There was a 1% drop in imaging volume per Medicare beneficiary between 2012 and 2013, according to new figures released by the Medicare Payment Advisory Commission (MedPAC). But despite the decline, MedPAC is pointing out that the use of imaging services remains higher than it was a decade ago.
"The growth in use of imaging and tests has led to concerns about appropriate use of these services," MedPAC wrote in its March report to Congress. "Physicians have warned that diagnostic tests are often ordered without an understanding of how the results could change patient treatment."
MedPAC acknowledged the decline in Medicare imaging volume in its 2015 "Report to the Congress: Medicare Payment Policy," but it also emphasized that overall cumulative growth in imaging volume from 2000 to 2009 totaled 85%, compared with a cumulative decrease in imaging volume since then of about 7%.
"The growth in imaging volume from 2000 to 2009 was exceeded only by the 86% growth in the use of tests -- such as allergy tests -- during those years," MedPAC wrote.
| Changes in Medicare imaging volume | |
| Average annual change in units of service per beneficiary, 2008-2012 | -0.5% |
| Change in units of service per beneficiary, 2012-2013 | -0.6% |
| Average change in volume per beneficiary, 2008-2012 | -1.4% |
| Change in volume per beneficiary, 2012-2013 | -1% |
| Percent of 2013 allowed changes | 11.5% |
The decrease in imaging volume is due in part to the shift in billing for cardiovascular imaging from physician offices to hospital outpatient departments, MedPAC found. In 2013 compared with 2012, the number of echocardiograms per beneficiary provided in hospital outpatient departments went up by 7.4%, but the number provided in professional offices decreased by 8%.
In addition, from 2012 to 2013, the number of cardiac nuclear medicine studies per beneficiary provided in hospital outpatient departments increased by 0.4%, while the number provided in professional offices decreased by 12.1%. These changes are in line with an increase in hospital-owned cardiology practices, according to MedPAC.
Some of imaging's 1% drop in imaging volume is due to decreases in units of service for nuclear medicine and echocardiography, MedPAC said. If these were excluded from calculations, the volume of all other imaging services from 2012 to 2013 would show a 0.8% increase.
The numbers from 2012 to 2013 parallel similar drops in recent years -- with MedPAC choosing to focus on long-term growth in imaging volume rather than short-term declines with each annual release of new numbers.
| Change in annual Medicare imaging volume, 2009-2013 | |
| Period | Volume change |
| 2012 to 2013 | -1% |
| 2011 to 2012 | -3.2% |
| 2010 to 2011 | -1% |
| 2009 to 2010 | -2.5% |
Primary care is undervalued
The report included a look at disparities in physician compensation, which are widest when primary care providers are compared with radiologists and nonsurgical proceduralists (for example, physicians who conduct cardiac catheterizations, gastrointestinal endoscopies and colonoscopies, or epidural steroid injections). MedPAC found that radiologists earn more than twice as much as primary care physicians: In 2012, radiologists earned on average $469,000 per year, while primary care doctors earned $222,000.
The nature of the physician fee schedule and its reliance on fee-for-service (FFS) medicine leads to an undervaluing of primary care and an overvaluing of specialty care, MedPAC said.
"FFS payment allows some specialties to more easily increase the volume of services they provide, while other specialties, particularly those that spend most of their time providing [evaluation and management] services, have limited ability to increase their volume," the group wrote.
Repeal the SGR
In its report, MedPAC emphasized again its long-standing recommendation to repeal the sustainable growth rate (SGR) formula. After years of legislative overrides, the policy is causing uncertainty for physician practices and has the potential to create instability for Medicare beneficiaries. And if Congress does not take action before the latest SGR fix expires on March 31, the physician payment rate will be reduced by 21.2% on April 1.
"Constant action on short-term legislative patches means that there is often little time to pursue more meaningful policies to improve the Medicare program," MedPAC wrote. "At this time, the budgetary cost of SGR repeal remains at historic lows (less than half the cost it was two years ago) ... the Commission continues to reiterate its recommendations and urges the Congress to repeal the SGR."
MedPAC suggested Congress take the following actions:
- Repeal the SGR and replace it with 10 years of legislated updates, with higher updates for primary care services than other services. Fees for services outside of primary care would be reduced in each of the first three years, followed by a freeze, while fees for primary care would be frozen for 10 years. Through these reductions and freezes, physicians would take on about one-third of the cost of repealing the SGR, according to MedPAC.
- Collect data to improve the relative valuation of services. The commission recommends that the Secretary of the Department of Health and Human Services (HHS) regularly collect data -- including service volume and work time -- to establish more accurate work and practice expense values.
- Target overpriced services. The HHS secretary should use data collected to identify overpriced services and adjust work and practice relative value units (RVUs) for these services.
- Encourage accountable care organizations (ACOs). Physicians who join or lead two-sided risk ACOs should be given a greater opportunity for shared savings than those in bonus-only ACOs or those who do not join any ACO, MedPAC wrote.
In any case, SGR repeal is MedPAC's primary concern.
"The commission's highest policy priority with respect to Medicare's payments to physicians and other health professionals is repeal of the SGR," the group concluded.
