Senate bill ties physicians’ pay to appropriateness criteria

October 7, 2009

A proposal that could allow higher payments for physicians who refer patients in accordance with appropriateness criteria has been added to a healthcare reform bill now before the Senate Finance Committee.

A proposal that could allow higher payments for physicians who refer patients in accordance with appropriateness criteria has been added to a healthcare reform bill now before the Senate Finance Committee.

The America's Healthy Future Act of 2009 would create the CMS Innovation Center, a new Medicare program charged with evaluating and implementing physician payment methods that keep quality patient care up and costs down. The bill builds upon a four-decade old law that gives the Secretary of Health and Human Services authority to test new reimbursement approaches. The bill would allocate $10 billion over 10 years to fund the center.

Among the methods suggested to the Senate panel, the innovation center would be required to scale down payments to physicians who do not consult appropriateness criteria before ordering advanced diagnostic imaging services for their patients, said Cynthia R. Moran, assistant executive director for government relations and economic policy at the American College of Radiology.

With the Congressional Budget Office counting up costs of the revised Senate bill, senators expressed concern that the new total will surpass the $856 billion originally estimated by finance committee chair Sen. Max Baucus (D-MT). Members of the Access to Medical Imaging Coalition suggested the innovation center, reasoning that it could help the Senate meet its fiscal goals for healthcare reform and avoid further cuts in radiology reimbursement, Moran said. The ACR is a member of AMIC, a coalition of medical societies, patient advocacy groups, and industry interests allied on imaging issues.

"We feel it is important for Congress to understand that most of the diagnostic imaging that's ordered in the country is not attributable to radiology, but to other physicians," Moran told Diagnostic Imaging. "The system needs to be corrected."

The center would study the practice patterns followed by physicians who refer high volumes of patients to advanced medical imaging. If the program finds that a physician deviates from appropriate utilization standards, his or her reimbursement could be affected, Moran said.

Implementing a policy that sets a sliding payment scale tied to appropriateness criteria would be a good way to educate physicians on how and when to order the right test for the right patients, Moran said. It could be based on physician decision-support order entry, another concept backed by the ACR.

"This is an area that really needs to be explored," Moran said.