Cardiologists boost imaging to compensate for lower DRA-related rates

The ability to self-refer may explain why cardiologists were better able than radiologists to adjust to Medicare rate cuts after the implementation of reimbursement reforms from the federal Deficit Reduction Act of 2005.

By delving into the Medicare Part B database, Dr. David Levin, a professor of radiology at Thomas Jefferson University Hospital in Philadelphia, identified stark differences in imaging-related payment and utilization patterns for cardiologists and radiologists in 2007, the first year the DRA took effect.

Levin found that outpatient Medicare payments to radiologists for private office imaging plummeted 18% to $2.33 billion, while they fell 10% to about $2.37 billion for cardiologists.

Cardiologists' relatively soft landing, according to Levin, stemmed from their ability to make up for the difference with higher volumes. In 2007, their utilization rate for office-based imaging rose 4%, while the rate for radiologists increased 1%.

"My suspicion was that cardiologists can self-refer to make up in volume what they were losing on a per case basis," Levin said in an interview. "The in-office ancillary exception [to the federal ban against self-referral] allows them to do that with impunity."

Though many radiologists will remember 2007 for the historic importance of the DRA cuts, it was also notable as the first year they were surpassed by cardiologists in the amount of money billed to Medicare for private office imaging procedures.

Levin also plotted that historical trend in the same study, presented at the 2009 RSNA meeting. He reported that private office imaging covered by Medicare rose sharply from 1997 to 2006 for cardiologists, while utilization stayed relatively flat for radiologists.

In 1997, radiologists performed about 275 private office imaging exams per 1000 Medicare beneficiaries, about 100 more (per 1000 beneficiaries) than cardiologists in that year. By 2006, the year before DRA implementation, cardiologists had matched the radiologists' performance. Both specialties performed about 350 procedures per 1000 beneficiaries.

"To me, that was indication that there was a lot of self-referral [by cardiologists] going on," Levin said.

All noninvasive diagnostic imaging, regardless of modality, was tabulated for Levin's study. For utilization questions, Levin considered only global and professional components to avoid double counting. For payments, technical, professional, and global reimbursements were addressed. Cardiologists tend to read imaging studies performed in their own offices to avoid losing revenue from the professional component of the bill, he said.

The findings suggest to Levin that any serious effort to address rising imaging utilization will have to deal with the self-referral issue.

"Everybody—the Government Accountability Office, [Department of] Health and Human Services, the Inspector General, MedPAC, and CMS—all recognize that self-referral is a problem, but they don't want to take it on because it is a political hot potato," he said.