Radiology has been to the mountaintop, and it has been paying a political price for it ever since, according to Dr. Bibb Allen Jr., vice chair of the American College of Radiology's (ACR) Board of Chancellors.
Radiology's ascent, as he explained in a lecture at the California Radiological Society (CRS) meeting on September 9, was accompanied by some of the highest incomes in medicine. Salaries peaked in the 2000s with the help of double-digit utilization growth for advanced imaging studies such as MRI, CT, and PET.
"The only problem was that such growth was unsustainable," Allen told a sympathetic audience in San Francisco in a talk that described the foes arrayed against radiology on the political landscape.
8 payment cuts in 6 years
From radiology's peak in 2005, the profession would see eight cuts in Medicare payment rates in six years. The changes did not stem from objective assessments of financial costs and clinical benefits, Allen said, but from misconceptions among healthcare policymakers in Washington, DC, about radiology.
"It is very frustrating; I've tried to figure it out," Allen said. "What drives irrational public policy? It is just ignorance."
Allen in particular took aim at the Medicare Payment Advisory Commission (MedPAC), an independent agency of the U.S. Department of Health and Human Services (HHS) that provides Congress with guidance on Medicare spending issues.
He also targeted the U.S. Centers for Medicare and Medicaid Services (CMS), which sets Medicare payment policy and reimbursement rates.
Fuming at MedPAC
Under the leadership of Glenn Hackbarth, MedPAC has taken increasingly aggressive stances against radiology, Allen said. ACR has been frustrated by MedPAC's tendency to focus on broad policies that harm all imaging services providers, while simultaneously refusing to take action against physicians who engage in imaging self-referral, a key contributor to wasteful imaging utilization, Allen said.
MedPAC has also incubated policies that chipped away at the incomes of radiologists and imaging services, Allen said.
In 2008, MedPAC challenged the assumption of a 50% utilization rate for high-tech imaging equipment in the scale that Medicare uses to calculate part B reimbursement. It later ignored survey data generated by the Radiology Business Management Association (RBMA) in favor of its own survey suggesting assumed utilization time should be more than doubled to 45 hours per week, Allen said.
Ultimately, the Patient Protection and Affordable Care Act (PPACA) would increase the assumed rate to 75% to cut reimbursement.
MedPAC also backed a 2009 Government Accountability Office (GAO) report that recommended Medicare part B discounts for imaging contiguous body parts during cross-sectional imaging performed during a single cross-sectional imaging session or during the same day.
The proposed multiple procedure payment reduction (MPPR) assumed that procedures could be performed and read 25% more efficiently because both sets of images were acquired during a single session. The actual efficiency was just 5%, according to a study published in the Journal of the American College of Radiology, but that information was overlooked when CMS proposed the rate reduction, Allen said.
In 2011, MedPAC's discontent with medical imaging was reflected in three separate proposals involving procedural bundling, he said. It also recommended requiring prior authorization for physician and other practitioners who order significantly more advanced imaging services than their peers.
DRA cuts Medicare reimbursement
Looking at the big picture, radiology's downturn actually began with the Deficit Reduction Act (DRA) of 2005. When implemented in 2007, DRA reforms lowered reimbursement for high-tech medical imaging to the lower of the Medicare Physician Fee Schedule (MPFS), which usually applied to radiology, and rates set by the Hospital Outpatient Prospective Payment System (HOPPS). HOPPS rates for technical and professional components were typically several percentage points lower than MPFS.
In another setback for radiology, the specialty's efforts to gain Medicare approval for screening CT colonography were blocked in May 2009. A CMS panel ruled that a pivotal efficacy trial, sponsored by the American College of Radiology Imaging Network (ACRIN), did not adequately describe the likely experience for a retirement-age population.
A self-congratulatory article about the decision later appeared in the New England Journal of Medicine.
"It was unbelievable to me that these guys, who actually wrote the coverage decision, also wrote an article in the NEJM touting this as a victory for evidence-based medicine," Allen said.
Evidence of growing federal animosity against radiology could be seen in efforts to denigrate the value of imaging services, he said. For evidence, Allen referred to the last Relative Value Scale Update Committee (RUC) meeting, where RUC members discussed 44 imaging procedures.
"No other medical society has been impacted to this degree," he said.
Finally, efforts to reduce Medicare payment rates for intensity-modulated radiation therapy (IMRT) led CMS staff members to examine RadiologyInfo.org; they found the site advised patients that the procedure takes 10 to 30 minutes, instead of the 60 minutes used in the Medicare relative value unit formula to calculate the technical fee. The difference led to a proposed cut to Medicare fees, Allen said.
Finding congressional support
ACR is looking to support form Congress, especially the Republican majority in the House after 2010, to beat back efforts to cut radiology reimbursement. Allen gave credit to RADPAC, radiology's political action committee, and its ability to channel $1.3 million in 2009 and 2010 to imaging-friendly candidates.
The Radiology Saves Lives campaign further strengthened ACR's position, Allen said. Eight of 10 voting-age adults who had received medical imaging exams said such procedures are essential for diagnosis and treatment. Seven of 10 opposed Medicare cuts for imaging services.
A 25% rate cut for contiguous body part imaging still appeared in the final rules for the updated Medicare Part B Fee Schedule announced in November 2011, but the policy was expanded to apply to entire group practices.
A 25% discount would have been applied to abdominal ultrasound read by one member of a group practice in the afternoon after an abdominal CT was interpreted by a radiologist from the same group in the morning, Allen said. However, CMS rescinded the policy a month later, after its staff was unable to explain the rationale for the discounts.
Additional pressure has arisen from Capitol Hill, where a House majority cosponsored the Diagnostic Imaging Services Access Protection Act (HR 3269) to prohibit CMS from implementing multiple procedure payment discounts for MR, CT, or diagnostic ultrasound.
Still, new threats seem to appear from thin air, Allen said. A proposal to raise the Medicare imaging equipment usage assumption to 90% arose in August to offset $800 million of federal costs for implementing the Korea Free Trade Agreement. ACR mobilized to kill the proposal, Allen said.
Sequestration -- a bipartisan plan to implement across-the-board federal cuts if the Obama administration and Congress cannot agree on long-term deficit reduction by year's end -- would lead to a 2% cut for Medicare fees to providers, Allen said.
Congressional failure to extend the moratorium against provisions of Medicare's Sustainable Growth Rate (SGR) would lead to about a 25% cut in physician payments. Enactment of Republican vice presidential candidate Paul Ryan's budget proposal would cut Medicare spending by 22%, Allen said.
Continual pressure on healthcare costs has led ACR to explore the possibility of supporting novel reimbursement models, such as value-added payment systems based on compliance with ACR Appropriateness Criteria and other quality measures.
The new Harvey L. Neiman Health Policy Institute is defining how the college's growing base of practice management data can test the effect of payment models, such as capitation, and delivery models, such as accountable care organizations, on radiological practice.
"This will ensure that when we get to the table on these questions, we will have the information we need," he said.
