JACR: Did DRA nip nuclear medicine access?

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In the wake of the passage of the Deficit Reduction Act (DRA), there were concerns that advanced imaging procedures would shift from private offices to hospital outpatient departments (HOPDs) and that access would be restricted. According to a study in the January issue of the Journal of the American College of Radiology, while there hasn’t been a large shift away from offices toward hospitals, the DRA did affect imaging volume and seems to have resulted in some loss of access to nuclear medicine.

The DRA, which was passed in 2005 and took effect in 2007, reduced the Medicare technical component payment for office imaging, lowering it to the level paid to hospitals. Many private office imaging facilities feared they would be forced to close as a result, according to the study’s background information.

“Not surprisingly, these steep cuts sparked dismay and anger within the radiology community,” wrote David C. Levin, MD, of Thomas Jefferson University Hospital in Philadelphia, and colleagues. “This was compounded by the fact that a number of commercial payers adopted similar cuts.”

Using Medicare data, Levin et al looked at trends in CT, MRI and nuclear medicine from 2000 to 2006 (prior to the DRA) and from 2007 to 2009 (after the DRA took effect).

Results showed that in all three modalities, growth before the DRA was more rapid than afterward. Compound annual growth rates (CAGRs) of office volumes for CT, MRI and nuclear medicine prior to the DRA were 17.5, 14.9 and 18.4 percent, respectively. After the DRA, the CAGR slipped to 2.1 percent for CT, -1.1 percent for MRI and -1.7 percent for nuclear medicine.

Hospital volumes, though, also took a steep dive with post-DRA CAGRs of hospital volumes for CT, MRI and nuclear medicine at 0.5, 1.0 and -2.5 percent, respectively.

“It seems apparent from this and other studies that a dramatic slowdown in the growth of imaging began around the middle of the past decade, after years of rapid increases,” wrote the authors. “The slowdown was not due to the DRA, or at least not solely to the DRA. The proof of this is that the slowdown was felt equally in HOPDs, which should not have been affected by the DRA.”

The researchers said there was no evidence that access to CT or MRI for Medicare beneficiaries was compromised by the DRA, but this might not be true for nuclear medicine. HOPD nuclear medicine volumes began to decline before the DRA took effect, while office nuclear medicine began dropping slightly in 2007, and then more rapidly in 2009. “Although there was no evidence of a shift from offices to HOPDs, this could signify loss of access to outpatient nuclear medicine for some seniors.”

The authors did acknowledge the role radiologists played in controlling the rapid growth of advanced imaging while maintaining access.

“In many instances, it is likely they were able to tighten their belts, institute new information technologies and workflows, and in general work harder and more efficiently,” wrote Levin et al. “This may have allowed them to keep their office facilities in operation despite lower Medicare revenues.”

Since imaging growth has slowed, the authors said there should be less downward pressure on imaging fees from health policy planners. They did caution, however, that nuclear medicine access may have been restricted by the DRA and that CT and MRI may have been pushed to their limits. Should additional Medicare reimbursement cuts be implemented, it could result in “adverse consequences not only for seniors but also for younger patients who are commercially insured.”