The New Era of Medical Imaging — Progress and Pitfalls
http://www.100md.com
《新英格兰医药杂志》
Rapid advances in biomedical imaging have greatly enhanced the ability of physicians to diagnose and treat a variety of diseases. This enhanced ability often leads to improved outcomes for patients. However, these improvements, combined with a rise in entrepreneurial activity by physicians, the practice of defensive medicine in order to thwart malpractice suits, and the power of patients who demand more tests, have led to sharp increases in the volume of imaging services and the expenditures for them. In recent years, this growth in spending has outstripped that of most other services covered by Medicare and private insurers. In response, many private insurers have narrowed their provider networks, required that selected imaging services be authorized in advance, and imposed other constraints to stem what they assert is, in some cases, unnecessary testing. Medicare has been slower to respond, but in February Congress shocked the imaging community by approving steep reductions in Medicare payments for certain imaging services beginning in 2007. These savings to Medicare were more than offset when, in the same measure, Congress repealed a scheduled reduction of 4.3 percent in Medicare's payments for all physician services and replaced this reduction with a one-year freeze on these payments. President George W. Bush signed the measure into law February 8.
This report reviews the impressive rise of new imaging techniques as useful clinical tools and discusses two provisions enacted by Congress that will sharply reduce Medicare payments for some imaging services by an estimated $2.8 billion over a five-year period. The Medicare Payment Advisory Commission (MedPAC) provided most of the information on trends in imaging that prodded Congress to examine the program's payment policies in relation to these imaging services. The work of this commission will also be discussed.1
The Rise of Medical Imaging
Dramatic improvements in imaging technology account for much of the rapid increase in the volume of these services and in the expenditures for their use. This growth has accelerated across virtually all clinical specialties. By offering these imaging services, specialists outside the field of radiology have invaded the territory that once was almost the exclusive preserve of radiologists. As a result, a turf war has broken out between radiologists and other specialists, particularly cardiologists. According to MedPAC, between 1999 and 2004, the growth in the volume of imaging services per Medicare beneficiary outstripped the growth of other services provided by physicians (Figure 1).1 According to the commission, by 2003, the share of Medicare payments to radiologists for imaging services had declined to 45 percent while the share received by cardiologists had surged to 25 percent. In 2004, the cost of imaging services reimbursed by all health insurers and paid for out of pocket by patients amounted to close to $100 billion, or an average of approximately $350 per person in the United States.2
Figure 1. Growth in the Volume of Physician Services per Beneficiary, 1999–2004.
Volume is measured as units of service multiplied by each service's relative value units from the physician fee schedule. Analysis includes claims for 100 percent of Medicare beneficiaries for all 12 months of each year. Evaluation and management service includes office visits and hospital visits. The category "Tests" excludes imaging.
Much of the rapid growth in imaging services is attributable to the expanded use of computed tomography (CT), magnetic resonance imaging (MRI), and ultrasonography; the emergence of more sophisticated models of these forms of technology; and the value that physicians attach to adding these tools to their standard of practice for diagnosing and treating diseases.3,4 For example, physicians are using CT in emergency situations to diagnose pulmonary emboli and appendicitis5 and to rule out heart attacks. Physicians are also using MRI, which was once mostly limited to the conduction of neurologic tests, for full-body scanning and studies of the musculoskeletal system, liver, adrenal glands, and kidneys.6 The use of positron-emission tomography has greatly expanded, too, particularly in oncology, and this type of imaging is being used to test for Alzheimer's disease and other degenerative diseases of the central nervous system.7 Insurers continue to ask whether the rapid rise in expenditures for imaging studies is leading to improvements in patient outcomes that equal or surpass the greater costs associated with providing these services.
Private and public insurers currently offer virtually unlimited coverage for imaging services, notwithstanding the new controls that private carriers began to apply several years ago. The federal government also invests substantial sums in imaging research. In 2000, Congress authorized the creation of the National Institute of Biomedical Imaging and Engineering, which currently has an annual budget of $299.8 million.8 The Departments of Defense, Energy, and Veterans Affairs also finance imaging services and conduct imaging research.
In an appearance before the House Appropriations Subcommittee on Labor, Health and Human Services, and Education on March 9, 2005, Dr. Roderic I. Pettigrew, director of the National Institute of Biomedical Imaging and Bioengineering, testified that recent advances in imaging techniques have "radically expanded" the capacity of physicians to diagnose and treat disease. In testimony, Pettigrew said:
Imaging devices such as computerized tomography, magnetic resonance imaging, and ultrasound allow physicians to see and diagnose disease that is hidden from normal view. On-line guidance during treatment of surgery, a concept referred to as image-guided interventions, will be the next step in reducing the trauma and improving the effectiveness of surgical procedures. Image-guided interventions, coupled with minimally-invasive treatments — which require only a small incision, or, in some cases, no incision — result in less damage to critical organs, less postoperative pain, fewer surgical complications, shorter hospital stays, lower health care costs, and fewer work days lost.9
The rapid growth in the volume of advanced imaging services has been driven by these advancements and by physicians who have an interest both in supplementing their professional fees with revenues from ancillary services and in enabling patients to receive imaging services conveniently in their doctors' offices, where study results become available to them more rapidly than in other settings. The number of physicians who have acquired advanced imaging equipment for their offices or who have invested in freestanding facilities is not readily available. During the past decade, the number of freestanding diagnostic imaging centers owned by radiologists, other specialists, private investors, or for-profit companies has more than doubled from approximately 2500 to 5760 (Jenkins S, Sg2: personal communication).
