The list of entities with imaging in their crosshairs goes on and on, but when it comes to eroding reimbursement and enhancing oversight, the current primary culprits are CMS and Congress, according to Maurine Spillman-Dennis, MBA, MPH, director of economics and government relations for the ACR®. In the “ACR Economic Update” presented on September 28 at the 2010 RBMA Fall Educational Conference in Austin, Texas, Spillman-Dennis and her colleague, Judith Burleson, MHSA, ACR director of metrics, outline some of the current challenges and opportunities facing the profession. Although the former outnumber the latter, the news isn’t all bad. The Spillman-Dennis portion of the presentation focuses on recent and upcoming changes in imaging reimbursement—and how the ACR is working to combat them, where possible. She begins with a look at the 2011 proposed (now final) Medicare Physician Fee Schedule (MPFS), which reduces the physician-payment conversion factor by 6.1% in 2011, adding to the 21.2% scheduled reduction that was delayed by Congress, over the summer, until November 30. Spillman-Dennis adds that it’s still difficult to tell whether action will be taken at that time; if Congress fails to delay the cuts or create a permanent change in the formula for the sustainable growth rate (SGR), imaging could be looking at reimbursement cuts on top of reimbursement cuts. The ACR also is concerned that the 2011 MPFS might undervalue certain imaging-procedure codes. “One of the big misperceptions out there is that imaging services are overpriced,” Spillman-Dennis explains. “That puts codes under the microscope—we have to justify maintaining their current value.” She notes that the DHHS secretary is likely to zero in on codes with the fastest growth, codes that pertain to new technologies or services, codes that tend to correspond with low RVUs, and codes not reviewed since the early 1990s. She adds, however, that the DHHS secretary also has the license to review any other codes, as the DHHS deems that review appropriate. “Basically, this is the whole fee schedule,” she concludes. “The days of review every five years are done.” The Patient Protection and Affordable Care Act (PPACA) mandated changing the equipment-utilization rate (for diagnostic equipment priced at over $1 million) to 75%; in the 2011 proposed MPFS, CMS issued a few clarifications of this change. First, the rate will also affect CT angiography (CTA) and MR angiography; second, the 75% rate will supersede the original CMS plan to increase the rate to 90%. The 2011 MPFS also proposes expanding the multiple-procedure reduction from 25% to 50% for the technical component of CT, MRI, and ultrasound—even if the body parts imaged are noncontiguous. The change applies to 11 families of codes, and CMS proposes adding cardiac CT and coronary CTA to these. In an ACR analysis of the potential impact of these changes, neuroradiologists and providers of portable radiography actually stand to benefit, while general radiology could suffer a 12% overall payment reduction, and IDTFs could see an even more onerous 20% reduction in reimbursement. When the ACR met with CMS to discuss the multiple-procedure reduction, the agency seemed to suggest that while the change might not be fair, Congress was just as likely to implement it down the line, Spillman-Dennis says. “We talked to them about how we’re in the process of bundling ourselves,” she adds. “The back and forth was cordial, and they seemed to get it, but who knows?” Many CMS calculations are based on the Physician Practice Information Survey, an update of the AMA’s Socioeconomic Monitoring System. The ACR paid around $75,000 to participate in this year’s survey, and the results weren’t promising: “We got hosed,” Spillman-Dennis says. According to the survey, radiologists’ practice expenses will decline by 33% next year, and that figure is what CMS will use in its allowances regarding practice expenses. The ACR’s stance is that the survey wasn’t an accurate representation of radiology because its 56 respondents were primarily hospital-based radiologists—without any practice expenses whatsoever. “We complained about the transparency and lack of access to data, and we asked them to delay implementation,” Spillman-Dennis says. In the face of these complaints, CMS agreed to transition in the new practice-expense calculation over four years. “Still,” Spillman-Dennis says, “it’s a hit.”Congress Takes a BiteWhen it comes to Congress, the other key agitator against imaging, the news isn’t much better. “We were the only physician specialty targeted for reductions in the health-care legislation,” Spillman-Dennis says. “There were proposals that would have had an even worse impact, but since 2008, congressional staff members have been looking for $3 billion from imaging to support other