Fight or Flight: Radiology Faces the Firing Squad
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 analysis1 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 study3 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 made by the Medicare Payment Advisory Commission (MedPAC) that calls for reducing professional fees for multiple procedures, but as Silva points out, that MedPAC recommendation did not include a percentage by which the professional component should be reduced. Bibb Allen Jr, MD, FACR, is a diagnostic radiologist at Birmingham Radiological Group in Alabama. He is also chair of the ACR’s Commission on Economics, and he is the ACR’s representative on the AMA/Specialty Society RVS Update Committee (RUC). The RUC meets periodically to review and update the RVUs assigned to designated specialty physician services, including those of radiologists. CMS and private insurers use the RUC data in setting reimbursement levels for physicians’ services. Allen says that the proposed 50% figure chosen by CMS for discounting professional fees in imaging under multiple-procedure payment reduction is certainly arbitrary. It is not, he adds, based on any firm precedent. For instance, the comparisons made with discounts for surgical services don’t hold, Allen says, because surgeons’ fees include follow-up care, hospital visits, and other activities that aren’t comparable to what radiologists do. “How CMS came up with 50% is a real conundrum to me,” Allen says. “CMS took the lead from MedPAC, which took the lead from the GAO, which did its study in 2009—and the GAO, in its study, said the efficiencies were only as high as 25%.” Nothing is simple when it comes to attempting to create a level playing field for various physicians’ contributions to care (through comparable RVUs). In its analysis of proposed cuts in imaging professional fees, CMS argues, based on the 2009 GAO study, that efficiencies are achieved for second and subsequent imaging exams because radiologists don’t have to repeat the preinterpretation work of studying the patient’s personal data or medical history or the postinterpretation work of discussing findings with referring physicians more than once. CMS implies that the preinterpretation and postinterpretation efficiencies justify the 50% reduction in the professional component. Allen says that this is nonsense, adding that the amounts of work done before and after interpretation are minor, compared with the work of interpretation and report preparation. He says, “To think that they constitute 50% is truly arbitrary on the part of CMS. It’s based on what CMS wants to do.” Allen contends that the intensity of work is also far higher for interpretation and reporting than it is for preinterpretation and postinterpretation activities. The ACR’s Counterstudy To dispute the CMS contention that preinterpretation and postinterpretation services account for a 50% efficiency on second exams, Allen and a group of colleagues conducted a study.4 The investigators included Silva and Pamela Kassing, MPA, RCC, the ACR’s senior director for economics and health policy. To conduct the study, Allen’s group repeated an analytical procedure that the GAO had used in 2009. The group consulted the MPFS results contained in the AMA RBRVS Data Manager for 2011, an updated edition of the same data bank that the GAO had analyzed in 2009. The RBRVS data were analyzed statistically to quantify values for preservice, intraservice (interpretation and reporting), and postservice work. The investigators found the preservice and postservice work, combined, took nowhere near the time expended for interpretation and reporting of same-session exams: The maximum efficiencies obtained in preserve and postservice activity varied by modality, but were in the range of 4.32% for CT exams to 8.15% for ultrasound tests. The study found that maximum multiple-procedure professional-fee reductions due to preservice and postservice duplication could be assessed for CT at a 2.96% rate and for ultrasound at a 5.45% rate. As Allen points out, these efficiency rates, all below 10%, do not approach the 50% level that CMS is proposing. Silva says that if the GAO had conducted its analysis of the RBRVS Data Manager material down to a level of granularity comparable to that of the ACR’s study, the GAO would have seen that the efficiency was, at most, 13%. “We reached the conclusion it was less than 13%,” he says. Kassing says that for her, the bottom line is about 5%. That’s what she contends can be saved, on average and across modalities, through efficiencies in preservice and postservice work during multiple same-session imaging exams. Like Allen and Silva, Kassing emphasizes that this is far less than the 50% efficiency-based payment reduction that CMS is proposing. “Medicare has not released any data analysis to show why that 50% number is substantiated,” she says. If all this weren’t enough, the ACR study also looked at preservice and postservice work for certain patient classifications; it determined that for cancer patients, chronically ill patients, and trauma patients, the preservice and postservice work could actually mean increased effort for multiple exams, especially when referrers were ordering different tests under stressful conditions. The intraservice work for these critical multiple procedures also took more time than usual, the ACR report says. Isolated and Ill If the multiple-procedure payment reduction is adopted, it will be the chronically ill patients who will be inconvenienced in care, Allen says. “I try to look at how many cases we do where there are multiple exams,” he says. “It’s always the hardest cases and the sickest patients—the trauma patients who may need a neck, abdomen, and chest CT, or the cancer patients with metastatic disease who need multiple different types of exams. To me, it is inappropriate to target the hardest hit. CMS thinks this is simple and easy to cut, yet it is whacking the hardest to treat.” Rural radiology practices and their patients will also be hard hit, Allen says, because trips to the distant hospital or imaging center are long and costly for rural patients. For that reason, multiple exams tend to be scheduled to avoid extra trips. Rural radiologists will be hit hard too, Allen says, because they typically read all imaging in the practice, whereas at academic sites or those with specialists on board, multiple exams are usually interpreted by more than one radiologist. Allen says that, according to his understanding, the proposed 50% cut in professional fees won’t apply if the different exams are interpreted by different physicians. “From the ACR perspective, and