The movement of imaging services to both freestanding centers and the offices of physicians is part of a larger trend — doctors are also opening ambulatory surgical centers and specialty hospitals to which they often refer their patients.10,11,12,13,14,15 These developments have upset physicians' relationships with hospitals and set off turf wars between radiologists and other specialists, some of whom have acquired imaging machines in their offices and are obtaining the necessary training to conduct studies and interpret their results without consulting a radiologist.16,17 Until recently, Congress paid little attention to the rapid rise in expenditures for imaging services and the Centers for Medicare and Medicaid Services (CMS) was slow to respond. Most of the publicity about the rise in costs has come through occasional newspaper articles that have focused on the proliferation of imaging equipment in selected markets and reported on schemes used by private companies to persuade physicians, through the use of financial incentives, to refer their patients to for-profit imaging centers owned by these companies.18,19,20,21,22,23
The Role of MedPAC
Given the multiple roles played by government in health care services — in this case as a payer of imaging services and supporter of imaging research — it is not surprising that its many entities hold multiple perspectives on issues such as imaging. In this case, MedPAC, which consists of 17 part-time members and a full-time staff with a broad mandate to advise Congress on issues that affect the program, took the lead in recommending new policies that relate to imaging services. In its March 2005 report, MedPAC acknowledged that in many instances, "imaging technology can improve patient outcomes by allowing greater precision in diagnosing and treating patients."1 After citing several examples, MedPAC's report added:
Despite such successes, however, evidence exists of overuse, underuse, and misuse of imaging services. Perhaps the most significant reason to be concerned about potential overuse of imaging services is the threefold variation in the number of imaging services provided across the country. This difference is twice that seen in the use of major procedures.24,25
MedPAC then asked, "Are regions that provide more imaging services improving patient outcomes?" No, it asserted. This conclusion is no different than that of most research that has been unable to determine whether, when additional resources are expended for imaging or any other health care service, better outcomes for patients necessarily result.
To underscore the growing concern in Congress over the rise in expenditures for imaging, on March 17, 2005, the House Ways and Means Subcommittee on Health held a hearing on managing the use of imaging services. Its first witness was the executive director of MedPAC, Mark E. Miller. Miller testified that, during the period from 1999 through 2003, the volume and complexity of imaging services grew by 45 percent, more than twice as fast as all physicians' services, which grew by 22 percent during the same period. Other issues registered by Miller included the absence of a clear link between the delivery of more imaging services and better outcomes for patients, a wide variation in the quality of images that are produced and their interpretations, and the reduction in standards of quality that apply when imaging services are delivered in physicians' offices as compared with hospitals.
Next, Miller outlined the policy recommendations of MedPAC, and he noted that they were approved unanimously by the 16 commission members who were present. The commission recommended that Congress direct the secretary of the Department of Health and Human Services to set quality standards for all providers who bill Medicare for performing diagnostic imaging services and interpreting these diagnostic tests. They also recommended that the secretary should measure physician use of imaging services "so that physicians can confidentially compare their practice patterns with those of their peers"26; that the secretary should expand the National Correct Coding Initiative of the CMS to improve the initiative's ability to detect improper claims for imaging services; that the secretary should reduce payments for multiple procedures for imaging of contiguous body parts; and that the secretary should strengthen the rules that govern the investments that physicians may make to facilities to which they refer Medicare patients.
The commission's recommendation that Medicare require physicians to meet standards in order to receive payment for interpreting imaging tests would be a major policy shift for the program. Medicare generally covers medically necessary services provided by physicians who are operating within the scope of practice of the state in which they are licensed, without regard to their specialty. The commission asserted that if its recommendation was adopted, "this policy should improve diagnostic accuracy and treatment. It should also help control the growth of imaging spending by restricting payment for interpretation to only qualified physicians."1 The CMS would probably need to seek authority from Congress to pursue this new policy, but as the commission noted, "there is a precedent. In 1992, Congress gave the FDA (Food and Drug Administration) authority to set standards for physicians who read mammograms."