initiatives.” As Spillman-Dennis sees it, the PPACA’s real hit to imaging was its missing provisions: no SGR fix and no tort reform. “The latest on the SGR is that Congress might not even extend it until the first of the year,” she adds. The PPACA also established the Independent Payment Advisory Board (IPAB)—otherwise known as the Medicare Payment Advisory Commission (MedPAC) on steroids, in health-policy circles. To differentiate IPAB from MedPAC, members of Congress did not build any oversight into the committee. “Their proposal is to extend the solvency of Medicare, improve quality of care, and reduce national health expenditures. That last part is what they’re really going to be focused on,” Spillman-Dennis says. The ACR is responding by proffering support for credible members for the board, in the hope of getting IPAB to focus on areas other than imaging. Spillman-Dennis notes that a key PPACA mandate affecting imaging is set to kick in soon. Beginning on January 1, 2011, a new disclosure requirement will be added to the in-office ancillary-services exception. It requires referring physicians to give patients options for additional imaging centers (other than the one that they recommend). Spillman-Dennis says that the in-office exception, however, is here to stay: “No one seems to be able to close that loophole,” she adds. Burleson’s portion of the discussion, which focused on recent efforts to link payment and quality, was slightly more optimistic. The PPACA establishes a national strategy for quality improvement, requiring CMS and the DHHS to develop priorities for quality initiatives through a transparent, collaborative process. The statute mandates that CMS review any quality measures that it establishes every few years. It must use an outside entity—in this case, Burleson says, probably the National Quality Forum—as a consultant, prior to making new rules. “One of the major criticisms of the legislation is that it didn’t go far enough to control future costs,” she says. “That being said, the CMS Center for Innovation was created to work through some of the new, innovative payment and delivery arrangements, and funding was included to test these new models.” These could include patient-centered models, accountable-care organizations, or shared-savings programs (with bundled payments based on episodes of care). The PPACA mandates the transition of the hospital-based value-purchasing program to a performance-based program; in 2013, quality measures will be introduced into the program, and in 2014, efficiency measures will be factored in as well. Though the efficiency measures have yet to be defined, Burleson notes, “Traditionally, efficiency measures are related to imaging.” In 2013, CMS also will begin implementing the value-based payment modifier, which it will extend to specialty areas in 2015. A 1.5% Physician Quality Reporting Initiative (PQRI) bonus will gradually shrink until 2015, when payment reductions for failing to report quality data are scheduled to begin. CMS is required to provide timely interim feedback reports on PQRI data, as well as an appeals process; participation in the PQRI, coupled with participation in a medical board’s maintenance-of-certification program, will result in an additional bonus for physicians through 2014. Some changes to the PQRI also might be in the offing. The MPFS 2011 rule proposes reducing the sample size for reporting to 50% and adding a new radiology measure: use of a reminder system for mammograms. The Hospital Outpatient Prospective Payment System 2011 proposed rule would add four imaging-related measures to the existing four, and in 2012, CMS proposes adding an imaging measure involving door-to-interpretation time for imaging of the head. “The current specs only include CT, but it’s likely they will also include MRI,” Burleson notes. CMS is also proposing to add 12 American Recovery and Reinvestment Act meaningful-use measures to the PQRI. Concerning meaningful use, Burleson observes that “probably 90% of radiologists would be eligible for the incentive program.” This represents a shift from what many in the imaging community originally anticipated, predicting that meaningful use would be likely to refer to the use of electronic medical records (EMRs). Burleson explains that the recently published meaningful-use definition leaves an unexpected back door open for radiology and other specialties. Providers must state that they are using EMR technology that has been certified by the Office of the National Coordinator for Health Information Technology, but there are both complete EMR systems and modular programs available. A PACS or RIS might have components that “can be certified as able to do certain things—fulfill certain requirements. Potentially, radiologists are eligible for the incentives,” Burleson says.