Insurer wants boost for primary care at imaging’s expense

April 24, 2009

The Blue Cross Blue Shield Association has recommended boosting payments to primary care physicians and paying for them with cuts to imaging services. The suggestion came during a congressional hearing on healthcare reform held by the Senate Finance Committee. Imaging proponents say they will challenge any proposal lacking evidence to support it.

The Blue Cross Blue Shield Association has recommended boosting payments to primary care physicians and paying for them with cuts to imaging services. The suggestion came during a congressional hearing on healthcare reform held by the Senate Finance Committee. Imaging proponents say they will challenge any proposal lacking evidence to support it.

"To attain the goal of having everyone covered, we must address the underlying problems of our current delivery system," said Allan Korn, senior vice president and chief medical officer of the Blues, at a roundtable discussion held April 21 by the Senate Finance Committee. "Escalating costs are the main reason people are unable to obtain health insurance, and rising healthcare costs must be addressed through delivery system reforms that increase quality and enhance value."

Delivery system reform entails moving Medicare away from the fee-for-service design and into one that pays for performance, according to Korn. To do this, he recommended a three-tiered strategy: a phase of immediate reforms; a second stage that could be planned and implemented within two years; and a last phase of major reforms that could be planned, tested, and implemented after that.

Increasing payments to primary care physicians while strengthening the primary care workforce -- a tier one goal -- is key to getting all other reforms moving, Korn said. To achieve this, he recommended adjusting payments through the Resource Based Relative Value Scale (RBRVS) to give primary care providers a 5% relative increase in 2010, 10% in 2011, and 15% after that.

"Paying for this could be done primarily by reducing payments for imaging services to providers who rely heavily on costly imaging machines," Korn said.

This proposition is nothing new, but it could be the first time health insurance industry officials have appealed to such specific measures in congressional hearings, said Orrin Marcella, the American College of Radiology's director of congressional affairs.

"This is the first time that I've heard one of the insurers actually chiming in on the specific utilization rate proposal," Marcella told Diagnostic Imaging.

This suggestion mirrors recommendations made by the Medicare Payment Advisory Commission in March to change metrics for Medicare reimbursement through the utilization of imaging equipment, according to Marcella. The MedPAC report recommended changing the utilization rate factor used to calculate the technical component of Medicare Part B reimbursement from 50% to 90%.

Changing the utilization rate assumption within the practice expense formula for CT, MR, and PET will lower the technical component payment for those modalities, Marcella said. Money savings could then be spread out into the rest of the Medicare Physician Fee Schedule, which in turn could help boost primary care reimbursement.

The response to the Blues' proposal will be exactly the same as to MedPAC's, he said.

"We shouldn't be making changes to the practice expense formula without hard data to support those changes," Marcella said.

Policymakers and experts are not looking at the most recent data available from Medicare to show that the growth in imaging has slowed significantly since 2006. Instead, they still resort to information that dates back to 2005 and before, Marcella said. Physicians have come to a better understanding of how to apply imaging technologies and what patients really need imaging.

Lawmakers see it differently, though, he said.

"We would encourage lawmakers and MedPAC and the Centers for Medicare and Medicaid Services, anyone who has a role in policymaking, to look at relevant new data before they go ahead with changes that could significantly harm the evolution of medicine," he said.

Senate Finance Committee chair Max Baucus (D-MT) and ranking member Chuck Grassley (R-IA) called for the series of three roundtable discussions on healthcare reform. The next two to review coverage and financing will be held May 5 and 14, respectively.

For more information from the Diagnostic Imaging and SearchMedica archives:

Medical imaging takes rap for fueling higher Medicare costsWhite House calls for imaging preauthorization in budget planCongress report predicts blitz of reimbursement cuts