New Medicare Policies Regarding Imaging
Last December, in a rush to adjourn and desperate to identify budget savings that would begin to pare the vast federal deficit, a Republican-controlled House–Senate conference committee that included no Democrats accepted only one of MedPAC's recommendations that related to imaging services. However, the committee also adopted a second imaging-related provision on the basis of a recommendation put forward by the CMS; this provision will lead to far larger reductions in Medicare payments than the reductions included in MedPAC's proposals. The provisions were contained in an omnibus bill that authorized overall reductions of $39.7 billion in federal spending during the next five years.
The provision recommended by MedPAC will, beginning in 2007, reduce by 50 percent the payment for the technical component of the second or subsequent imaging of contiguous body parts in the same imaging session. (A physician whose office both performs an imaging study and interprets the results of that study submits a bill that includes two components — one technical and one professional.) For example, currently, Medicare's allowable payment is $980.41 for a freestanding facility's MRI of the abdomen. Medicare's allowable payment is $530.57 for an MRI of a patient's pelvis that is performed during the same session. This payment would be reduced by 50 percent under the new policy. The provision was based on the premise that savings in clerical time, preparation, and supplies occur with multiple studies of contiguous body parts with the use of the same type of imaging technique during one visit with a patient.
The more controversial provision stipulates that rates of payment for imaging services delivered in physician offices must not exceed rates of payment for the same services provided in hospital outpatient departments. Until now, payments for services delivered in these different settings were calculated through separate fee schedules. In some instances, the physician fee schedule that applied to services delivered in non-hospital diagnostic imaging facilities allowed higher Medicare payments on the basis of a calculation of the costs incurred in providing the service. Effective January 1, 2007, as a result of this new law, payments will be reduced by more than half for many of the billing codes that doctors use most frequently when they charge Medicare for providing imaging services outside of hospitals. For example, the technical component of MRI of a patient's brain is one of the billing codes most heavily used by physicians who provide imaging services. Medicare's payment for this service delivered in a non-hospital diagnostic imaging facility currently is $995.19, as compared with $506.26 if it is billed at the rate allowed if the same service is delivered in a hospital outpatient department and paid under Medicare's separate payment system. Under the new law, the rate allowed for this same MRI in a non-hospital diagnostic imaging facility would be $506.26, or 49.1 percent less. The imaging community was caught off guard by the provision because, after the proposal was recommended by the CMS, its contents were not shared except with a few House and Senate conferees, and it was approved in a closed session without a dissenting voice.
The American College of Radiology (ACR) and the American College of Cardiology (ACC) both opposed the provision that reduced Medicare's payments for certain imaging services. Members of the ACR were the most vocal in their opposition; they called the payment reductions "broad-based and indiscriminate" in a letter that was sent to every member of Congress. The letter, dated January 10, 2006, and signed by Dr. James P. Borgstede, chair of the ACR's Board of Chancellors, added:
Most troubling to me is that this capricious policy was incorporated into the conference report without any consultation with the numerous physician and patient stakeholders that would be affected by its implementation. This legislative `slight of hand' was performed despite the ACR's good-faith efforts over the last year to work with the policy for diagnostic imaging reimbursement that would require all facilities and physicians, regardless of their specialty, who provides those services to meet mandatory federal quality and safety standards.
Specialists Divided over Imaging
Organized medicine is divided over many issues related to imaging services. This lack of consensus has weakened its influence on policy regarding imaging and complicated the task of policymaking by Congress and the executive branch. The conflict pits radiologists against other specialists — particularly cardiologists — but also neurologists, oncologists, and orthopedists who have acquired their own advanced imaging equipment and now perform imaging studies in their offices. Radiologists perform, supervise, and interpret imaging studies ordered by other physicians and, as a rule, do not generate demand for initial consultation, although they do often suggest additional testing. Physicians who are not radiologists, yet who perform and interpret imaging studies in their own offices, are in a better position to influence the volume of imaging performed.
The issues on which physicians differ were clearly evident at the past two annual meetings of the American Medical Association. In both 2004 and 2005, its house of delegates overwhelmingly approved resolutions that put the association on record against any effort to ban or discourage the delivery of imaging services in physician offices or that sought to repeal the "in-office ancillary services exception" under the federal anti-kickback law; this exception allows doctors to provide imaging services in their own offices. The ACR opposed the adoption of both of these resolutions. With Republicans in control of Congress, there is no likelihood that this exception will be entirely removed, although it could well be refined as concern about the referral of patients by physicians to facilities in which they hold an ownership interest continues to fester.27,28 For example, Medicare recently added nuclear medicine to the list of services that, starting in 2007, physicians may no longer provide in facilities they own.
