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For other articles and previous issues click here. May 30, 2005 Controlling
Interest — Imaging’s Growth Creates Competition and
Cost Concerns A study by the independent Medicare Payment Advisory Commission (MedPAC) found that between 1999 and 2002, the volume of imaging services provided to Medicare patients grew by an average of 9% per year. That’s more than four times the 2% growth rate MedPAC found for evaluation and management services and more than double the 4% growth rate it saw for medical procedures. Similarly, in October 2003, the Blue Cross and Blue Shield Association reported that from 1999 to 2001, its costs for outpatient diagnostic imaging increased by 18% while per-member-per-month costs for CT and MRI services rose a staggering 45% to 47% over the same period. Radiologists and their physician colleagues in other specialties differ over the significance of the increased utilization of diagnostic imaging—especially in the higher-cost modalities, CT, MRI, and PET—and what, if anything, should be done to control it and the associated charges. The American College of Radiology (ACR) and MedPAC favor developing quality control and educational standards for those who perform and interpret imaging studies. Those physicians who would meet the standards might be known as designated physician imagers (DPI), or some other term, but only such physicians could be reimbursed by Medicare for CT, MRI, and PET procedures. Such an approach would control escalating costs by making it harder for nonradiologists, especially those entrepreneurs who promote office-based medical imaging, to qualify for Medicare reimbursement, says James Borgstede, MD, FACR, chair of the ACR Board of Chancellors. Who Should Image? Borgstede worries that if nothing is done to control expenditures for diagnostic medical imaging, Medicare will make drastic across-the-board cuts in reimbursement, driving out not only the entrepreneurs but also long-time, quality imagers. In a follow-up interview, Borgstede paints a bleak scenario. If across-the-board cuts were implemented, hospitals, entrepreneurs, and manufacturers could focus on and invest in other departments or services, but radiologists who do imaging exclusively could not afford to practice. “No one would do research or development or have money to invest in updating their diagnostic equipment. It would be a disaster for quality patient care,” he says. However, a national coalition of more than 20 physician and medical groups that use in-office imaging as part of their diagnosis and treatment regime has formed to challenge any attempt by Congress to limit who can be reimbursed for performing and interpreting higher-cost diagnostic images before Congress studies all the issues. Kim Allan Williams, MD, FACC, FAHA, FCCP, a professor of medicine and radiology at The University of Chicago, is a spokesman for the Coalition for Patient-Centered Imaging (CPCI), which includes the American College of Cardiology, the American Society of Nuclear Cardiology, the American College of Obstetricians and Gynecologists, the American Gastroenterological Association, the American Urological Association, and the American Academy of Neurology. Too Much of a Good Thing? “It’s ironic,” he says in an interview after his testimony, “that you get to the point where you can do things well thanks to diagnostic imaging and then you have it questioned because it costs a lot.” Each side sees the issues—which are economics, patient safety, and convenience—differently. Borgstede and the ACR believe much of the problem of runaway growth in diagnostic imaging relates to self-referral. The federal Physician Self-Referral Act—commonly known as Stark II for its author, Rep. Fortney “Pete” Stark (D-Calif.)—was enacted in 1993 and amended in 1995. The law prohibits physicians from referring Medicare or Medicaid patients to facilities in which they or their family members have a financial investment. However, the law allows exceptions for in-office ancillary services, which means that members of a group practice can refer patients for imaging or other ancillary services in facilities they own and operate as a part of their regular office practice. Multiple Issues “It seems to me that a lot of this growth is economically motivated imaging rather than imaging that needs to be performed,” Borgstede says. Patient safety is also at risk here, Borgstede adds. If physicians are financially motivated to order tests, patients are being unnecessarily exposed to radiation. Borgstede believes that if Congress sets quality and safety standards for providers performing medical imaging and physicians interpreting it, it would curtail physicians who are economically motivated to order diagnostic tests. Requiring those who do imaging to have a minimum number of continuing medical education credits, perform a minimum number of exams per year, and have accredited facilities that are regularly inspected, “would set hurdles the entrepreneurs would not be willing to jump,” Borgstede says. Unfortunately, Borgstede says, the equipment many entrepreneurial nonradiologist physicians currently invest in is rarely, if ever, subject to any accreditation or inspection process. The ACR is not suggesting that only radiologists be allowed to perform and interpret diagnostic images. “What we’re saying is that people who perform imaging services must be able to demonstrate quality,” Borgstede says. While Borgstede doesn’t see the issue as a turf battle, he says radiologists are the most qualified of all medical specialties to perform and interpret diagnostic images. Diagnostic radiologists are required to complete a minimum of four to six years of post-medical school education in all aspects of medical imaging. Their education includes formal training in advanced physics and radiation safety. Other medical specialties performing medical imaging may have from as little as two days to no more than 10 months of imaging education, Borgstede says. Education and training is particularly important in the high-end imaging modalities, he says. “CT scans can produce hundreds and hundreds of images. You have to know not only how to set up equipment to produce a quality image but also how to interpret those images. It’s not merely understanding the body part from a clinical perspective.” The ACR believes the problem of increased utilization is not merely a shift in the