MedPAC recommendations get it wrong on imaging, says MITA

The Medical Imaging & Technology Alliance (MITA) said the Medicare Payment Advisory Commission’s (MedPAC) March 2017 report to Congress misrepresents the growth in imaging utilization, a criticism consistently levied by imaging advocates against MedPAC over the past decade.

The report, entitled “March 2017 Report to the Congress on Medicare Payment Policy,” recycles past statements about medical imaging resource consumption without presenting new data or evidence, according to MITA.

“The latest MedPAC report fails to take into account the many new advances in imaging technologies that, when used appropriately, are proven to help prevent costly, invasive procedures down the road,” said Patrick Hope, executive director of MITA. “Rather than again pursuing arbitrary cuts to reimbursement for these procedures, an evidence-based approach rooted in appropriate use criteria (AUC) is the best policy solution to guide utilization and ensure optimal results for patients.”

MedPAC has called on Congress to reduce imaging reimbursement since at least 2011, when they recommended Congress pass legislation placing restrictions on doctors who order substantially more exams than their peers.  

"In the last decade, ancillary services have reached high levels of use, fueled at least in part by unduly high payments," MedPAC said in a 2011 press release.

The crux of their argument is the rise in imaging utilization since the beginning of the millennium. While it’s widely acknowledged the amount of CT and MR procedures per-capita increased for a time, several studies have asserted the growth slowed by 2007 and has been in decline since 2009, and MedPAC isn’t taking those evaluations into account.

“Yes, imaging utilization is up from 2000, But it peaked several years ago, and is now holding stable (CT) or continuing to decline (MR),” wrote Rich Duszak, MD, Affiliate Senior Research Fellow at the Harvey L. Neiman Health Policy Institute. “The reasons for this downturn are many, but align with the American College of Radiology’s Imaging 3.0 initiatives to improve communication, carefully consider cost and radiation dose, and pursue real-time clinical decision support tools.”

Another analysis indicated the slowdown in imaging started in the Medicare population but extended to the non-Medicare, commercially insured population by 2009. Higher cost sharing, prior authorization, reduced reimbursements, and the fear of radiation are countering nonmedical incentives to order an imaging study, according to Levy et al. This illuminates a little explored method to reduce unnecessary imaging, they said.

“Comparative effectiveness research can improve guidance for physicians but is unlikely to neatly distinguish necessary from unnecessary applications.  Identifying and reducing the nonmedical incentives driving utilization is a complementary approach to improved research," the authors wrote. “The current move toward bundled payments can be seen as a particular version of this strategy, countering nonmedical incentives by putting an opportunity cost on a procedure’s use.”

Instead, the 2017 MedPAC report continues to use old data and outdated methodologies to justify their recommended reimbursement cuts. Imaging reimbursement has already been hit hard since 2006, with some payments reduced by more than 60 percent.

“As an alternative to further indiscriminate reimbursement cuts, and to enhance patient safety by preventing exposure to unnecessary radiation, MITA has long advocated for the implementation of physician-developed appropriate-use-criteria (AUC) to guide decision-making,” MITA said in a press release. “For example, one study from the Cleveland Clinic demonstrated how incorporating single-photon emission computed tomography (SPECT) appropriate use criteria into electronic records helped a group of primary care physicians and cardiologists determine when to order specific imaging tests.”