The conflict between radiologists and other specialists was also pronounced in the testimony delivered by representatives of the ACR and the ACC before the House Ways and Means Subcommittee on Health in March 2005. Borgstede said the ACR was
deeply concerned with the exponential growth in office-based imaging by those who may lack the education, training, equipment, and clinical personnel to safely and effectively use these studies to better their patients' health. . . . For this reason, the ACR supports many of the MedPAC recommendations that link Medicare reimbursement to quality, safety, and training standards for physicians and facilities which provide medical imaging services. Private payers such as United HealthCare, Anthem, and Blue Cross and Blue Shield have already enacted similar guidelines with little additional burden on physicians to comply with these quality measures and no decline in patient access to care.26
In testimony immediately after Borgstede's statement, Dr. Kim Allan Williams, representing the ACC and 20 other health organizations that compose the Coalition for Patient-Centered Imaging, said:
Let me begin by saying that we do take exception to the concept implied by MedPAC that physician specialists are providing substandard care for their patients by providing poor-quality medical imaging in their offices. There is really no credible evidence to support that notion. We agree with MedPAC that safety and patient quality of imaging are of utmost importance, and we agree with the fact that there needs to be careful study of the growth in medical imaging services. But let's keep safety and quality in the in-office medical imaging as the focus, not the agenda of one physician group or another.26
Conclusions
With the new assault on the growth of Medicare spending overall by the administration of President George W. Bush, the rapid increase in expenditures for imaging studies will remain a highly visible target, although the proposed 2007 budget does not contain any specific provisions that would further reduce payments for imaging. Meanwhile, MedPAC is preparing to accelerate its plan to recommend refinements of Medicare's physician fee schedule. The commission is making its recommendations on the basis of the belief that the overpricing of some services, including imaging services, has been a factor in the rapid increase in their use.29 In the private sector, the imaging community has begun to take steps to better document the quality of the services it provides. Imaging experts, gathered recently in Washington, D.C., by the ACC and Duke University, initiated efforts to develop new metrics to measure quality. According to one of its sponsors, the conference achieved this goal with agreements by the ACC and each of the cardiovascular imaging societies to place quality at the top of their agendas (Douglas P, Duke University: personal communication). There also is a growing recognition that the clinical effectiveness of new forms of imaging technology should be investigated and proved before they are used widely. General Electric, the largest manufacturer of imaging equipment in the United States, recently announced its intention to sponsor clinical trials that will reach beyond earlier industry-sponsored trials. These trials focused mostly on the quality of the actual images to test the clinical effectiveness of new forms of technology such as new CT techniques to image the heart and breast (Clarke W: personal communication).
The importance of advanced imaging technology to the practice of medicine has been heralded by physicians,2,3,30 and its greater availability in physicians' offices is supported by the public.31 As insurers reduce their rates of payment and tighten the management of imaging services, the acquisition of advanced imaging equipment by physicians, hospitals, and for-profit companies that own independent diagnostic imaging facilities could slow. Although new efforts to better account for the quality of imaging services and their clinical effectiveness are steps forward, these pursuits will be hampered as long as the turf wars between radiologists and other specialists continue apace. These struggles also will dilute the power of the imaging community as it seeks to persuade Congress that Medicare policy should be hammered out through thoughtful deliberations among all of the stakeholders rather than in hasty private discussions driven by an imperative to slash federal spending.
No potential conflict of interest relevant to this article was reported.
Source Information
Mr. Iglehart is a national correspondent for the Journal.
References
Report to the Congress: Medicare payment policy. Washington, D.C.: Medicare Payment Advisory Commission, 2005.
Farnsworth C. Testimony March 17, 2005, before the House Ways and Means Subcommittee on Health. Washington, D.C.: Committee on Ways and Means, 2005.
Looking back on the millennium in medicine. N Engl J Med 2000;342:42-49.
Fuchs VR, Sox HC Jr. Physicians' views of the relative importance of thirty medical innovations. Health Aff (Millwood) 2001;20:30-42.
Raman SS, Lu DS, Kadell BM, Vodopich DJ, Sayre J, Cryer H. Accuracy of nonfocused helical CT for the diagnosis of acute appendicitis: a 5-year review. AJR Am J Roentgenol 2002;178:1319-1325.
Special report: imaging: the race is on. Chicago: Tiber Group, 2003.
Juweid ME, Cheson BD. Positron-emission tomography and assessment of cancer therapy. N Engl J Med 2006;354:496-507.
Morgan D, Babcock CR. Medical groups win budget boon: late congressional moves provide increased funding. Washington Post. December 26, 2000:A1.
Pettigrew RI, National Institute of Biomedical Imaging and Bioengineering. Testimony on fiscal year 2006 budget request, March 9, 2005, before the House Appropriations Subcommittee on Labor-HHS-Education. (Accessed June 8, 2006, at http://www.nibib.nih.gov/About/BudgetLegislation.)
Iglehart JK. The emergence of physician-owned specialty hospitals. N Engl J Med 2005;352:78-84.
Guterman S. Specialty hospitals: a problem or a symptom? Health Aff (Millwood) 2006;25:95-105.
Greenwald L, Cromwell J, Adamache W, et al. Specialty versus community hospitals: referrals, quality, and community benefits. Health Aff (Millwood) 2006;25:106-118.
