ACR pursues designated physician imager legislation

Faced with possible Medicare payment cuts, the American College of Radiology plans to lobby Congress for legislation that would require Medicare to define physician qualifications for performing diagnostic imaging.

Congressional approval of the designated physician imager (DPI) will be the ACR's top legislative priority of 2005, according to Dr. James Borgstede, chair of the ACR board of chancellors.

The college will support legislation limiting Medicare reimbursement for CT, MR, and PET procedures to medical facilities and physicians that meet specific quality control and educational criteria. The move could save Medicare $3 billion annually, he said.

The ACR will promote DPIs as a way for Medicare to slow escalating diagnostic imaging costs without cutting reimbursement rates, Borgstede said. Diagnostic imaging is the fastest growing category of physician services covered by Medicare, rising at 15% per year since 1999, according to the Medicare Physician Payment Advisory Commission.

In fiscal 2002, Medicare spent $6.5 billion on outpatient diagnostic imaging. Diagnostic imaging now accounts for 14% of total spending for services provided through the Medicare fee schedule, according to MedPAC.

DPIs would save money by making it harder for nonradiologists - who have promoted office-based medical imaging that is fueling higher Medicare utilization - to qualify for Medicare payment, Borgstede said.

Office-based imaging is exempt from federal law banning physician self-referral, and the ACR government relations committee decided to push for DPIs after learning that the Republican Congress would be unwilling to close that loophole, he said. The ACR's proposal excludes imaging modalities that are already widely used in office practice, such as general radiography, nuclear cardiology, and sonography.

The college moved ahead with the lobbying plan with the understanding that mandatory federal accreditation for CT, MR, and PET would be essential to the DPI concept, Borgstede said. Implementation would probably involve the Centers for Medicare and Medicaid Services. It would set minimum educational, reading volume, and continuing medical education requirements for physicians seeking DPI certification. Equipment performance, quality control programming, and the use of registered technologists would probably also be regulated.

"This will be a level playing field," Borgstede said. "If physicians are willing to meet standards for these three modalities, they can perform imaging."

Nonradiologists with extensive imaging experience don't appear threatened. Dr. Gerald M. Pohost, a cardiologist and chief of cardiovascular medicine at the University of Southern California, sees potential advantages.

"People need to be qualified to perform interpretations. If they are not qualified, they need training that allows them to make appropriate diagnoses," he said.

The ACR's announcement on Jan. 6 coincided with the opening of the 109th Congress. It came less than a week before a crucial Jan. 12 meeting of the influential MedPAC Commission that will finalize Congressional recommendations to control rising Medicare imaging costs.

Draft recommendations announced at a MedPAC meeting in December included provisions that would ask Congress to develop standards for physicians who interpret imaging studies. According to testimony by MedPAC staff, those criteria may include minimum requirements for formal training, continuing education, and experience for physicians who bill Medicare for interpreting imaging procedures.

At the same meeting, some MedPAC members expressed support for rate cuts to control imaging utilization.

Borgstede painted a gloomy picture for future radiological practice if Congress uses rate cuts to get Medicare imaging costs under control. He predicted a spiraling cycle of increasing office-based self-referral leading to additional rate cuts.

"Radiologists would be left with the shambles," he said.