site of services from hospital to office settings—as its opponents claim. “If you look at imaging measured in number of procedures and dollars per 1,000 beneficiaries, you’ll see it has increased significantly in both hospital and office settings since 2000,” Borgstede says. Convenience “If you look at Medicare billing data, only 3% of imaging procedures done by nonradiologists are billed on the same claim as the office visit,” Borgstede says. “That would imply that the imaging is done at a different time. The idea of patient convenience doesn’t hold water. If the patient is coming back for imaging, where is the convenience?” Borgstede believes that if Congress were to follow through and enact facility accreditation and personnel certification requirements, Medicare could save up to $4 billion over the next decade. “This would be a major step in protecting the solvency of this important taxpayor-supported program and ensuring that Americans are receiving the highest quality care from the physicians most qualified to provide imaging services,” he told the House committee. Another approach to solving the problem would be repealing the provision of the Stark law that allows for in-office ancillary exceptions. However, Borgstede says, Congress does not appear likely to favor that solution. Kim Williams of the CPCI says radiologists are misplacing the blame for rising utilization of diagnostic imaging. It’s a number of factors, none of which is imaging by specialists rather than radiologists, he says. Defensive Medicine A more important driver, he says, is the fact that integrating imaging into patient diagnosis and treatment improves patient outcomes. The increased utilization is because physicians like himself, a cardiologist and nuclear medicine specialist, are making more use of the latest technologies. “Medical imaging allows us to advance patient care in ways that were not possible 10 years ago,” he says. “When specialists conduct diagnostic exams in their offices, they can read the images immediately to expedite diagnosis and begin treatment. The result of in-office imaging has been better health outcomes for patients with acute conditions and better maintenance and treatment for those with chronic conditions.” Williams doesn’t buy the safety argument that radiologists are more qualified to interpret exams than specialists. The ability of a physician to interpret a diagnostic image cannot be determined based exclusively on the physician’s specialty, he says, but rather on the specific training in that imaging modality. Radiologists may be good at understanding all kinds of imaging, but specialists have detailed knowledge of the organ or systems being imaged and have the expertise to interpret the exams they need, he says. “The specialists really know the organs they deal with in a way that is always going to make them better suited to understand exactly what is going on in that image and to base their treatment on those images,” Williams says. “It’s part of the specialty training and focusing on the organ that makes them good at what they do.” Some specialists don’t always trust readings from radiologists as much as they trust those read by clinician-imagers, Williams says. He says radiologists need to meet the challenge of giving clinically useful results to the specialists and not just listing the findings and saying, “Please correlate clinically.” Some recent initiatives, such as setting up centers of excellence for cardiac imaging for radiologists to obtain further training, should help get this process started, he says. Convenience is indeed an issue, Williams argues. Patients recognize that their specialists are trained and want them to be able to perform medical imaging in their offices. A poll conducted for the CPCI by Fabrizio, McLaughlin & Associates found that 85% of consumers believe they should have the option of having their medical imaging done at their specialists’ office. Furthermore, to argue that equipment used by nonradiologist physicians in their offices is in any way unsafe does not make sense, Williams says. Various aspects of medical imaging equipment safety are regulated by the Nuclear Regulatory Commission, the FDA, the Occupational Safety and Health Administration, and state authorities. Besides, Williams told the committee, there is “no credible, published, peer-reviewed literature documenting safety concerns arising from the use or misuse of diagnostic imaging.” Self-Referral “If we were to restrict imaging,” he adds, “you may find out that many of the critical gains that we have made in cardiovascular mortality get reversed.” Williams says those arguing for restrictions shouldn’t be looking at how much is being spent overall, but the value of those expenditures. Medicare could be spending more for diagnostic imaging but less on surgery and patient care because the problem, thanks to the proliferation of imaging, is identified up front and the proper course of treatment begun sooner. Williams says more research is needed on the causes of the rise in utilization of imaging. “We have to go about this in a very careful, data collection-type mode, as we do all scientific research and medical practice,” he says. “If you’re going to make some government policy, you want it to be sound policy based on sound data and not someone saying, ‘Hey this looks like it’s too much!’” It’s also important to understand that the greatest increases are in the higher technologies, such as CT and MRI, areas that are already dominated by radiology, Williams says. Radiologists are trying to tell Congress this is not a turf battle, but it certainly is, Williams says. The real problem is that radiologists are concerned about their future and perhaps rightfully so. “If neurologists take the brain, cardiologists take the heart, [and] orthopedists take the joints, [then] the next thing you know the radiologists have little to do.” The best models for practice, Williams says, seem to be where clinical imaging specialists and radiologists work together and make each other stronger. The House Ways and Means Subcommittee on Health is chaired by Reps. Nancy Johnson (R-Conn.) and Stark. There’s no word on when Congress may act, if at all, on MedPAC’s and ACR’s recommendation to enact imaging standards. — Beth W. Orenstein of Northampton, Pa., is a freelance medical writer and frequent contributor to Radiology Today. |
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