Stensland J, Winter A. Do physician-owned cardiac hospitals increase utilization? Health Aff (Millwood) 2006;25:119-129.
Mitchell JM. Effects of physician-owned limited-service hospitals: evidence from Arizona. Health Aff (Millwood) 2005;24:Suppl 3 Web Exclusives:W5-481.
Pham HH, Devers KJ, May JH, Berenson R. Financial pressures spur physician entrepreneurialism. Health Aff (Millwood) 2004;23:70-81.
Levin DC, Rao VM. Turf wars in radiology: the overutilization of imaging resulting from self-referral. J Am Coll Radiol 2004;1:169-72.
Kouri BE, Parsons RG, Alpert HR. Physician self-referral for diagnostic imaging: review of the empiric literature. AJR Am J Roentgenol 2002;179:843-850.
Abelson R. An M.R.I. machine for every doctor? Someone has to pay. New York Times. March 13, 2004:A1.
Goldstein J. Health insurers trying to reduce imaging tests. Philadelphia Inquirer. August 19, 2005:A1.
Armstrong D. MRI and CT centers offer doctors way to profit on scans. Wall Street Journal. May 2, 2005:A1.
Vandewater J. Unnecessary tests can be dangerous as well as expensive. St. Louis Post-Dispatch. September 25, 2004:A11.
Abelson R, Freudenheim M. The conglomerate will see you now: is what's good for G.E. good for health care? New York Times. July 18, 2004:BU1.
Levin DC. Me and my M.R.I. New York Times. July 6, 2004:A19.
Fuhrmans V. Overuse of medical scans is under fire. Wall Street Journal. January 12, 2005:D1.
Report to the Congress: variation and innovation in Medicare. Washington, D.C.: Medicare Payment Advisory Commission, June 2003.
Miller M. Testimony March 17, 2005, before the House Ways and Means Subcommittee on Health. Washington, D.C.: Committee on Ways and Means, 2005. (Accessed June 8, 2006, at http://waysandmeans.house.gov/hearings.asp?formmode=detail&hearing=392&comm=1.)
Fisher E, Wennberg D, Stukel T, et al. The implications of regional variations in Medicare spending. 1. The content, quality and accessibility of care. Ann Intern Med 2003;138:273-287.
Report to the Congress: issues in modernizing the Medicare program. Washington, D.C.: Medicare Payment Advisory Commission, June 2005.
Hadley J, Zuckerman S. Physician-owned specialty hospitals: a market signal for Medicare payment revisions. Health Aff (Millwood) 2005;24:Suppl 3 Web Exclusives:W5-491.
Gullo K. New poll shows U.S. adults strongly favor and value new medical technologies in their doctor's office. Wall Street Journal. October 14, 2005.
Report to the Congress: Medicare payment policy. Washington, D.C.: Medicare Payment Advisory Commission, March 2006.(John K. Iglehart)
This report reviews the impressive rise of new imaging techniques as useful clinical tools and discusses two provisions enacted by Congress that will sharply reduce Medicare payments for some imaging services by an estimated $2.8 billion over a five-year period. The Medicare Payment Advisory Commission (MedPAC) provided most of the information on trends in imaging that prodded Congress to examine the program's payment policies in relation to these imaging services. The work of this commission will also be discussed.1
The Rise of Medical Imaging
Dramatic improvements in imaging technology account for much of the rapid increase in the volume of these services and in the expenditures for their use. This growth has accelerated across virtually all clinical specialties. By offering these imaging services, specialists outside the field of radiology have invaded the territory that once was almost the exclusive preserve of radiologists. As a result, a turf war has broken out between radiologists and other specialists, particularly cardiologists. According to MedPAC, between 1999 and 2004, the growth in the volume of imaging services per Medicare beneficiary outstripped the growth of other services provided by physicians (Figure 1).1 According to the commission, by 2003, the share of Medicare payments to radiologists for imaging services had declined to 45 percent while the share received by cardiologists had surged to 25 percent. In 2004, the cost of imaging services reimbursed by all health insurers and paid for out of pocket by patients amounted to close to $100 billion, or an average of approximately $350 per person in the United States.2
Figure 1. Growth in the Volume of Physician Services per Beneficiary, 1999–2004.
Volume is measured as units of service multiplied by each service's relative value units from the physician fee schedule. Analysis includes claims for 100 percent of Medicare beneficiaries for all 12 months of each year. Evaluation and management service includes office visits and hospital visits. The category "Tests" excludes imaging.
