Radiology Goes to Washington

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Imaging representatives convened in front of Congress last week at a House Ways and Means Health Subcommittee hearing to focus on managing the use of imaging services -- a topic of growing concern after the Medicare Payment Advisory Commission (MedPAC) recommended to Congress in March that standards be adopted to limit who can provide imaging under the U.S. federal health plan.
MedPAC said Congress should enact laws directing the Secretary of Health and Human Services (HHS) to set quality and safety standards for providers that bill Medicare for performing diagnostic imaging services and for physicians who bill Medicare for interpreting diagnostic imaging studies.
According to MedPAC, between 1999 and 2002, per-beneficiary growth in the volume and complexity of imaging services was twice as high as the growth for all services paid under the Medicare physician fee schedule.
"Diagnostic imaging services paid under Medicare's physician fee schedule grew more rapidly than any other type of physician service between 1999 and 2003," said Mark Miller, executive director of MedPAC, at last week's hearing. "While the sum of all physician services grew 22 percent in those years, imaging services grew twice as fast, by 45 percent."  
"In dollar terms, Medicare spending for imaging services paid under the physician fee schedule grew over 60 percent, from $5.7 billion in 1999 to $9.3 billion in 2003," he continued.  "Beneficiaries' spending on these services also has increased, both directly through co-payments and indirectly through increased part B premiums."
He added that Medicare payments for MRI increased by 99 percent between 1999 and 2003. In addition, over the same period, Medicare payments for nuclear medicine increased 85 percent, and payments for CT scans increased by 82 percent, Miller said.
While the development of quality standards that MedPACS is recommending for all providers that receive payment for performing and interpreting imaging studies are seen as a way to improve the accuracy of diagnostic tests, it will also help control spending.  
On behalf of the American College or Radiology (ACR), an advocate of MedPAC's recommendations, James Borgstede, MD, chairman of the ACR board of chancellors, explained that the problem is that more than half of hospital imaging services are now being performed by physicians who are not radiologists, a trend that could harm patients and result in higher health costs.
Non-radiologists who own imaging equipment are up to seven times more likely to order diagnostic tests than those who refer patients to a facility in which they have no financial interest, Borgstede said.
As part of his testimony, Borgstede cited Medicare records that show imaging use by non-radiologists skyrocketed from 1998 to 2003. In Alabama and Ohio, for instance, in-office imaging among non-radiologists was up more than 3,000 percent -- 30 times the national average by all providers during that span.
Other examples include Arizona where imaging by non-radiologists is up as much 1,317 percent -- or 10 times the national average. In Georgia, it's up 503 percent; Louisiana, up 852 percent; Minnesota, up 442 percent; and in Texas, up 1,630 percent.
Borgstede also noted that inappropriate utilization of medical imaging procedures is a primary driver in escalating insurance costs. Premiums for family healthcare coverage have risen 59 percent since 2000, compared with inflation growth of only 9 percent. American businesses spend, on average, nearly $10,000 per employee for family healthcare coverage.
Speaking on behalf of the Coalition for Patient-Centered Imaging (CPCI), which represents more than 18 physician organizations that use in-office imaging as part of their diagnosis and treatment regimens, Kim Allan Williams, MD, professor of medicine and radiology and director of Nuclear Cardiology at The University of Chicago, said, "there is unquestionable value for physicians being empowered to integrate imaging into patient diagnoses and prescribed courses of treatment."
"As a cardiologist, medical imaging allows me to advance patient care in ways that were not possible 10 years ago," Williams continued. "When I conduct images in my office, I can read them 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 of those with chronic conditions."
Supporters of using in-office imaging as a way to diagnosis illness say it is more about patient care while opponents have been more likely to argue up to this point that issue more akin a 'turf war.'    
Consumers are safer, healthier, and live longer today because of medical imaging, said David Rollo, MD, chief medical officer of Philips Medical System. Rollo testified before the committee on behalf of the National Electrical Manufacturers Association (NEMA). If Congress requires additional standards for medical imaging or imaging quality to be developed, Rollo said NEMA wants to play a central role.  
Rollo said the industry was happy to discuss questions of appropriate utilization, but that it must be based on a clear reflection of the peer-reviewed literature on imaging.