DRA pain lingers, but other changesshow progress for radiology practice

Advanced imaging procedures covered by Medicare took a beating in 2007 under a congressionally mandated deficit reduction law, falling $1.7 billion, a drop of 12.7%, to $12.1 billion, according to a report from the federal General Accountability Office.

The report was striking because it was the first to detail impact on imaging of the much-despised Deficit Reduction Act, enacted by a lame-duck Congress in 2005 with provisions aimed at avoiding drastic cuts to physician fees. Alas, issues regarding physician fees are still with us. Alas again, the DRA remains the law of the land.

A close look at the GAO report reveals a couple of troubling details:

In 2007, DRA fee caps reduced the fee for one in four physician imaging tests overall, and advanced imaging modalities-CT and MR, in particular-were more likely to be paid at lower rates. Those modalities, plus nuclear medicine, made up about two-thirds of all scans paid at lower rates.

Despite the fee cuts, per-beneficiary imaging volume continued to grow in 2007, increasing 3.2%, according to the GAO. (This rise was down from 5.9% per year from 2000 through 2006.)

The Centers for Medicare and Medicaid Services said that continued imaging growth in 2007 suggests that overall beneficiary access to imaging has not suffered. Others, however, wonder about that assertion and about whether radiology remains disproportionately affected by the DRA.

The Access to Medical Imaging Coalition, a group made up of vendors and medical specialty associations, cites anecdotal evidence that patients are being turned away from imaging at the point of service. Apparently, there are no hard data on this, but the GAO acknowledges that its national results may not apply locally.

The American College of Radiology, meanwhile, asserts that the DRA may actually boost inappropriate utilization because physicians who own imaging equipment and self-refer scans can increase volume to make up for cuts in reimbursement. How often this happens is difficult to know, but a June 2008 report by the GAO identified self-referral as a driver of increased imaging utilization.

What all this information suggests is that the DRA remains a flawed instrument: ill-suited to controlling inappropriate utilization by self-referrers and a blunderbuss that aims its force at high-tech MR and CT scans where so much of today’s imaging advancement is taking place. Whether it is actually reducing access to care remains an open question but one that bears watching.

Luckily, radiology has had some notable successes on other fronts.

CMS has proposed revisions to its rules that would require all physician offices providing imaging studies (except mammography) to register as independent diagnostic testing facilities. This would make them subject to higher standards than they are now and act as a brake on self-referral.

In addition, recent federal legislation establishes a process for accreditation of providers of advanced diagnostic imaging services (essentially, everything except x-ray, ultrasound, and fluoroscopy). Supporters of the accreditation requirement say it will help curb inappropriate and low-quality scans, something they say will work in favor of radiology. The Access to Medical Imaging Coalition hopes that this step will shift the debate away from simply curbing high-tech imaging utilization to one over which procedures work and are necessary.

Unfortunately, the time frame for the legislation is distant. A pilot project begins in 2010; the accreditation requirement takes effect in 2012.

Still, the CMS regulation and the accreditation legislation do represent steps in the right direction that, over time, will provide a more positive approach to imaging than the one embodied in the DRA.