Much of the rapid growth in imaging services is attributable to the expanded use of computed tomography (CT), magnetic resonance imaging (MRI), and ultrasonography; the emergence of more sophisticated models of these forms of technology; and the value that physicians attach to adding these tools to their standard of practice for diagnosing and treating diseases.3,4 For example, physicians are using CT in emergency situations to diagnose pulmonary emboli and appendicitis5 and to rule out heart attacks. Physicians are also using MRI, which was once mostly limited to the conduction of neurologic tests, for full-body scanning and studies of the musculoskeletal system, liver, adrenal glands, and kidneys.6 The use of positron-emission tomography has greatly expanded, too, particularly in oncology, and this type of imaging is being used to test for Alzheimer's disease and other degenerative diseases of the central nervous system.7 Insurers continue to ask whether the rapid rise in expenditures for imaging studies is leading to improvements in patient outcomes that equal or surpass the greater costs associated with providing these services.
Private and public insurers currently offer virtually unlimited coverage for imaging services, notwithstanding the new controls that private carriers began to apply several years ago. The federal government also invests substantial sums in imaging research. In 2000, Congress authorized the creation of the National Institute of Biomedical Imaging and Engineering, which currently has an annual budget of $299.8 million.8 The Departments of Defense, Energy, and Veterans Affairs also finance imaging services and conduct imaging research.
In an appearance before the House Appropriations Subcommittee on Labor, Health and Human Services, and Education on March 9, 2005, Dr. Roderic I. Pettigrew, director of the National Institute of Biomedical Imaging and Bioengineering, testified that recent advances in imaging techniques have "radically expanded" the capacity of physicians to diagnose and treat disease. In testimony, Pettigrew said:
Imaging devices such as computerized tomography, magnetic resonance imaging, and ultrasound allow physicians to see and diagnose disease that is hidden from normal view. On-line guidance during treatment of surgery, a concept referred to as image-guided interventions, will be the next step in reducing the trauma and improving the effectiveness of surgical procedures. Image-guided interventions, coupled with minimally-invasive treatments — which require only a small incision, or, in some cases, no incision — result in less damage to critical organs, less postoperative pain, fewer surgical complications, shorter hospital stays, lower health care costs, and fewer work days lost.9
The rapid growth in the volume of advanced imaging services has been driven by these advancements and by physicians who have an interest both in supplementing their professional fees with revenues from ancillary services and in enabling patients to receive imaging services conveniently in their doctors' offices, where study results become available to them more rapidly than in other settings. The number of physicians who have acquired advanced imaging equipment for their offices or who have invested in freestanding facilities is not readily available. During the past decade, the number of freestanding diagnostic imaging centers owned by radiologists, other specialists, private investors, or for-profit companies has more than doubled from approximately 2500 to 5760 (Jenkins S, Sg2: personal communication).
The movement of imaging services to both freestanding centers and the offices of physicians is part of a larger trend — doctors are also opening ambulatory surgical centers and specialty hospitals to which they often refer their patients.10,11,12,13,14,15 These developments have upset physicians' relationships with hospitals and set off turf wars between radiologists and other specialists, some of whom have acquired imaging machines in their offices and are obtaining the necessary training to conduct studies and interpret their results without consulting a radiologist.16,17 Until recently, Congress paid little attention to the rapid rise in expenditures for imaging services and the Centers for Medicare and Medicaid Services (CMS) was slow to respond. Most of the publicity about the rise in costs has come through occasional newspaper articles that have focused on the proliferation of imaging equipment in selected markets and reported on schemes used by private companies to persuade physicians, through the use of financial incentives, to refer their patients to for-profit imaging centers owned by these companies.18,19,20,21,22,23
The Role of MedPAC
Given the multiple roles played by government in health care services — in this case as a payer of imaging services and supporter of imaging research — it is not surprising that its many entities hold multiple perspectives on issues such as imaging. In this case, MedPAC, which consists of 17 part-time members and a full-time staff with a broad mandate to advise Congress on issues that affect the program, took the lead in recommending new policies that relate to imaging services. In its March 2005 report, MedPAC acknowledged that in many instances, "imaging technology can improve patient outcomes by allowing greater precision in diagnosing and treating patients."1 After citing several examples, MedPAC's report added:
Despite such successes, however, evidence exists of overuse, underuse, and misuse of imaging services. Perhaps the most significant reason to be concerned about potential overuse of imaging services is the threefold variation in the number of imaging services provided across the country. This difference is twice that seen in the use of major procedures.24,25
MedPAC then asked, "Are regions that provide more imaging services improving patient outcomes?" No, it asserted. This conclusion is no different than that of most research that has been unable to determine whether, when additional resources are expended for imaging or any other health care service, better outcomes for patients necessarily result.
To underscore the growing concern in Congress over the rise in expenditures for imaging, on March 17, 2005, the House Ways and Means Subcommittee on Health held a hearing on managing the use of imaging services. Its first witness was the executive director of MedPAC, Mark E. Miller. Miller testified that, during the period from 1999 through 2003, the volume and complexity of imaging services grew by 45 percent, more than twice as fast as all physicians' services, which grew by 22 percent during the same period. Other issues registered by Miller included the absence of a clear link between the delivery of more imaging services and better outcomes for patients, a wide variation in the quality of images that are produced and their interpretations, and the reduction in standards of quality that apply when imaging services are delivered in physicians' offices as compared with hospitals.
