Buying Time: Chances for DRA Reversal Grow Slim, but Moratorium Might Fly

Those hoping for a repeal of cuts to diagnostic imaging contained in the Deficit Reduction Act (DRA) may have to drastically lower their expectations for 2006 was the word coming out of both the American College of Radiology (ACR) Annual Meeting and Chapter Leadership Conference and the National Coalition for Quality Diagnostic Imaging Services (NCQDIS) Member’s Conference. Both conferences, held just 2 weeks apart, drew large contingents to Washington, DC, to lobby against the cuts, particularly the provision in the DRA to reduce the technical component for diagnostic imaging services to the lower of either the reimbursement under the Medicare Physician Fee Schedule (MPFS) or the Hospital Outpatient Prospective Payment System (HOPPS). However, the current political climate meant there was only so much the members of each organization could do when they got there. “There’s not a lot going on in health care this year,” said Barrett Thornhill, health legislative assistant in the office of Senator Mike Crapo (R-Ind), to the NCQDIS members that gathered at the Washington Marriott on June 5. “And that’s probably a good thing for you guys,” he added. What he meant was that as hard as the diagnostic imaging industry had been hit earlier in the year by reimbursement cuts — the field makes up only 10% of Medicare spending, but was a source of a third of the Medicare cuts in the DRA — it was not yet off the chopping block. A new health care bill, far from being the hoped for vehicle to carry a reversal of the DRA cuts, could instead include another 10% cut to diagnostic imaging services. “I think diagnostic imaging is going to continue to be a target,” Thornhill said. Switching Strategies   With such bleak prospects for a reversal, ACR and NCQDIS, together with their lobbyists and “Big Tent” coalition partners, such as the National Electrical Manufacturers Association (NEMA), are changing their strategies to try to buy time. On the heels of the NCQDIS lobbying event, the Access to Medical Imaging Coalition (new name for the “Big Tent” coalition) announced that Senator Gordon Smith (R-Ore) and Representative Joe Pitts (R-Pa) had agreed to sponsor bills in their respective chambers of Congress calling for a 2-year moratorium on the implementation of Section 5102 of the DRA—the portion of the Act that would reduce reimbursement to the lower of either MPFS or HOPPS—so that the issue could be studied further. At press time of this column, sources expected the legislation to be introduced in the next 10 days. While not as ideal as having the provision overturned completely, a moratorium is not a bad option, especially this year, said Liz Quam, director of the Center for Diagnostic Imaging (CDI) Institute in Minneapolis, Minn, and chair of the public policy committee of NCQDIS. “As my CFO says, ‘a moratorium is money in the pocket, too,’” she said. While in theory, the $8.6 billion less Medicare will spend on diagnostic imaging in coming years under the DRA Section 5102 are future savings, the reality is that the government has already spent that money to fund other programs and therefore the moratorium will “cost” it about $1.5 billion. This could be a stumbling block as this money would likely have to be found by cutting another part of Medicare, said Dan Boston, a representative of NCQDIS’s lobbying firm Health Policy Source Inc, in his presentation to NCQDIS’s members who came to Washington. However, “if Congress deems something a priority, they will find the cash,” he added. Pulling Out All the Stops To make sure that Congress does deem it a priority and also takes diagnostic imaging off the short list of services it may cut into further in the future, ACR, NCQDIS and the Access to Medical Imaging Coalition are working hard to build better relationships with policymakers. “We really need to create a dialogue,” Boston said. A legislator will naturally have a relationship with his personal physician or dentist who he will see at office visits, but unless he needs a special test, he will not meet a diagnostic imaging testing facility employee or owner. Therefore, those in diagnostic imaging need to “work a little bit harder,” Boston said. Quam described how at CDI she and others have not only held fund-raising events for their elected officials, but also put a lot of effort into personal communication to build these types of relationships. “It is not something you can write a check for,” she said. “It really is shoe leather.” On the “shoe leather” effort side, the groups involved with the Access to Medical Imaging Coalition may have a good start. The ACR drew more than 350 of its members to Washington between May 20th and 25th and recorded more than 250 meetings between members and their elected officials. The NCQDIS, which is a smaller organization, drew around 50 members to Washington, but recorded between 185 and 190 meetings with legislators on June 6 and was able to build on the groundwork laid by the ACR members’ meetings 2 weeks before. “Having never been to one of these meetings before, I had never realized that you could have an effect,” said Mark Stein, MD, a radiologist with offices in Irvine and Santa Ana, Calif, who attended the ACR meeting. The Access to Medical Imaging Coalition will also be working on gathering more financial data on practices’ real-world expenses for providing imaging services and how those compare with the MPFS and HOPPS rates in preparation for possible hearings on imaging reimbursement in the fall, wrote Keith Snyder, senior health policy analyst of Health Policy Source Inc, in an email. Gathering pertinent data and hard facts on the issue quickly will be key as there is a chance the 2-year moratorium, if it even passes, may be shortened to only 1 year for fiscal reasons. However, even a shorter moratorium is better than none