Contrast industry may be hard hit by looming Medicare payment reform

Lobbyists fight for adequate contrast reimbursement

In November, the medical imaging community breathed a sigh of relief when industry advocates persuaded the Health Care Financing Administration to postpone cuts in technical reimbursement for outpatient studies at independent imaging centers (SCAN 11/25/98). But as lobby groups continue to study proposed reimbursement rules coming out of HCFA, they are discovering more and more regulations that, if finalized, could dramatically affect both how radiology is practiced in the U.S. and sales of medical imaging contrast and equipment.

The latest regulatory skirmish affects contrast manufacturers and arises out of a rule published Sept. 2 in the Federal Register stating that HCFA will pay a flat rate for the technical component of any hospital-based outpatient imaging procedure, whether it requires contrast media or not.

In the last decade, HCFA has explored the idea of managing outpatient reimbursements with a system similar to the diagnosis-related groups (DRGs) schedule it has used for inpatient services. HCFA's prospective payment methodology applies what it calls an ambulatory patient classification (APC) schedule to outpatient services. APCs are the agency's attempt to move Medicare's payment base from a fee-for-service method to bundled reimbursements.

To this end, HCFA has been pursuing a strategy of changing both independent and hospital-based outpatient imaging reimbursement protocols. In June, the agency proposed that Medicare payments for the technical component of independent imaging center tests be cut 24% over a four-year period and physician's professional fees be cut 8% to 10%. The industry won a reprieve on this rule last November when HCFA decided to postpone through 2000 the proposed technical component cuts. Professional component cuts of roughly 8% went into effect Jan. 1 of this year, however.

Although delaying technical cuts at freestanding centers was a key victory, lobbyists were acutely aware that the battle wasn't over: In September, HCFA published a rule that dealt with the hospital-based side of the outpatient care equation, setting flat payment rates for hospital outpatient procedures. The rule could affect payments for more than 40 million contrast-enhanced imaging procedures performed each year in the U.S. Groups like the National Coalition for Quality Diagnostic Imaging Services (NCQDIS), the American College of Radiology (ACR), the American Hospital Association (AHA), and the newly formed Medical Imaging Contrast Agents Association (MICAA) are concerned about how this rule will affect contrast media use and reimbursement.

No separate reimbursement for contrast? HCFA's existing reimbursement policy allows hospitals to bill the agency separately for the purchase price of contrast agents used in an imaging exam, if a patient meets certain medical criteria. With the exception of chemotherapy agents, the September rule doesn't include any separate APC codes for drug and equipment supplies associated with a scan, including contrast agents and radiopharmaceuticals. Instead, the guideline proposes an overall flat rate for technical fees of any hospital-based imaging procedure.

Industry analysts believe HCFA's APC codes will prove financially insupportable to hospital-based outpatient centers. For example, the rule proposes that the total allowance for the technical component of an MRI exam be about $403, even though MR exams can cost as much as $1000, depending on the scan. Hospitals that choose not to pass along increased costs to patients will be faced with operating-cost deficits. If contrast agents aren't reimbursed adequately, hospitals and their physicians won't be inclined to use them, which could affect the quality of patient care, according to Dr. Val Runge, Rosenbaum professor of diagnostic radiology at the University of Kentucky in Lexington.

"If these codes are implemented in final form, they will put pressure on hospitals and physicians to inappropriately decrease contrast use," Runge said. "What the proposed codes would do is dramatically cut contrast media administration, which could cause markedly lowered diagnostic performance of (imaging) exams."

If the proposed rule forces hospitals and physicians to make different medical decisions than they would normally make, HCFA is overstepping its authority, according to Cherrill Farnsworth, executive director of Houston-based NCQDIS.

"(The guideline) is troublesome because of a pattern of behavior coming out of HCFA where the agency is making medical decisions," Farnsworth said. "It should be radiologists who make the decision whether contrast is necessary or not. If doctors aren't paid for it, they won't use it."

Manufacturers mobilize. At least one industry association, the Nuclear Medicine APC Task Force, has been partly successful in lobbying HCFA for better categories: The September rule includes more APC groupings for nuclear medicine procedures than the initial rule, although it still does not include a separate provision for the reimbursement of radiopharmaceuticals.

Other contrast manufacturers and their advocates formed MICAA late last year to formulate an industry-wide response to the proposed APC codes by the March 8 deadline for comments. MICAA would like to see contrast continue to be reimbursed separately, according to John Campbell, director of marketing at Bracco Diagnostics of Princeton, NJ.

"MICAA (would like to provide information) on the continued need for separate reimbursement," Campbell said. "We don't understand the calculations that have been used to determine the APCs, and since we know that there's a great deal of variability in billing and in charges for contrast media, we don't know if HCFA has taken the use of contrast into consideration."

HCFA is now taking comments and is not expected to issue a final rule until a summary of those comments has been published. Implementation of the rule was initially scheduled for January 2000, but will most likely be postponed until April 2000, due to Y2K issues, the agency has said. Until then, contrast manufacturers plan to continue their efforts to educate HCFA on how the rule could negatively affect the contrast industry, physicians, and patients.