Fight or Flight: Radiology Faces the Firing Squad

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Radiology might become the first medical specialty to face Medicare’s mythical death panel. If the specialty keeps taking hits, it might die, critics of proposed Medicare reimbursement cuts warn. The death-panel idea began as a political slur, meant to tar advocates of expense reduction for end-of-life care. As it turns out, in the current budget-cutting environment, radiology practices—not the elderly—might be the ones getting killed.

Jeff Goldsmith, PhD, a health-care consultant and professor of public health sciences at the University of Virginia, says, “Cut the prices enough, and the field is not going to renew itself. Attacking the professional fees is the wrong message. That’s not where the waste is.”

Goldsmith notes that radiology has already seen its income cut, through the DRA and again under the Patient Protection and Affordable Care Act (PPACA). He reports that imaging volumes, which rose rapidly in the middle of the last decade, have since tailed off, going from double-digit acceleration to no growth. Nonetheless, radiology is still a constant target for cost cutting, he says. More cuts, Goldsmith adds, will discourage medical students from becoming radiologists. Just as bad, they will push aside the development of newer technologies (such as molecular imaging) that hold great promise for clinical care.

Goldsmith isn’t the only one who is concerned about proposed cuts in professional fees paid by CMS. The whole radiology profession appears to be worried. Ezequiel (Zeke) Silva III, MD, RCC, FACR, is treasurer and director of interventional radiology with South Texas Radiology Group in San Antonio; he has tracked reimbursement reductions. He is also chair of the ACR® practice-expense subcommittee. In a recent analysis 1 in the Journal of the American College of Radiology: JACR, he writes that reimbursement cuts to radiology from 2006 to 2009 sliced more than $1.3 billion from the CMS imaging pie. Proposed reductions, if adopted, will nearly double that hit by 2013, he adds.

Silva says that it’s past time for CMS, Congress, and other government planners to take the target off radiology’s back. His voice (and the voices of thousands of radiologists like him) appears to be falling on deaf ears, however. CMS is proposing cuts now where it hasn’t made them before. Largely for the first time, the agency is targeting radiologists’ professional fees. It’s this step into new territory that has so many physicians up in arms.

A 50% Solution

On August 30, 2011, CMS closed its comment period on the proposed 2012 Medicare Physician Fee Schedule (MPFS), 2 which includes a plan to chop 50% off the professional fees for any second and subsequent CT, MRI, or ultrasound exam performed on the same day for one patient and interpreted by the same radiologist who interpreted the patient’s first exam of the day. The fee reductions would begin in 2012. CMS estimates that this would save about $200 million per year.

A patient could, for example, undergo CT and ultrasound exams on the same day. The interpretation fee for the higher-paying exam would be paid in full; the interpretation for the second exam would be paid at half of the established rate. The cuts would apply to both professional fees and technical fees (where CMS previously applied the discount).

CMS classifies the cuts in both technical and professional fees as being part of its multiple-procedure payment-reduction policy, but the multiple-procedure reduction has never been applied in a blanket fashion to professional fees, as CMS is now proposing.
One mystery is how CMS arrived at the proposed 50% figure for reducing professional fees. The 50% size of the payment reduction, not yet explained by CMS, is a huge bone of contention between CMS and radiologists (and the ACR).

In its history of recommendations leading to the cuts under the proposed rule, CMS cites a July 2009 study 3 done by the Government Accountability Office (GAO) on multiple-procedure discounts. That study found that a multiple-procedure payment reduction of 25% in the professional component would be justified, due to efficiencies gained when multiple tests are performed. As Silva and others affiliated with the ACR contend, however, that GAO study was flawed to begin with—and even if it had not been flawed, its recommendation of a 25% reduction in professional fees due to efficiency gains is only half of the cut that CMS is proposing this time.

The proposed rule also refers to a 2010 recommendation