at all as it gives the diagnostic imaging field more time to make its case to lawmakers. “I would be thrilled if next year I was standing up here fighting to extend the moratorium,” Boston said. Policymakers can be swayed when they truly understand the issue, but the MPFS and HOPPS comparison case is very complex and their time is limited, Thornhill explained. He urged NCQDIS members to use invitations to tour their centers and possible sponsored educational retreats for health legislative assistants to get longer meetings where the issue could be explained more fully than in 15-minute office visits with members of Congress and their staff. “I think the facts are on your side, so I would stick to them,” he said. Channeling Frustration   For those familiar with the issues within diagnostic imaging, it can be frustrating that a rule that treats MPFS and HOPPS as if the two payment methodologies were equal could possibly be viewed as a good solution to reducing Medicare costs—especially when the legislation does nothing to curb the part of rising diagnostic imaging testing costs due to self-referral situations where physicians may profit from ordering additional tests for their own patients. If private insurers and Medicare were only more educated about what they were buying and from whom when they purchased diagnostic imaging services, there could be legitimate savings, said Cherrill Farnsworth, executive director of NCQDIS. “If they do that, they don’t need to make cuts to radiology,” she added. Quam called the DRA a “meat cleaver” approach to controlling spending on diagnostic imaging. However, she, together with Farnsworth, also counseled patience to NCQDIS members who expressed frustration that under the “Big Tent” strategy they could not suggest to legislators an anti-self referral way to control imaging costs. “The reason we are part of the Big Tent is because we want to win,” she said. Likewise, complaining to legislators about how the cuts were added to the DRA at the last minute without a chance for the diagnostic imaging field to comment on them is a valid point but cannot be the only argument. “Whining about process will only get you so far,” she said. “You still have to have substance.” Grassroots Effort With less than 45 days of legislative business left before the November mid-term elections, an important part of that substance will likely need to come from grassroots lobbying where members of Congress will hopefully hear how the cuts may impact not only independent diagnostic imaging centers in their home districts, but also the Medicare beneficiaries they treat. Stein, for example, is concerned about mammography in his area of southern California, as his imaging group may have to stop doing these procedures if the DRA cuts go into effect. His imaging center group has found another diagnostic testing provider that may be able to take over their mammography patients, but that is not the case for many imaging centers across the country that are in the same situation of perhaps being unable to continue to afford to offer certain testing modalities. “Up to now, for the multimodality centers, some of the money that MR and CT have generated will no longer be available to keep the breast centers going,” he said. “The low-end stuff is going to go away. There are not many places you are going to have a chest X-ray done quickly anymore.” Out in Redding, Calif, MDimaging has already gotten a jump on the grassroots lobbying effort without waiting for direction from the major organized radiology groups. After New York radiologists independently helped convince Representative Carolyn McCarthy (D-NY) to introduce a resolution to eliminate section 5102 of the DRA, Amjad Rasheed, MD, a member of the executive committee of MDimaging, made sure his center did what it could to try to get his Republican House Representative, Wally Herger (R-Calif), who is a member of the House Ways and Means Committee to push for the McCarthy bill, which is currently before that committee. Herger had originally voted for the DRA, is not up for election this year, and would likely face the wrath of his party if he supported a Democratic bill, especially one that would “cost” $8.6 billion by eliminating a large chunk of the DRA’s savings on imaging. However, Rasheed is putting his faith in the power of the people. He has had MDimaging staff write letters and call Herger’s offices, both in Washington and in Redding. “We’ve been telling them our story and explaining to them what about the Deficit Reduction Act that we see as potentially a big problem for us,” he said. Out of MDimaging’s 17 radiologists, all but those who were out for vacation have sent letters and called, Rasheed said, and he is also asking MDimaging’s 150 employees—a large group for Redding which has less than 90,000 people—and their families and friends to get involved, too. In fact, he has even reached out to a historical competitor in a nearby community. “We’ve called them and asked them to call their congressman [Herger] as well and let their voices be heard. I think we need to unite on this one issue because this is really the survival of outpatient imaging. “Locally, there is no argument that this is not a good thing in terms of access to care as well as employment for our people, and we are just trying to get our Representative to understand that this bill does not help his constituents at all. And if he wants to do something that hurts his constituents, he is not really representing us.” Can a groundswell of grassroots optimism and enthusiasm, such as that held by Rasheed, combined with the pragmatism and political savvy of organized radiology groups and their paid lobbyists win a moratorium and a later reversal of the DRA cuts to diagnostic imaging? Time will tell. “We will see what happens,” Stein said. “It is going to be an interesting ride for the next 2 to 3 years.”