Next, Miller outlined the policy recommendations of MedPAC, and he noted that they were approved unanimously by the 16 commission members who were present. The commission recommended that Congress direct the secretary of the Department of Health and Human Services to set quality standards for all providers who bill Medicare for performing diagnostic imaging services and interpreting these diagnostic tests. They also recommended that the secretary should measure physician use of imaging services "so that physicians can confidentially compare their practice patterns with those of their peers"26; that the secretary should expand the National Correct Coding Initiative of the CMS to improve the initiative's ability to detect improper claims for imaging services; that the secretary should reduce payments for multiple procedures for imaging of contiguous body parts; and that the secretary should strengthen the rules that govern the investments that physicians may make to facilities to which they refer Medicare patients.
The commission's recommendation that Medicare require physicians to meet standards in order to receive payment for interpreting imaging tests would be a major policy shift for the program. Medicare generally covers medically necessary services provided by physicians who are operating within the scope of practice of the state in which they are licensed, without regard to their specialty. The commission asserted that if its recommendation was adopted, "this policy should improve diagnostic accuracy and treatment. It should also help control the growth of imaging spending by restricting payment for interpretation to only qualified physicians."1 The CMS would probably need to seek authority from Congress to pursue this new policy, but as the commission noted, "there is a precedent. In 1992, Congress gave the FDA (Food and Drug Administration) authority to set standards for physicians who read mammograms."
New Medicare Policies Regarding Imaging
Last December, in a rush to adjourn and desperate to identify budget savings that would begin to pare the vast federal deficit, a Republican-controlled House–Senate conference committee that included no Democrats accepted only one of MedPAC's recommendations that related to imaging services. However, the committee also adopted a second imaging-related provision on the basis of a recommendation put forward by the CMS; this provision will lead to far larger reductions in Medicare payments than the reductions included in MedPAC's proposals. The provisions were contained in an omnibus bill that authorized overall reductions of $39.7 billion in federal spending during the next five years.
The provision recommended by MedPAC will, beginning in 2007, reduce by 50 percent the payment for the technical component of the second or subsequent imaging of contiguous body parts in the same imaging session. (A physician whose office both performs an imaging study and interprets the results of that study submits a bill that includes two components — one technical and one professional.) For example, currently, Medicare's allowable payment is $980.41 for a freestanding facility's MRI of the abdomen. Medicare's allowable payment is $530.57 for an MRI of a patient's pelvis that is performed during the same session. This payment would be reduced by 50 percent under the new policy. The provision was based on the premise that savings in clerical time, preparation, and supplies occur with multiple studies of contiguous body parts with the use of the same type of imaging technique during one visit with a patient.
The more controversial provision stipulates that rates of payment for imaging services delivered in physician offices must not exceed rates of payment for the same services provided in hospital outpatient departments. Until now, payments for services delivered in these different settings were calculated through separate fee schedules. In some instances, the physician fee schedule that applied to services delivered in non-hospital diagnostic imaging facilities allowed higher Medicare payments on the basis of a calculation of the costs incurred in providing the service. Effective January 1, 2007, as a result of this new law, payments will be reduced by more than half for many of the billing codes that doctors use most frequently when they charge Medicare for providing imaging services outside of hospitals. For example, the technical component of MRI of a patient's brain is one of the billing codes most heavily used by physicians who provide imaging services. Medicare's payment for this service delivered in a non-hospital diagnostic imaging facility currently is $995.19, as compared with $506.26 if it is billed at the rate allowed if the same service is delivered in a hospital outpatient department and paid under Medicare's separate payment system. Under the new law, the rate allowed for this same MRI in a non-hospital diagnostic imaging facility would be $506.26, or 49.1 percent less. The imaging community was caught off guard by the provision because, after the proposal was recommended by the CMS, its contents were not shared except with a few House and Senate conferees, and it was approved in a closed session without a dissenting voice.
The American College of Radiology (ACR) and the American College of Cardiology (ACC) both opposed the provision that reduced Medicare's payments for certain imaging services. Members of the ACR were the most vocal in their opposition; they called the payment reductions "broad-based and indiscriminate" in a letter that was sent to every member of Congress. The letter, dated January 10, 2006, and signed by Dr. James P. Borgstede, chair of the ACR's Board of Chancellors, added:
Most troubling to me is that this capricious policy was incorporated into the conference report without any consultation with the numerous physician and patient stakeholders that would be affected by its implementation. This legislative `slight of hand' was performed despite the ACR's good-faith efforts over the last year to work with the policy for diagnostic imaging reimbursement that would require all facilities and physicians, regardless of their specialty, who provides those services to meet mandatory federal quality and safety standards.
