Medicare commission sets priorities for cutting imaging costs

January 21, 2005

Plans to set national quality standards for performing and interpreting outpatient diagnostic imaging covered by Medicare are among recommendations approved in January by the influential Medicare Payment Advisory Commission (MedPAC) to curb fast-rising federal costs associated with high-tech medical imaging.

Plans to set national quality standards for performing and interpreting outpatient diagnostic imaging covered by Medicare are among recommendations approved in January by the influential Medicare Payment Advisory Commission (MedPAC) to curb fast-rising federal costs associated with high-tech medical imaging.

The 16-member advisory commission unanimously approved recommendations last week that would close several loopholes in the federal Stark II anti-self-referral law. It will ask Congress to extend the self-referral restrictions to freestanding nuclear medicine and PET services for the first time and close a loophole in Stark II regulations that allows physicians to invest in leasing equipment in imaging centers to which they refer patients.

The commission fell short of recommending a ban against office-based self-referral, a practice critics say is a major contributor to the 14% annual increase in Medicare outpatient imaging costs for the past two years.

The MedPAC report asks Congress to authorize the Centers for Medicare and Medicaid Services (CMS), the administrator of the Medicare program, to more closely monitor physicians - including radiologists - who order imaging. Recognizing the need for reforms growing out of the rapidly rising utilization of CT and MRI, it would revise coding edits to restrict unbundled technical payments for procedures performed on contiguous body parts.

The report will be issued to Congress in March.

Intense debate on the terms for quality standards preceded the commission's approval of those controversial provisions. CMS would be asked to establish standards governing imaging equipment, nonphysician staff, image quality, supervising physicians, and patient safety if Congress adopts the MedPAC recommendation covering quality standards for performing diagnostic imaging.

The recommendations covering the interpretation of imaging would involve the possible credentialing of physicians who read imaging studies. Federal privileging rights may be based on the physician's training, continuing educational experience, and reading volumes. Private organizations would administer the standards.

"We are going into an interesting world in having the Secretary [of the Department of Health and Human Services] establish standards for certain kinds of physician activity," said commission member Sheila Burke.

Burke said she didn't recall any other instance in which Medicare has established by regulation specific requirements for physicians who are qualified to bill for certain kinds of activities. The Mammography Quality Standards Act, however, does authorize the FDA to enforce minimum educational and reading volume standards for physicians who interpret mammography.

Although fully supporting the recommendations, Burke sounded a note of caution that Medicare might suddenly take over responsibilities previously handled by licensing boards and specialty societies.

MedPAC chair Glenn M. Hackbarth agreed that the agency is "breaking new ground" with national standards for imagers and imaging. But he suggested that the path is not an unfamiliar one, given federal requirements for facility accreditation.

CMS already imposes those types of standards on services provided in independent diagnostic testing facilities, said Thomas Greeson, a healthcare lawyer with Reed Smith in Falls Church, VA.

"In many ways, this kind of requirement would only extend that protection to Medicare beneficiaries who receive services performed in physician offices," Greeson said. "And it makes sense to assure there are appropriate standards for those who perform and interpret imaging services."

A recent trend among insurance carriers has been to enact stricter accreditation and privileging guidelines regarding the use of high-end diagnostic imaging services such as MRI, CT, and PET. Some carriers have co-opted the American College of Radiology appropriateness criteria.

The MedPAC panel envisions the DHHS consulting with various organizations, looking at education curricula, and then determining, for example, what it means to be properly trained to interpret an MR scan.

The commission stopped short of delineating specific suggestions for the standards. The bottom line, according to Hackbarth, is to monitor the proliferation of subpar equipment, ensure that technicians are properly trained to take quality images, and guarantee that qualified physicians read the images.

In testimony before the commission, Dr. Ken Heithoff, a representative of the National Coalition of Quality Diagnostic Imaging Services, urged the panel to consider privileging policies that address the technical as well as the professional components of diagnostic imaging services.

As physicians of all stripes experience a decrease in reimbursements, they look for ways to augment their incomes, Heithoff said. Many take up diagnostic imaging, using lower cost, lower quality equipment. Yet they are reimbursed the same as a full-fledged imaging center.

Camille Bonta, a spokesperson for the American College of Cardiology, commented on two studies mentioned by staff analyst Ariel Winter. The first involved a survey of 1000 imaging providers by BlueCross BlueShield of Massachusetts. The study found that about one-third of the providers had some kind of deficiency, of which 10% could not be remedied easily. Bonta pointed out that the failure rate was highest among podiatrists and chiropractors when compared with specialty physicians and surgical physicians.

The second study, Winter said, surveyed nearly 100 nonradiologist offices and found that about three-quarters had some kind of deficiency, while one-third had serious deficiencies (AJR 2000;175:9-15). Bonta reminded the panel that the study included only x-ray images, and MedPAC would be wise to look at studies that included CT, MR, and nuclear medicine if it intends to make recommendations that affect these modalities.

Furthermore, she said, the study handpicked five radiology practices and 95 nonradiology practices as the samples in their study.

"I hardly think that that is a scientific study," she said.

Dr. David Levin, national medical director for HealthHelp, a utilization management company, told Diagnostic Imaging that the 92 nonradiology offices in the study Bonta questioned were chosen because they had the highest billings to the carrier. Regarding radiology, after the first five offices passed inspection, the insurance carrier decided that was representative of radiology as a whole.

"The assumption is that radiologists are trained to do good-quality images," Levin said.

For more information from the Diagnostic Imaging archives:

ACR pursues designated physician imager legislation

Medicare proposals aim to curb rising imaging costs

Self-referral course draws stealth response from cardiologists

Specialists coddled, self-referral ignored