Radiology Braces for Change Ahead

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Some US employees still enjoy Cadillac-style health plans in which little is paid out of pocket and coverage includes almost every health need, but health care costs for its workers helped send Cadillac maker General Motors into bankruptcy. Moreover, for every worker or family with a Cadillac plan, there’s a family with big deductibles, limited coverage, or no health insurance at all. For the past several weeks, Congress has been on display wrestling with this problem, taking its members, health providers, and the public at large on a trip to health-reform school.

For radiology, the health-reform stakes are high, especially since ballooning payments for imaging over the past decade have marked imaging as a target. There is fear that the golden age of radiology may be drawing to a close. All those advanced imaging tests that help save lives and guide referrers may now be held back by payors that are watching every dime.

imagePam Kassing, MPA, RCC

Bob Wood is president of BGR Government Affairs, LLC, one arm of a major Washington, DC, lobbying company. He says, “This is very different from health reform in 1993, when traditional business interests, as well as provider groups, came out in opposition. This time, there are a number of provider groups that are OK with health reform, or at least not willing to come out in opposition. You couple that with large employers or the US Chamber of Commerce and the National Association of Manufacturers (and others) trying to get out of the pension business, and very few groups are opposing health reform.”

Reform is not just what is being proposed in Congress, either. CMS is also signaling a willingness to cut many of its reimbursement amounts for imaging services.

Michael R. Mabry, executive director of the RBMA, says, “This is the perfect storm.” He offers an unsettling number: “Medicare intends to use a new practice-expense RVU. Currently, radiology has $204 per hour, and Medicare is proposing something in the $130–$140 range. That change alone will cut both the technical and professional components. We’re still trying to figure out how to quantify that impact.”

Quantifying impact, right now, is a huge problem, since health reform is a rapidly moving target. Both houses of Congress are entertaining and altering proposals daily, and CMS is creating side bets through its own proposals. What this leaves radiology to do is focus on some key issues and wait to see what happens next.

Utilization Management

If there is a mantra for radiology, these days, it is “the right test, for the right reason, at the right time.” Bibb Allen, MD, FACR, chair of the ACR’s economics commission, invokes that phrase; so do Mabry and Pam Kassing, MPA, RCC, the ACR’s senior director of economic and health policy. The reason that this mantra is repeated is that it describes concisely the ACR’s stance on utilization management, one of the key health-reform issues for radiology. To achieve optimal utilization, the ACR advocates use of a computerized decision-support tool (ideally, accessible online) by ordering physicians. Decision support should incorporate exam-appropriateness criteria and, if need be, consultation between the referring physician and a radiologist.

The ACR has memberships in the Access to Medical Imaging Coalition and, according to Kassing, in a new electronic-ordering coalition, both of which could grease the wheels for a decision-support effort. “We believe Congress should mandate an order-entry system where the referring physician orders the study and is then given feedback,” Kassing says.

The ACR argues that decision support is a superior and less punitive way to control overutilization than the alternative favored for Medicare by the White House (but not yet written into legislation): the use of commercial radiology benefit management (RBM) companies to preauthorize high-end outpatient scans for the Medicare and Medicaid populations. Both Kassing and Allen say that an RBM-use clause will probably find its way into the Senate health-reform bill that is still being formulated. “We will have lots of comments,” Allen says.

The RBMs are telling their story to Congress, too. According to National Imaging Associates (NIA), a major RBM, between 1999 and 2005, the number of US imaging centers increased 52%, while the growth in imaging volume was 40%, with insurers’ costs for imaging growing 18% to 20% annually over that span. Moreover, according to NIA, in 2006, advanced imaging such