Congress grills officials about imaging benefits, costs

Various representatives of the imaging community got a chance yesterday to plead their case before Congress for a two-year delay on Medicare reimbursement cuts slated to take effect Jan. 1, 2007.

Provisions in the Deficit Reduction Act of 2005 call for capping the technical component reimbursement of in-office imaging at the lesser amount of either the Medicare Physician Fee Schedule (PFS) rate or the Hospital Outpatient Prospective Payment System rate (HOPPS).

"While the ACR understands Congress's need to make difficult budget decisions, section 5102(b) of the DRA is troubling to the college," said Dr. Arl Van Moore Jr., chair of the American College of Radiology board of chancellors.

Moore told members of the House Committee on Energy and Commerce subcommittee on health that HOPPS was never intended to accurately reflect costs at the procedure level. For example, he said, hospital-reporting systems may not uniformly delineate capital equipment costs.

Consequently, reimbursement from HOPPS is generally lower than from the PFS. Physicians performing nonhospital imaging and getting paid based on HOPPS stand to lose between 20% to 50% revenue, depending on their patient Medicare mix and their volume of advanced imaging (CT, MRI, and PET).

"ACR believes picking and choosing between the two payment systems based upon whichever is cheaper invalidates and corrupts both systems, not only for imaging services but for all of medicine," he said.

The DRA policy also does not address imaging utilization. Physicians who refer patients to their own equipment can take advantage of this policy and recover losses by ramping up volume, the exact opposite of what Congress intended, Moore said.

He referred members of Congress to the Medicare Payment Advisory Committee (MedPAC) recommendations, which echo ACR proposals for all imaging providers, regardless of specialty, to meet federal standards for physician training, equipment maintenance, and certification of nonphysician staff. He cited the Mammography Quality Standards Act, initiated in 1992, as precedence for national federal standards.

Also testifying before the panel was Dr. Pamela S. Douglas, immediate past president of the American College of Cardiology.

"We recognize that Congress is concerned about the cost of imaging, but caution must be exercised to ensure that policies are driven by what is best for patient care and not solely by budgetary constraints," she said.

Douglas detailed efforts by the ACC and other imaging providers to develop appropriateness criteria, which include accreditation, training programs, guidelines, and performance measures.

"The purpose of these is to address overuse, underuse, and misuse of imaging. These criteria are patient-centric and ask whether the right test is used for the right patient at the right time," she said.

She concluded by saying that it is important that the federal government recognize specialty society efforts to ensure quality and safety and that these not be duplicated on the federal level.

High-tech imaging often represents 15% of imaging volume, 50% of costs, and three-quarters of diagnostic imaging inflation, said John Donahue, president and CEO of National Imaging Associates, a radiology utilization management company.

The cause of the disparity is not simple to deduce, he said. He cited a frequent lack of clinical consensus on how to apply new imaging, malpractice concerns by physicians, direct-to-consumer advertising, and self-referral.

"Some referring providers with access to equipment are up to four times more likely to order an imaging study than those without access to equipment," Donahue said.

He suggested that utilization management companies such as his be the gatekeepers on a federal level for appropriate imaging.

Herb Kuhn, director of the Center for Medicare Management within the Centers for Medicare and Medicaid Services, and Glenn M. Hackbarth, chair of MedPAC, also appeared before the panel.

Kuhn made it clear that CMS is not recommending that only radiologists be able to perform imaging. He suggested that the government set up the imaging standards and private organizations review the qualifications.

Hackworth was asked to prove his statement that doctors are increasing imaging utilization to supplement their professional fees. He said he can show slides from presentations where doctors say just that. He also cited studies that show that more imaging doesn't necessarily increase better outcomes.

Many House members cited the benfits of imaging with personal anecdotes. California Democratic congresswoman Anna G. Eshoo said that Congress is talking out of both sides of its mouth. On one hand, it celebrates imaging, and on the other, it is cutting funding for it.

"Maybe our chairman [Nathan Deal, R-TX] today wants to explain the cuts. I think he voted for them," Eshoo said.

For more information from the Diagnostic Imaging archives:

CMS proposes palatable change in practice expense RVUs

Congress says 'wait' on hefty reimbursement cuts

Moore takes over reins at ACR

ACR lobbies Congress to freeze budget cuts for two years