Senate report considers financial penalties for inappropriate imaging

Financial penalties would be enforced against physicians who frequently recommend inappropriate medical imaging under a set of policy options outlined in a potentially influential report issued April 30 by the Senate Finance Committee.  

Sen. Max Baucus (D-MT), chairman of the Senate Finance Committee, and Sen. Charles Grassley (R-IA), the committee's ranking Republican, wrote the 51-page document that was the subject of a six-hour closed-door meeting of committee members on Thursday.

The Finance Committee plans to issue additional reports covering healthcare insurance and financing in the coming weeks. The documents are expected to serve as a blueprint for proposed comprehensive healthcare legislation to be considered by the committee by midyear and debated on Senate floor this summer.

The American College of Radiology found a lot to like in the delivery system report, said Orrin Marcella, director of Congressional Affairs for the society. Provisions aimed physician self-referral and inappropriate utilization included the following:

• Physician self-referral disclosure: The proposal would amend the in-office ancillary services exception to federal self-referral law to require physicians to disclose to patients their financial interests in MRI, CT, PET, and possible other services in their offices.
• Compliance with appropriateness criteria: The report proposes adopting appropriateness criteria for high-tech imaging including criteria for measuring compliance levels. A new sliding scale for payments would be established in 2013, with financial penalties in the form of lower rates for the facilities and physicians who order an extraordinarily large number of inappropriate procedures.
• Utilization data collection and sharing: The document outlines the creation of a new imaging information organization to collect and share imaging utilization data with feedback to ordering physicians on their compliance with appropriateness criteria. The objective would be to help physicians minimize wasteful scanning and avoidable patient radiation exposure.
• Diagnostic Imaging Exchange Network: Baucus and Grassley recommend creating five regional Diagnostic Imaging Exchange Networks covering the country. These networks would help physicians determine the necessity, safety, and appropriateness of imaging. Their mission would be to minimize duplicative scans and patient radiation exposure. In a step that could address the cumulative effects of radiation-based imaging studies, the report recommends equipping physicians with information technologies to access a patient's entire imaging history when ordering new studies.

The proposal's reliance on appropriateness criteria to curb the wasteful use of high-tech imaging appears to lay groundwork for the type of decision-support order entry systems backed by the ACR, Marcella said.

"The ACR sees this as an opportunity for e-order entry. That is certainly something we encourage," he said.

The committee is also considering prior authorization techniques to control high-tech imaging utilization, though the report devotes only one sentence to that topic, saying that it is exploring other imaging-related options including the use of radiology benefit managers for certain imaging services.

"The ACR supports everything except the sentence devoted to RBMs," Marcella said. "We see the adherence to appropriateness criteria policy as certainly a better way to insure that the images that are ordered are appropriate than the RBMs and hopefully legislators will embrace this policy as an alternative to RBMs."

In a written statement, the Access to Medical Imaging Coalition endorsed the report's proposed policies for appropriateness criteria and the proposed creation of the exchange network.

The network would produce savings to the Medicare program by eliminating many duplicative scans while improving patient safety through the reduction of radiation exposure, according to the AMIC statement.

The report expressed general support for comparative effectiveness research, though it did not address its application to medical imaging. Marcella was encouraged that the authors referred to clinical comparative effectiveness rather than cost comparative effectiveness. This may help allay fears that the comparative effectiveness movement would focus too much on identifying the cheapest options rather than the most medically potent methods, he said.

The sections of the report devoted to the sustainable growth rate policy for the Medicare Physician Fee Schedule were reassuring, according to Marcella, because the senators committed to preventing the 20% rate cut awaiting all Medicare participating physicians in 2010. The first of two options discussed would update the fee schedule by 1% for the next two years, and then leave the rates unchanged in 2012. It would revert to current law in 2013, which would again require a drastic cut.

"This suggests that they are attempting to buy some time with these next three years to come up with a better way to pay physicians," Marcella said.

The second option would follow the same course as the first for the next three years. It would then phase in a series of cuts with a floor of 3% cuts for physician services after 2012 before adopting regional systems of reimbursement that get at geographic differences in medical utilization.

"These are the studies that show that Medicare patients in Miami get a whole lot more care than patients in Burlington, VT," Marcella said.