Specialists Divided over Imaging
Organized medicine is divided over many issues related to imaging services. This lack of consensus has weakened its influence on policy regarding imaging and complicated the task of policymaking by Congress and the executive branch. The conflict pits radiologists against other specialists — particularly cardiologists — but also neurologists, oncologists, and orthopedists who have acquired their own advanced imaging equipment and now perform imaging studies in their offices. Radiologists perform, supervise, and interpret imaging studies ordered by other physicians and, as a rule, do not generate demand for initial consultation, although they do often suggest additional testing. Physicians who are not radiologists, yet who perform and interpret imaging studies in their own offices, are in a better position to influence the volume of imaging performed.
The issues on which physicians differ were clearly evident at the past two annual meetings of the American Medical Association. In both 2004 and 2005, its house of delegates overwhelmingly approved resolutions that put the association on record against any effort to ban or discourage the delivery of imaging services in physician offices or that sought to repeal the "in-office ancillary services exception" under the federal anti-kickback law; this exception allows doctors to provide imaging services in their own offices. The ACR opposed the adoption of both of these resolutions. With Republicans in control of Congress, there is no likelihood that this exception will be entirely removed, although it could well be refined as concern about the referral of patients by physicians to facilities in which they hold an ownership interest continues to fester.27,28 For example, Medicare recently added nuclear medicine to the list of services that, starting in 2007, physicians may no longer provide in facilities they own.
The conflict between radiologists and other specialists was also pronounced in the testimony delivered by representatives of the ACR and the ACC before the House Ways and Means Subcommittee on Health in March 2005. Borgstede said the ACR was
deeply concerned with the exponential growth in office-based imaging by those who may lack the education, training, equipment, and clinical personnel to safely and effectively use these studies to better their patients' health. . . . For this reason, the ACR supports many of the MedPAC recommendations that link Medicare reimbursement to quality, safety, and training standards for physicians and facilities which provide medical imaging services. Private payers such as United HealthCare, Anthem, and Blue Cross and Blue Shield have already enacted similar guidelines with little additional burden on physicians to comply with these quality measures and no decline in patient access to care.26
In testimony immediately after Borgstede's statement, Dr. Kim Allan Williams, representing the ACC and 20 other health organizations that compose the Coalition for Patient-Centered Imaging, said:
Let me begin by saying that we do take exception to the concept implied by MedPAC that physician specialists are providing substandard care for their patients by providing poor-quality medical imaging in their offices. There is really no credible evidence to support that notion. We agree with MedPAC that safety and patient quality of imaging are of utmost importance, and we agree with the fact that there needs to be careful study of the growth in medical imaging services. But let's keep safety and quality in the in-office medical imaging as the focus, not the agenda of one physician group or another.26
Conclusions
With the new assault on the growth of Medicare spending overall by the administration of President George W. Bush, the rapid increase in expenditures for imaging studies will remain a highly visible target, although the proposed 2007 budget does not contain any specific provisions that would further reduce payments for imaging. Meanwhile, MedPAC is preparing to accelerate its plan to recommend refinements of Medicare's physician fee schedule. The commission is making its recommendations on the basis of the belief that the overpricing of some services, including imaging services, has been a factor in the rapid increase in their use.29 In the private sector, the imaging community has begun to take steps to better document the quality of the services it provides. Imaging experts, gathered recently in Washington, D.C., by the ACC and Duke University, initiated efforts to develop new metrics to measure quality. According to one of its sponsors, the conference achieved this goal with agreements by the ACC and each of the cardiovascular imaging societies to place quality at the top of their agendas (Douglas P, Duke University: personal communication). There also is a growing recognition that the clinical effectiveness of new forms of imaging technology should be investigated and proved before they are used widely. General Electric, the largest manufacturer of imaging equipment in the United States, recently announced its intention to sponsor clinical trials that will reach beyond earlier industry-sponsored trials. These trials focused mostly on the quality of the actual images to test the clinical effectiveness of new forms of technology such as new CT techniques to image the heart and breast (Clarke W: personal communication).
The importance of advanced imaging technology to the practice of medicine has been heralded by physicians,2,3,30 and its greater availability in physicians' offices is supported by the public.31 As insurers reduce their rates of payment and tighten the management of imaging services, the acquisition of advanced imaging equipment by physicians, hospitals, and for-profit companies that own independent diagnostic imaging facilities could slow. Although new efforts to better account for the quality of imaging services and their clinical effectiveness are steps forward, these pursuits will be hampered as long as the turf wars between radiologists and other specialists continue apace. These struggles also will dilute the power of the imaging community as it seeks to persuade Congress that Medicare policy should be hammered out through thoughtful deliberations among all of the stakeholders rather than in hasty private discussions driven by an imperative to slash federal spending.
No potential conflict of interest relevant to this article was reported.
Source Information
Mr. Iglehart is a national correspondent for the Journal.
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Report to the Congress: Medicare payment policy. Washington, D.C.: Medicare Payment Advisory Commission, March 2006.(John K. Iglehart)