ACR concerned pay cap on CT-based colon cancer screening could make service ‘untenable’
The American College of Radiology is expressing concern about a potential Medicare pay cap on CT-based colon cancer screening.
In July, the federal payment program proposed covering this vital imaging exam, which serves as an alternative to colonoscopies that require sedation. ACR previously praised the policy update after lobbying for it since 2008.
However, in its detailed analysis of the policy, submitted to the Centers for Medicare & Medicaid Services Sept. 6, the college criticized plans to subject CT colonography to the Deficit Reduction Act. According to this federal policy, the technical component of imaging services paid under the physician fee schedule are capped at the amount reimbursed through the Hospital Outpatient Payment System ($106.3), rather than $566.22 for the technical component.
This reduction of $459.92 (or 81.2%) will make it “untenable for many radiologists to provide CTC,” charged CEO Dana Smetherman, MD, MBA.
“Therefore, while the ACR is appreciative that CMS is changing its longstanding policy by proposing to pay for screening CTC under the colon cancer screening benefit, the proposed coverage change will have limited benefit unless CMS can provide payment for screening CTC under the [physician fee schedule] rate that makes it viable to perform,” she wrote to CMS Administrator Chiquita Brooks-LaSure.
ACR noted that the logic behind the Deficit Reduction Act provision is that the hospital cost of a service should always be greater than physicians’ for imaging services. But this assumes that the physician payment must be too high, rather than the hospital outpatient one too low. The ACR “does not believe this is the case with CT, MRI and other advanced diagnostic imaging services, including CTC, where the OPPS payment is well below the resources required to perform the test,” Smetherman wrote.
A potential long-term remedy would be to eliminate the Deficit Reduction Act cap for imaging services. This would allow for resource-based payment for screening CTC and other radiological exams paid under the physician fee schedule. As a “complementary solution,” the college also is requesting that Medicare default all costs and charges under the outpatient schedule to a single diagnostic radiology cost center and not use the CT- and MRI-specific ones for valuing outpatient and inpatient services.
“The ACR recognizes that CMS cannot adopt the first of these two solutions as it would require a statutory change that could only be enacted by Congress,” Smetherman wrote. “However, the ACR requests that CMS pursue the second of these solutions in the 2025 [Outpatient Perspective Payment System] final rule.”
Another possible short-term solution, she added, would be to not apply the cap to screening services such as CT colonography. Medicare already does this for screening and diagnostic mammography, and it is unclear why Congress decided to do this only for breast cancer imaging. ACR speculated this could stem from concerns about the potential impact on such breast cancer services. Smetherman charged that the same logic should apply to CTC, given the prevalence of the disease. Colorectal cancer is the leading cancer killer among men under 50 and No. 2 on the list for women of the same age.
Black Americans are 20% more likely to develop the disease and 40% likelier to die from it, according to the American Cancer Society. ACR believes capping payment for CTC—a critical option for those who cannot take off work to get screened—may only deepen disparities.
“The proposed payment of $106.30 would make the provision of screening CTC financially unviable for many imaging practices which could disproportionately affect underserved communities and exacerbate colorectal cancer disparities in diagnosis and early treatment,” ACR noted. “A payment of $566.22 will encourage the provision of screening CTC and contribute to early identification and treatment of colon cancer to the better of patients and our healthcare system.”
ACR also is urging Medicare to pay for any necessary follow-up colonoscopy after a covered CTC exam. Removing cost-sharing for colonoscopies after abnormal CT colonography results would help to “meaningfully increase access to care across the full continuum of colorectal cancer screening and will save lives,” ACR added.
The college highlighted its concerns about CTC coverage in a news update published Thursday.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.