Medicare proposals aim to curb rising imaging costs

Physician credentialing and benchmarking are two of seven draft recommendations the influential Medicare Payment Advisory Commission is considering as part of an effort to define strategies to reduce escalating Medicare imaging costs.

Staff analyst Ariel Winter presented draft recommendations to MedPAC in a meeting Dec. 9. The advisory group will meet again this month to decide on final recommendations. The proposal will be presented to Congress in March.

MedPAC has been gathering information for more than a year to support a possible regulatory assault on fast-rising costs of diagnostic imaging covered by Medicare. A MedPAC staff report in October found that CT, MR, and nuclear medicine utilization paid by Medicare rose 15% annually between fiscal 1999 and 2002. In fiscal 2002, Medicare spent $6.5 billion on medical imaging. This constituted 14% of total spending for services provided through the Medicare fee schedule, according to the report.

Draft recommendations from the advisory group would ask Congress to develop standards for physicians who interpret imaging studies. Criteria may include minimum requirements for formal training, continuing education, and experience for physicians who bill Medicare for interpreting imaging procedures, Winter said.

Several accrediting organizations, including the American College of Radiology and the American Institute of Ultrasound in Medicine, could be sanctioned to set standards covering formal training, CME, and clinical experience. MedPAC may ask the Centers for Medicare and Medicaid Services to use similar criteria by selecting private accreditation organizations to ensure that physicians meet specific standards, although the standards may be relaxed to assure access in underserved areas, according to Winter.

Draft recommendations asked the commissioners to consider advising Medicare to adopt quality standards for imaging providers. The proposal would ask Congress to instruct Medicare to require that all diagnostic imaging providers meet quality standards for imaging equipment, nonphysician staff, images, and patient safety protocols. Separate sets of national standards may be developed for each of the imaging modalities and each setting in which it is performed.

In a follow-up discussion, few commissioners appeared ready to challenge the right of physicians to perform imaging on equipment operating in their offices. Draft recommendations, however, would ask Congress to extend Stark anti-self-referral restrictions to freestanding nuclear medicine and PET services, although self-referrers could still provide them under the in-office ancillary exception of the law, Winter said. Preauthorization strategies were not included in the draft.

Nuclear medicine facilities were not covered in the Stark final rules because CMS decided that nuclear medicine is not commonly thought to be a part of radiology, he said. CMS has reconsidered that position and is planning to issue a rule that would add nuclear medicine to the list of Stark-covered services.

The draft recommendations would also have MedPAC ask CMS to expand the definition of physician ownership to include an interests in a business that generates much of its revenue from a provider of designated health services. This would restrict self-referring physicians from owning equipment that is leased to imaging centers to which they refer patients, Winter said.

Another proposal would instruct CMS to track the utilization patterns of individual physicians to bill the federal programs for the interpretation of diagnostic imaging. Physicians would be benchmarked, according to this proposal, and advised confidentially when overutilization is suspected.

Improvements to Medicare's coding edits were recommended to detect unbundling and other practices that exploit coding weaknesses to inflate charges, Winter said. Draft recommendations suggest that the technical component of payments for multiple diagnostic exams performed on contiguous body parts should be reduced.

MedPAC commissioners have shown in previous meetings that they are inclined to support federal funding for consumer education to help beneficiaries make better decisions about medical imaging. Outreach would emphasize radiation exposure dangers linked to overuse of imaging that exposes patients to ionizing radiation.

Deliberations among commissioners following Winter's report indicated the reluctance of some panel members to support regulations that would favor medical specialties in the competition for medical imaging business. Dr. Ray S. Stowers, an osteopath at Oklahoma State University, stressed that accreditation requirements should enable all types of medical specialists to participate.

Commission chair Glenn M. Hackbarth of Bend, OR, said that credentialing requirements should reflect practice skills.

"They should not be knowledge-based, not specialty-based," he said.

Final recommendations may also consider costly practices that are common among radiologists. Stowers asked whether MedPAC should recommend restricting payments to radiologists for emergency room imaging that is over-read after therapy has been performed. He mentioned the need to restrict radiologists from ordering tests the referring physicians did not request.

Some commissioners, such as Dr. Nicholas J. Wolter of Billings, MT, support recommendations that would cut reimbursement rates for high-priced modalities to discourage overutilization.

"CT, MRI, ultrasound, and nuclear medicine are large margin services," he said. "I think that we should look at reimbursement models that would be a leverage point for controlling inappropriate utilization."

For more information from the Diagnostic Imaging archives:

Utilization review takes aim at imaging expenses

Radiologists move to protect MR and CT turf

Specialists coddled, self-referral ignored

Imaging utilization protocols aid STAT decisions in the ER