Doom and gloom expert interview!:
Planned Medicare Cuts in Imaging: An Expert Interview: Imaging Growth
Feds Seek $820M in Imaging Cuts: Will Access Suffer?
Editor's Note
The Obama Administration's proposed budget for Medicare contains 2 provisions that could dramatically restrict the provision of high-end imaging tests to Medicare patients. One would increase to 95% the assumed utilization rate for advanced diagnostic equipment, such as magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine, which would cut payments for these advanced imaging procedures by an estimated $820 million over 10 years. The other would require physicians to obtain authorization before ordering advanced imaging tests. This program would be modeled after programs that private insurers have increasingly plugged into their plans in recent years.
We asked David Levin, MD, the Emeritus Professor and Chairman of the Department of Radiology at Thomas Jefferson University Hospital in Philadelphia, to comment on these proposals. Since his retirement as Chair at Jefferson, Dr. Levin has conducted extensive research into Medicare payments for imaging procedures. He also has experience working as a consultant for HealthHelp, one of the radiology business management (RBM) companies that could be involved in the prior authorization program.
Medscape: President Obama's budget proposes an $820 million cut over the next 10 years in Medicare spending for high-end imaging. These procedures are not identified in the budget document, but generally they're considered to be CT, MRI, and nuclear medicine. You've done a lot of research about radiology procedures and Medicare. Given what is being spent by Medicare on radiology, what effect do you believe this will have on the specialty?
Dr. Levin: It's certainly going to have an impact on radiologists' incomes, there's no doubt about that. Whether it's going to affect access to radiology or the availability of radiology facilities is a little harder to predict. An article was just published in the
Journal of the American College of Radiology [JACR] showing that until now the 2005 Deficit Reduction Act [DRA], which everybody was concerned about, didn't really impact CT and MRI very much, but there has been a drop in the availability of nuclear medicine. The question is whether that is due to a decrease in access or to other factors.
David C. Levin, MD
In terms of access, I think we're on the edge of the cliff right now and nobody knows whether we're going to stay on top or fall over. My hunch is that radiologists are going to suck it up and keep fulfilling their professional obligations, but it's certainly going to dampen the whole milieu of the speciality. It's going to dampen research, it's going to dampen the job market, and it's going to dampen acquisition of new and updated equipment. And it could well dampen access.
I don't like the whole situation, but I think the vast majority of people in radiology are dedicated, want to do a good job, and want to take care of their patients and will continue to do that. They might have to work longer hours, and they will have to put up with lower incomes, but hopefully they're going to continue to fulfill these professional obligations.
Procedures in Jeopardy?
Medscape: Are there any procedures that you think are at particular risk right now?
Dr. Levin: I think PET [positron emission tomography] scanning is at risk, and I think CT is partially at risk. As of this year they're bundling CT of the abdomen and pelvis, and that's certainly going to push down reimbursements for CT. Another area that I think is at risk is coronary CT angiography [CTA], which, surprisingly, has not been growing at all. That was a procedure that a lot of people were very interested in 5-7 years ago, and there were a lot of predictions about how the use of this procedure was going to skyrocket and how it was going to improve the diagnosis of coronary artery disease. That has not happened at all. In fact, the use of coronary CTA has gone down.
It's a fairly labor-intensive procedure, and the reimbursements are low. Reimbursements are higher for a cardiac nuclear scan, and that's much less labor-intensive than coronary CTA. I think that shows how low reimbursements have affected the use of a very good procedure that should be much more widely used.
Nuclear Cardiology
Medscape: Let's look at nuclear scans in particular, because I know you mentioned them in the article that you referenced from JACR. They are more expensive. Could this push down the use of nuclear procedures, and could CTA become more attractive in that context?
Dr. Levin: I can't really answer that, but I do know that nuclear cardiology took a big hit in 2010 when Medicare bundled 3 scan codes into 1. There was a substantial drop-off in the number of cardiac nuclear scans, but because of the bundling it's not clear that patient volume actually fell.
There's certainly going to be a drop-off in private-office nuclear scans done by cardiologists and a corresponding increase in hospital-based cardiac nuclear scans, because a lot of cardiologists are moving their practices into hospitals. As for cardiac CTA, it's too early to tell. I think what's probably going to happen is that volumes will begin to rise. A study just coming out now in the
Journal of the American College of Cardiology shows that it is substantially better than nuclear scans in detecting coronary artery disease.
Bundling of Codes
Medscape: Many specialties rely on imaging. Will there be corollary effects on cardiology, orthopaedics, neurology, oncology, emergency medicine, and others? Can you discuss any of these in any detail?
Dr. Levin: Like we were just saying, cardiology has been hit very hard. The cardiologists took a hit twice, actually. In 2009 they took a hit in echocardiography because there was a bundling of major codes. Then in 2010 there was bundling of the codes in cardiac nuclear scanning.
In radiology, we saw the first sign of it in 2010 with the bundling of the CT abdomen and pelvis codes. Now we're looking at an increase in the utilization factor, which will cut practice-expense reimbursement. I think it's inevitable that unless somebody changes their mind on this, radiology is going to be hit as well. The Feds went after cardiology first, and now they're going after radiology.
The question now is how this is going to impact these other specialties. I'm concerned that if access to MRI and CT done by radiologists is lost', it's going to prompt these other specialists to try to get into the field themselves and start putting in their own MRI and CT units. To a large extent, it's already happening. A lot of orthopaedic surgeons have put in their own MRI units. A lot of neurologists have put in their own MRI and CT units. Oncologists are putting in CT scanners. I'm concerned that if radiologists drop out of the picture and if there is a decrease in access to this high-end imaging through radiologists, it's going to encourage some of these other people to get into the field, even though they don't have proper training.
