Proposed Imaging Pay Cuts May Limit Access

Policy makers are turning their attention to outpatient medical imaging services as they try to cut costs from the health care system.

But although physicians acknowledge the high price tag associated with advanced imaging modalities, some in the cardiology, rheumatology, and radiology communities say the types of cuts being proposed could hurt access, especially in rural and underserved communities. And they argue that the proposed cuts would not address the real problem of inappropriate use.

In July, officials at the Centers for Medicare and Medicaid Services issued the 2010 Physician Fee Schedule proposed rule, which includes a plan to increase the assumed utilization rate for certain imaging equipment from 50% to 90%. The utilization rate change would apply to all equipment priced at $1 million or more.

The CMS said the change will bring payment more in line with the actual costs for maintaining and operating the equipment without harming access, but opponents disagree.

Health reform legislation being considered in the House (H.R. 3200) includes its own cut to imaging services. The bill would change the utilization assumption from 50% to 75% for advanced diagnostic imaging services such as CT, magnetic resonance imaging, nuclear medicine, and positron emission tomography (PET). It would also adjust the technical component “discount” on single-session imaging to consecutive body parts from 25% to 50%. If enacted into law, the changes in the House bill would go into effect in January 2011.

As written, the proposals would not affect lower-cost imaging services such as bone density testing and ultrasound.

Nonetheless, the proposals could hurt the adoption of MRIs in rheumatology offices and have negative consequences for patient care and the overall cost of health care, said Dr. Norman B. Gaylis, a rheumatologist in Aventura, Fla., and the president of the International Society of Extremity MRI in Rheumatology (ISEMIR).

ISEMIR estimates that about 75 rheumatology practices in the United States are using office-based MRIs. The MRI actually saves the health system money, he said, by picking up erosions far earlier than x-rays would, thus making an earlier diagnosis possible.

The technology also allows physicians to determine whether a patient should be taking an expensive biologic agent, Dr. Gaylis said. Moving forward, if the patient responds to the biologic, the physician can use the MRI to stop the medication when the patient shows signs of remission, something that can't be effectively measured without an MRI.

The American College of Cardiology (ACC) expects the proposals to result in payment cuts to cardiac magnetic resonance imaging, cardiac computed tomography, and nonhospital cardiac catheterization services.

Dr. Jack Lewin, CEO of the ACC, said that it's appropriate for Congress and the administration to investigate how to make imaging more efficient. But the best approach is not price cutting, he said in an interview. Instead, the ACC favors utilizing appropriate use criteria at the point of care so that the ordering physician can quickly see if the current science supports the use of a particular imaging study.

“We have the science,” Dr. Lewin commented. “We can give doctors who are ordering these tests for their patients the information as to which is the right test to order and when it's really indicated.”

The widespread use of appropriate-use criteria tools would save the same amount of money as the “blunt instrument cuts” proposed by Congress, Dr. Lewin said, but without some of the unintended consequences. For example, he predicted that the cuts as proposed would force some imaging centers to close their doors and would likely have the greatest impact on poor communities and ethnic minorities.

Dr. Michael Graham, president of the Society of Nuclear Medicine, said he is concerned about the impact these cuts would have on access in rural areas. If rural imaging facilities are forced to close, patients may have to drive twice as far and wait twice as long to get a study, he said in an interview. “The reality is that studies will not get done. It's going to be a major problem.”

Policy makers who are targeting advanced imaging modalities should also consider the impact on lower-cost imaging services, said Dr. James Borgstede of the University of Colorado, Denver, and a past chair of the Small and Rural Practice Commission at the American College of Radiology.

When physicians go to a rural area to perform imaging services, they often use the higher-cost imaging to support the lower-cost services like plain film x-rays and mammograms, he said in an interview.

“The government has to reimburse us appropriately,” Dr. Borgstede said. “We're small businessmen, and if you lose a dollar on every piece of imaging you do, you don't make it up on volume.”