in my own practice, I want to put the patient first,” Allen says. “We’re not going to make people come back for a different exam on a different day, but people who are less scrupulous might do that.” While he depicts himself as an industry outsider, Goldsmith has done his homework in radiology. Along with Bruce Hillman, MD, a radiologist and prominent ACR member, Goldsmith wrote a popular book on imaging called The Sorcerer’s Apprentice: How Medical Imaging Is Reshaping Health Care.5 Goldsmith says that one reason that radiology keeps taking reimbursement hits is that it’s not fighting back hard enough. “I would argue the field is not doing a very good job of making its case,” Goldsmith says. “When you just trample over a professional group without them defending themselves, there is the motive to go on doing that—and do more.” Goldsmith says that oncologists have fought harder than radiologists against reimbursement cuts, for instance, by protecting huge fees for chemotherapy. Hospitals have fought harder, too, he says. Radiology hasn’t fought hard enough; therefore, Goldsmith adds, it remains a more tempting target. He says that the political action committee run on behalf of radiologists through the ACR (RADPAC) only has a relatively small lobbying budget. “It’s not enough,” he states. Radiologists need to press harder on the conflict-of-interest button, he notes. Conflicts of interest that allow self-referring nonradiologists to collect imaging fees for patients that they send to their own imaging equipment represent the real excess in imaging fees, Goldsmith says. He adds that radiologists also need to stand up and make clear to policymakers that they’ve taken more than their share of reimbursement cuts. “The imaging boom is over,” he says. “Growth is down to the low single digits—or it’s negative growth—on almost every modality.” Goldsmith says that a lot is at stake if CMS makes cuts in professional fees that are then adopted by private insurers. The withering of the radiology profession is only one negative. More reimbursement cuts will also retard investment in technology—especially molecular imaging, where molecular probes are the next big thing, Goldsmith says. Molecular imaging offers the chance to image, diagnose, and initiate treatment all in one session for the patient, Goldman says—exactly the scenario that CMS is talking about penalizing as multiprocedural. Radiology, Goldsmith says, needs to fight harder against taking more hits. Public officials need to be reminded that radiology has already been hammered with cuts. “There’s no cognizance of the effects of earlier reductions on the cost trends,” Goldsmith says. “Radiology has done an ineffective job of making its case.” Entering Battle At the ACR, though, the perception is different. There is the sense of having fought the good fight, all along. The introduction of the proposed 50% cut has upped the ante, however, and the ACR is enlisting allies and marshalling resources to convince bureaucrats and legislators that the proposed cuts to professional fees are unwarranted and unfair. Allen says that no dollar figure has yet been attached to the projected professional-fee cuts, other than the CMS estimate of $200 million in annual savings for itself. The ACR will conduct its own volumetric analysis, Allen says, to determine the number of multiple-procedure exam series that might be hit, under the proposed rule. A grassroots effort is also going forward, with ACR members and radiology practices urged to lobby their legislators. The ACR has attorneys and consultants looking at the CMS proposal, but there might not be much to challenge on legal grounds. Kassing says that the PPACA specifically gives CMS the authority to look for misvalued codes, and the DHHS secretary also has discretionary powers to seek out misvaluations. Maurine Spillman-Dennis is a senior director of economics and health policy for the ACR. Like Allen and Kassing, she has been deeply involved in developing the strategy to oppose the proposed rule. Allen says that the ACR will send CMS officials and Congress enough copies of the ACR’s counterstudy on preservice and postservice efficiencies to paper the walls of their offices. Spillman-Dennis adds that the ACR’s study will be central to seeking what she calls “at least a stay of execution” in the implementation of the proposed rule. “Five years ago, the regulatory climate was different,” Spillman-Dennis says. “I don’t think, now, decisions are being driven by career officials. It’s the policymakers outside CMS who are putting the pressure on CMS to make these changes. They want this money, and they want it now.” Spillman-Dennis says that other specialty societies are also watching what happens in response to the proposed attack on professional fees for radiologists. “Many people are hiding and praying CMS doesn’t come after them next,” she says. Kassing agrees that if radiologists lose professional fees, it will open the door for other physicians to lose fees. Moreover, professional fees for radiologists in categories other than multiple-procedure payment could come under threat, she adds. Opposing the proposed rule is an important fight. Kassing calls herself an optimist, nonetheless. “Our membership is going to respond heavily to this rule,” she says. She expects other specialty societies to join the fight. The AMA has already written a letter to Congress opposing MedPAC’s recommendation of blanket cutting of professional fees, she says. Spillman-Dennis says that the RBMA prepared a template for its members to use in adding their voices in opposition to the proposed multiple-procedure payment reduction. “We put the bullet points in,” she says. “We made the letter so it can stand on its own, with instructions on how to send it to CMS—or senders could use the letter and embellish it from their own practices.” Enough Is Enough For Silva, the bottom line is that radiology has already been battered by more than its share of reimbursement cuts. He says that the RUC has already stated that fee cutting should not be done across the board in any category, but should be done only on a code-by-code basis for each specific procedure. “No one wants to raise taxes, so there is tremendous pressure to reduce expenses and payments to Medicare,” Silva says. “Every single time the federal government wants to save money, radiology has been an easy place to find that. In the PPACA, the only specialty specifically targeted for reduction was radiology. I think we can demonstrate that we have absorbed our fair share of the pay reductions in the fee schedule.” George Wiley is a contributing writer for Radiology Business Journal.