The cuts could reduce their profitability, but they can always increase their volume by self-referring. Radiologists can't do that.
Prior Authorization
Medscape: In another part of the budget there is a requirement for prior authorization of advanced imaging procedures. You've seen how prior authorization worked in the commercial market. What could it mean in the Medicare market? Should we expect to see a sharp drop in imaging volumes as a result of this?
Dr. Levin: If Medicare institutes prior authorization, you're going to see perhaps a small and somewhat progressive drop, but not a sharp drop in imaging volumes. The reason I say that is because the sharp drop has already occurred. Medicare reimbursements for imaging have dropped substantially since 2006 as a result of a number of factors. Figuring it out will be complicated because part of the declines will reflect code bundling.
Here I need to disclose that I'm a consultant for one of the RBM companies, HealthHelp.
Ideally, there would be a way to reduce the hassle that the ordering physicians have to go through. There's been a lot of talk about computerized decision support, and I think it has a real role to play. I could foresee the RBMs having good decision support systems on their front ends. For example, if an ordering physician wants to get an MRI or a CT or a PET scan, he or she would initially go through a computerized decision support system to seek approval. If the request didn't pass the decision support system criteria, it would get sent to a radiologist who would do a peer-to-peer phone call for consultation. I think a combination of decision support and prior authorization is probably the best way to go.
Also, if the Administration does implement prior authorization they ought to do a pilot first. I think it would be a mistake to try to bring all 45 million Medicare patients into prior authorization in 1 fell swoop. We ought to do a small pilot first and see how it works and what the effects of it are. It could be confined to a particular RBM or geographic area, but there should be a test.
What Are the Tradeoffs?
Medscape: Generally, when we're looking at cuts in imaging expenditures and enactment of prior authorization programs, we're looking at tradeoffs. What tradeoffs do you see if both of these elements are extended in Medicare?
Dr. Levin: The tradeoff is basically the availability of needed imaging. If you cut reimbursements for imaging by increasing the utilization factor and then you institute a prior authorization program, both of these things are most likely going to lead to some degree of reduction in the utilization of imaging. The tradeoff is going to be, well, how far do you go? If you go too far then you're depriving patients of necessary care. I think that's the big tradeoff -- you don't want to deprive patients of necessary care.
Here in our department, I do some cardiac imaging, and the major payer in Philadelphia uses one of the RBMs. Since I'm involved with coronary CTA, I can tell you that we see denials all the time. Patients are put on the schedule and then they drop off the schedule because the procedure has been denied. I think in a lot of instances those patients needed those coronary CTAs, but they're being denied so they don't get it. The same thing could happen in the Medicare program. It depends on how they institute prior authorization. I think if they institute it in a way that there is no actual denial of care and where you have knowledgeable people fielding the approval calls, then it could work. It could work in a way that would limit unnecessary imaging but wouldn't go over the line and start limiting the use of needed studies.
Imaging Growth
Medscape: Let's talk about tradeoffs in terms of the $820 million cutback in the imaging expenditures from the higher utilization rate.
Dr. Levin: That's when it gets back to what we were talking about before. It's hard to predict what's going to happen. You could have radiologists bailing out of their office practices or have independent diagnostic testing facilities closing down, and that would limit access.
''Like I said before, radiologists are for the most part hard-working, honorable people who I think want to provide good care to patients. I think that they may just say, "Look, we'll have to swallow this," but I don't know. I could be wrong.
Medscape: There was a big ramp-up in advanced imaging volume during the first half of the past decade, but there's some evidence to suggest that the growth in advanced imaging slowed and has perhaps leveled off. What does your research tell you?
Dr. Levin: There's absolutely no question that the growth in advanced imaging has leveled off and is even starting to go down. It reached a peak in 2006, and it's been going down ever since. If you look at the Medicare part B database, which is what we do in our research group here, there's no question that imaging utilization has gone down and continues to do so. Not only that, but the money that the Medicare program pays for imaging has also gone down and continues to go down.
Reimbursements took a big hit in 2007 following the DRA, and even since then they've continued to go on down. However you look at it -- whether you want to look at growth in volume or growth in spending -- they are both down. That's why I'm not so sure that the administration really needs to do what they're doing here in terms of increasing the equipment utilization factor. They've already achieved a major goal.
We're still researching this and I don't have the exact figures yet, but my hunch is that when we get to look at the details of the data, we're going to see that since 2006, Medicare Part B reimbursements for noninvasive diagnostic imaging have dropped somewhere in the vicinity of 15%-20%, maybe even a little more.
Other Cost-Control Strategies
Medscape: Finally, are there better imaging cost-control strategies than the ones the Obama Administration has put in its budget?
Dr. Levin: There are 2 things that they should do that they haven't done that trouble me. First, they have not done anything meaningful about malpractice concerns among physicians. I'm absolutely convinced that a significant amount of the utilization of imaging today is because of concerns about malpractice. I think the Democratic Party is too closely allied to the trial lawyers and that has prevented the Democrats and the Obama Administration from attempting any meaningful tort reform. If they put in strict limits on non-economic damages the way some states have already, I think you'd see a significant drop in imaging utilization.
The second issue is self-referral. What growth is still occurring in imaging is largely occurring among nonradiologists. You see cardiologists and urologists putting in CT scanners, orthopaedic surgeons putting in MRIs, and neurologists putting in both CTs and MRIs. If they did something with real teeth in it, like repealing the in-office ancillary services exception to the Stark law, you could see a real impact, a significant drop in utilization because self-referral would be greatly restricted. Those are the 2 things that the government needs to do. What little remaining fat there is in imaging is in those 2 major areas.
-Medscape Radiology
