Even before its official release, a new proposal to curb the overuse of costly MRIs and other advanced imaging in Medicare is sparking a furor among physician and patient groups. The battle shows how hard it is to make even small changes in the sprawling program for the elderly – much less overhaul it.
The recommendation, expected from a congressional advisory group Wednesday, would require some physicians and their patients to get pre-approval from Medicare for advanced imaging services, such as MRIs, CT scans and nuclear medicine. The proposal would apply to doctors deemed to have high rates of inappropriate use of such imaging.
"There's some bad behavior going on out there, with physicians buying imaging equipment and generating unnecessary services," said Robert Berenson, vice chairman of the Medicare Payment Advisory Commission, which crafted the proposal for Congress. "It seems prudent to target high utilizers for authorization." Of the doctors who order advanced imaging, 10 percent is responsible for half of the procedures.
Imaging is one of the fastest-growing Medicare costs, rising from $6.5 billion to $11.7 billion between 2000 and 2009, according to federal figures. Industry groups claim the use of all imaging services declined between 2008 and 2009, but MedPAC disputes that data and counters that usage is on the rise.
The debate comes as a bipartisan panel led by Vice President Joe Biden intensifies negotiations over raising the federal debt ceiling, which administration officials have said will expire Aug. 2. Republican leaders insist that any final deal include changes to federal entitlement programs.
In his fiscal 2010 budget proposal, President Barack Obama tried to restrict the growth of imaging costs by requiring the use of radiology benefit managers in Medicare. That proposal did not become law, although many private insurers use similar controls.
The Government Accountability Office also suggested the prior authorization could prove fruitful. The Centers for Medicare and Medicaid Services "could add more front-end approaches to better ensure appropriate payments, such as requiring physicians to obtain prior authorization from Medicare before ordering an imaging service," Kathleen King, GAO’s director of health care, told the House Energy and Commerce Subcommittee on Oversight and Investigations in March.
But opponents say that new restrictions on imaging are premature, given that laws and regulations approved over the past five years have slowed imaging’s growth. They also argue that advanced imaging can save Medicare money by enabling doctors to appropriately tailor medical care.
"Medicare payment for diagnostic imaging services in non-hospital settings have been subjected to a series of cuts in recent years, and many (payments) will have been reduced by 25-40 percent by 2013," said a March letter from two dozen physician groups to MedPAC Chairman Glenn Hackbarth. "Medicare payment reductions carry a significant risk of unintended consequences and should not be imposed until the current cuts have been fully phased in."
Dave Fisher, executive director of the Medical Imaging and Technology Alliance, which represents manufacturers of medical imaging products, says that physicians should determine what is best for their patients. "There's no value to inappropriate imaging," he said. "Let the physician decide what the right scans are for the right condition."
Some lawmakers also oppose the move. In a May 20 letter to Hackbarth, House Energy and Commerce Health Subcommittee Chairman Joe Pitts, R-Pa., and ranking member Frank Pallone, D-N.J., call into question MedPAC's conclusion that imaging is a major driver of the program's increased spending. While Pitts and Pallone fought over last year's health law, the two have joined forces to oppose MedPAC’s recommendation.
Congress is not required to follow any MedPAC recommendations, but some observers think Capitol Hill may give these recommendations a closer look as it works to control the federal deficit.
Lawmakers previous have taken several steps to control Medicare imaging expenditures. As part of the Deficit Reduction Act of 2005, Medicare cannot pay a physician more for imaging services done in his office or a free-standing imaging center than the program pays for a similar service offered in a hospital outpatient facility.
A 2008 law required imaging centers and physician offices to become accredited by a government-approved entity by Jan. 1, and created a demonstration project to test the appropriate use of specific imaging services.
Moreover, last year’s health overhaul law reduced imaging payments by $3 billion over 10 years.
The health law also requires doctors who refer Medicare and Medicaid patients to in-house imaging machines to disclose that they own the equipment, and provide patients with a list of 10 alternative sites within 25 miles.
Berenson maintains the 2005 imaging changes did not create access problems for seniors and the disabled, and there is no reason why Congress should stop there.
"The GAO did a study and found that the impact of the [change] was that spending decreased 12 to 13 percent, volume continued to increase, but less," he said. "That's a pretty good result. There were no access problems and significant savings. We should continue to look for opportunities to reduce overpriced services. Nothing bad happens."
KHN's Juan E. Gastelum contributed to this article.
This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.