Medical Imaging An Issue Snapshot for Physicians

Background

Medical imaging, whether conducted in a specialist's office, a hospital, or a radiology center, has proven to be a significant tool in the diagnosis and treatment of disease, so much so that in 1999 the New England Journal of Medicine called medical imaging one of the "great medical developments of the past thousand years." A number of forces - including changes in standards of care for many illnesses, expansions in coverage decisions, and shifts in the site of service from hospitals to the outpatient setting - have resulted in a noticeable growth in imaging services.

The American College of Radiology

The radiology community, particularly the American College of Radiology (ACR), has launched an aggressive assault on this growth, in particular an assault on physicians who provide imaging services outside of an imaging facility or hospital. The ACR has executed a detailed strategy for further limiting physicians' ability to own imaging equipment and to provide imaging services to patients in their offices - what they call "self-referral." ACR's strategy is an attempt to control the provision of, and thereby the reimbursement for, imaging services. According to ACR documents, the ACR leadership is committed to making self-referral its priority issue with a plan of action that they describe as having "a dedication, sophistication, and determination of unrivaled focus."

ACR has waged a misinformation campaign that overstates the growth in imaging services by non-radiologists, distorts the reasons for growth, and describes imaging services by non-radiologists as "substandard" and "unnecessary." ACR has used this desperate rhetoric and misinformation on Capitol Hill in an attempt to convince lawmakers of the potential savings to Medicare that would result if non-radiologists were restricted from providing imaging services to patients in their offices.

While legislation has not been introduced on ACR's behalf, ACR has widely circulated its principles for legislation that emphasize accreditation and physician certification for computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET), using ACR's standards.

The Coalition for Patient-Centered Imaging

The Coalition for Patient-Centered Imaging (CPCI) is fighting back. CPCI was formed in 2004 and now has the formal support of 23 physician and medical organizations (statement of principles included in binder) . CPCI has met with more than 50 congressional offices, testified before the House Ways and Means Health Subcommittee, held a briefing for Hill staff and members of the press, and issued numerous press statements. CPCI's message that office-based imaging is good medicine and better patient care has broken through. Our messages are strong and persuasive. Now is the time for physicians across the country to reinforce those messages by speaking directly with their members of Congress and their staffs. Physicians must use their personal experiences to convince lawmakers that physician specialists are appropriately trained to provide and interpret imaging services and that when they do, it constitutes good patient care.

Legislative and Regulatory History

Stark Self-Referral Laws

Under the 1992 federal Stark self-referral laws, Congress extended restrictions on physicians' self-referral of radiology services to entities in which they have ownership interest. The law, however, includes an in-office ancillary services exception that allows physicians to refer patients for ancillary services in their own practices, including diagnostic imaging services. ACR's early strategy was to convince lawmakers to remove the in-office ancillary exception to the Stark laws. That proposal was met with resistance on Capitol Hill and forced ACR to change its strategy to seek other restrictive policies such as accreditation and physician certification.

MedPAC Report

In its March 2005 report to Congress, the Medicare Payment Advisory Commission (MedPAC) examined and reported higher growth rates for imaging services than for other Medicare Part B services. While MedPAC's growth rates have been disputed in a study conducted by The Lewin Group (executive summary included in binder) on behalf of the American College of Cardiology (ACC) and other CPCI organizations, the ACR and others in the radiology community are using the growth trends in medical imaging utilization to advance an agenda that would limit the ability of specialists to administer and interpret office-based imaging tests.

In its report, MedPAC issued several recommendations, including the adoption and enforcement of federal accreditation and physician certification standards ( MedPAC recommendations included in binder) .

CPCI has criticized the MedPAC report for its assumption that the growth is being driven by the over-utilization of imaging services as a result of self-referral and for its lack of analysis for other logical reasons behind the growth, including changing demographics and the migration from invasive to non-invasive diagnostic tools. MedPAC has acknowledged that some of the growth in imaging services under Park B is due to the shift of these procedures out of the hospital setting. However, MedPAC's final growth figures do not accurately account for this shift, effectively overstating the true growth. Further discussion on MedPAC's report can be found in this binder.

Congress

On March 17, the Ways and Means Health Subcommittee held a hearing on managing the use of imaging services. Testifying on behalf of CPCI and the ACC was Dr. Kim Williams (testimony included in binder) . Overall, the hearing was favorable to CPCI, with Subcommittee Chair Nancy Johnson, R-CT, and Ranking Member Pete Stark, D-Calif., both agreeing that MedPAC's report does not effectively conclude what amount, if any, of the growth in imaging is inappropriate.

Centers for Medicare and Medicaid Services

In April 2005, representatives of CPCI met with top CMS officials to discuss the growth in diagnostic imaging service. It was clear from that meeting that CMS has a strong interest in accreditation of facilities. The group talked about making sure CMS has accurate data to fairly assess the growth in imaging services.  CMS was very interested in the ACC-commissioned study from The Lewin Group and asked for the data to be shared at a follow up meeting, which was held in May.  Another meeting is pending to go over 2004 data.  

Legislative and Regulatory Outlook

ACR is attempting to achieve their objectives legislatively, both federal and state, and through various regulatory avenues.

Congress

The goal of CPCI at this stage is to educate Congress about the patient benefits of office-based imaging and to prevent the introduction of imaging legislation or the inclusion of imaging language in any piece of legislation likely to make its way through Congress that would seek to limit access to appropriate care. Many members of Congress view this issue as a "turf battle" and are unwilling to insert themselves into the debate through the introduction of legislation. However, the across-the-board growth in Part B services, including medical imaging, has fueled the discussion in Congress on the need for a value-based payment system for Medicare that uses outcomes measurement and physician profiling as tools to ensure appropriate, evidence-based care. CPCI strongly rejects the singling out of medical imaging by Congress for cost-savings unless it can be proven that federal regulation of imaging services is needed to improve patient safety and quality of imaging services and that regulation will not unfairly benefit one specialty over another and will not impede timely patient access to imaging services.

Legislative action on medical imaging may also be diminished by the lack of interest by Republican leaders to move any Medicare legislation through Congress this year for the fear that Democrats will seek to reopen the debate on the Medicare prescription drug benefit and derail its 2006 implementation. CPCI lobbyists are aware that congressional committee staff have been in frequent communication with CMS and seem willing to defer to CMS to act administratively if it determined regulatory action is needed.

Centers for Medicare and Medicaid Services

As early as July 15 it is expected that CMS could publish the 2006 Medicare Fee Schedule proposed rule. It is strongly suspected that the proposed rule will address the growth in medical imaging services, but there have not been strong indications of whether CMS will seek to implement any of MedPAC's recommendations, specifically those relating to accreditation and physician certification. Based on meetings with CMS officials, there seems to be a strong interest in setting standards for accreditation and requiring compliance as a condition of Medicare payment. CPCI will continue to caution against the implementation of standards as a cost-containment mechanism and will oppose any standards that are specialty-specific or that are based on the standards of one organization.

Action Requested

    ü Explain to your members of Congress the importance of medical imaging both for diagnosis and treatment, why it is appropriate for physician specialists to perform imaging in their offices, and why office-based testing by the treating physician constitutes good patient care .

    ü Tell your members of Congress to reject policies that would effectively restrict the ability of physician specialists to provide office-based imaging services to their patients.

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