Medicare’s proposed cardiac CTA policy: A disaster in the making

The Centers for Medicare and Medicaid Services is weighing comments from the medical community regarding a plan, announced last month, to overturn local Medicare coverage of cardiac CT angiography for the diagnosis of coronary artery disease. The only exception would be for patients enrolled in research trials preapproved by Medicare.

This proposed policy caught just about everyone by surprise. Its timing right before the holidays and the short, 30-day comment period have given rise to questions. Some have raised the specter of a conspiracy fomented by large organizations and shadowy figures motivated by greed.

Let's put all that aside and look at the bigger picture. Medicare has never been keen on paying much for medical reimbursements. Lately, medical imaging has been caught in the crosshairs of Medicare and legislators seeking to trim back spending, the result, lamentably, of our own success as an industry in advancing the technology and its use.

While this proposed CMS policy may have come as a surprise, we should not be surprised that it came. The sudden growth in popularity of medical procedures in the past has drawn concern from Medicare about overuse. Typically, such concerns have involved Medicare-approved procedures, and CMS has responded by reducing reimbursements. The current situation, however, is different and much more dangerous.

Because it involves a procedure - cardiac CTA for CAD - not yet covered by a national CMS policy, insurance companies contracted to Medicare have been making decisions affecting the local areas under their control. This system has worked well in the past. The proposed CMS policy would short-circuit it.

In its proposed decision memo for CTA, issued Dec. 13, 2007, CMS states that all uses of cardiac CTA for the diagnosis of CAD other than for Medicare-approved clinical studies are "noncovered," specifically citing the use of cardiac CTA to screen asymptomatic patients for CAD.

"Cardiac CTA for uses other than the diagnosis of CAD remains at contractor discretion," the memo said.

Contractor discretion is a key component of the U.S. healthcare system. When presented with convincing clinical data that a technology is clinically valuable, local contractors have exercised their judgment to bring advanced technologies to the increasingly aging U.S. population. The reason, simply, is that the bureaucracy behind Medicare coverage decisions is to medical insurance what a supertanker is to shipping. It has enormous value but reacts slowly to changing circumstances.

If CMS alters its current policy of deferring to local contractors' assessment, much more will be at stake than the use of cardiac CTA. A precedent will be set that could delay the development of new technologies. CMS could implement a broad-based policy for Medicare contractors to delay their coverage of new technologies and require them to wait for national decisions, which themselves depend on large-scale studies to prove their value. Worse yet, without the interim reimbursement provided at the discretion of contractors, there may not be the installed base or expertise necessary to conduct such large-scale trials. Lacking reimbursement, the incentive to acquire new technology will be gone and, with it, the incentive to develop such technology.

These risks need not be taken. CMS can remain on its present course and allow contractor discretion for cardiac CTA for CAD while it conducts whatever trials it deems necessary to determine long-term coverage. If cardiac CTA is not warranted for the diagnosis of CAD, CMS can then issue a national coverage policy to stop payments. Doing so now is premature and sets a dangerous precedent that could provide serious harm in the near and long term.