Your Undivided Attention

The June 2011 MedPAC Report to the Congress1 has the undivided attention of the entire specialty, just days after its release—for good reason. Pages 27 through 59 detail the commission’s recommendations to curtail further the amount of imaging occurring in medicine and to redistribute professional income from image-reading specialties to primary-care practitioners. There are some good ideas in the report, but there also are some bad ones. For instance, a good deal of time is spent detailing how Medicare might build a rather complex preauthorization system to tide us over until new payment forms and delivery models remove the incentives to overutilize imaging. Since we currently have a stimulus program that will lavish billions of dollars on health IT, doesn’t it make more sense to require computerized provider order entry (with built-in clinical decision support) for imaging than to build an expensive, overly complex legacy system to monitor outliers that would be obsolete within a few years? Although the commission acknowledges that the growth in imaging slowed to 2% between 2008 and 2009 (and it probably slowed even further between 2009 and 2010), MedPAC believes that further efficiencies can be achieved by eliminating unnecessary exams. It appears to be gunning for negative growth. Four Big Ideas MedPAC makes four recommendations to reduce spending further on imaging—and this time, the professional component is on the table. Space constraints allow just a brief outline of those recommendations. First, “The Secretary should accelerate and expand efforts to package discrete services in the physician fee schedule into larger units for payment.”1 MedPAC suggests that CMS consider lowering the bundling threshold a second time (it was just lowered from 90% to 75%), to include scrutiny of codes performed together less than 75%, but more than 50%, of the time. Second, “The Congress should direct the Secretary to apply a multiple procedure payment reduction to the professional component of diagnostic imaging services provided by the same practitioner in the same session.”1 Why wait for the RVS Update Committee and its time-consuming scientific approach to pricing medical services? MedPAC says that CMS should consider an across-the-board reduction in the professional component (as recently enacted for the technical component) for studies performed for a patient, on the same day, by the same practitioner. Reasoning that the physician gains efficiencies when he or she does not have to review the patient’s medical history, review the final report, and follow up with the referring physician twice, MedPAC suggests a discount on the second study. This makes sense, but may be difficult to apply to radiology workflow, since studies usually are routed by subspecialty and read as they show up in the radiologist’s queue. One concern would be derailing the quality-improvement trend in radiology that supports the review of more information rather than less, including laboratory results, physician notes, and other information in the electronic medical record. An unintended consequence of reducing professional rates could be the discouragement of an expanded consulting role for radiologists. Third, “The Congress should direct the Secretary to reduce the physician work component of imaging and other diagnostic tests that are ordered and performed by the same practitioner.”¹ Throughout its report, MedPAC underscores the relationship between self-referral and overutilization, but confesses to a reluctance to tighten the in-office ancillary exception because it does not want to constrain accountable-care organizations—when (and if) they ever materialize—from including imaging. What it does propose is to discount imaging reimbursement for practitioners who both order and interpret an exam, to account for the efficiencies gained in not having to review the patient’s medical history (since that took place during the office visit), review the final report, and follow up with a referring physician. This makes sense. Fourth, “The Congress should direct the Secretary to establish a prior authorization program for practitioners who order substantially more advanced diagnostic imaging services than their peers.”1 MedPAC recommends instituting a prior-authorization program for outliers who fail to change their behavior after participating in a prior-notification program. Only those physicians who are identified as overutilizers would be required to participate, although MedPAC acknowledges the difficulty of adjusting the averages to account for differences in population. It also suggests that providers could use a decision-support system, if it syncs with the appropriateness criteria used by CMS. Even though the Patient Protection and Affordable Care Act mentions use of a radiology benefit management company, MedPAC notes that Congress will have to enact legislation to ensure the constitutionality of the program. MedPAC projects that the program could save under $50 million in the first year and less than $1 billion over 5 years, including the cost of developing and managing a prior-authorization process. In the months and years ahead, radiology will need to do its part to help Medicare shave costs by submitting to appropriate reimbursement adjustments, but radiologists owe it to their specialty to ensure that those adjustments are reasonable. Today, however, radiology has arrived at a defining moment: It is now or never. What are you going to do to take control of the overutilization problem? If radiologists had been willing to accept the responsibility for imaging appropriateness rather than worrying about alienating referring physicians, then MedPAC might be talking about gutting a different specialty.