuable, he continued. "We are seeing a number of papers in the literature that show how imaging is saving money downstream."

As an example, patients who are imaged early in their hospital stay are released earlier, which saves hospital days. People who get more imaging have better outcomes. "We have evidence-based research that shows the value of imagining; therefore, we should expect to see some growth," said Dr. Allen.

But questions remain. Did the use of imaging grow faster than the ability of the medical community to learn where imaging is most effective, and were physicians therefore ordering unnecessary imaging studies?

"It's possible that there may have been a gap in knowledge, and there may have been some economic conflicts of interest, such as self-referrals, that might have pushed that growth," Dr. Allen pointed out.

Since the 1990s, the ACR has been promoting the appropriate use of imaging. There are now decision support tools that identify the best test and the best time, he explained.

Even though imaging was initially targeted because of the asymmetric growth, there is no real reason "to keep imaging on the chopping block from a health policy standpoint, since we are back to 2004 levels," Dr. Allen said.

A recent analysis by the Medical Imaging and Technology Alliance supports these assertions. It found that imaging spending (per beneficiary spending in Medicare carrier payments) has decreased by 13.2% since 2006.

"This decline in imaging spending is in direct contrast to what is occurring in the rest of the Medicare program," according to the report. "During the same time period, Medicare carrier-paid claims spending for nonimaging services grew by nearly 20%."

Overall, Medicare carrier-paid claims for imaging are lower than they were in 2001, having declined by almost 25% since the enactment of the DRA.

Potential Lack of Access

Critics point out that these cuts might curtail access to imaging; it could force many suburban and rural imaging providers to close.

Last July, when the CMS first released the MPPR proposal, Rep. Olson, along with Rep. Jason Altmire (D-Pennsylvania), led a bipartisan group of 61 members of Congress in signing and circulating a letter to their colleagues.

In their letter, they warned that "these payment cuts are making it extremely difficult for radiologists to keep their practices and free-standing imaging centers open for business and available to patients. Without access to these facilities, patient access to valuable community-based diagnostic imaging services could be compromised and the vast majority of imaging services may be delivered in the hospital setting, potentially at a higher cost to Medicare."

The cuts do not only affect advanced imaging; they affect other radiology services as well. The number of centers offering mammography and the number of mammography scanners nationwide has decreased; this decline accelerated soon after imaging cuts began. Currently there are 212 fewer mammography facilities and 1131 fewer mammography scanners than in July 2007, according to the ACR.

However, a recent study has found that Medicare Part B medical imaging payment reforms from the DRA have not reduced access to older adults, as had been predicted, at least for now (J Am Coll Radiol. 2012;9:27-32). They also do not appear to have caused an inconvenient shift of high-tech imaging from private physician offices to outpatient hospital facilities.

The study, conducted by David C. Levin, MD, from the Center for Research on Utilization of Imaging Services at Thomas Jefferson University Hospital and Jefferson Medical College in Philadelphia, Pennsylvania, and colleagues, showed that CT use grew more rapidly in physician offices than in hospital-based outpatient departments from 2007 to 2009 (2.1% vs 0.5%).

In addition, the volume of nuclear medicine declined in both settings, but the drop was steeper for hospital outpatient imaging than for offices (2.5% vs 1.7%). MRI volumes remained about the same, with a 1.0% increase in the hospital outpatient setting and a 1.1% decline in office-based services.


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