WASHINGTON — A congressional committee wrestled with whether or how much to regulate or impose standards on imaging procedures at a hearing last month on managing Medicare's imaging costs.
“I'm concerned about putting in a whole group of new structures [to monitor imaging procedures] because the system is structure-heavy already,” said Rep. Nancy Johnson (R-Conn.), chair of the health subcommittee of the House Ways and Means Committee. “I'm not sure putting in more oversight is really what we need.”
Mark Miller, Ph.D., executive director of the Medicare Payment Advisory Commission (MedPAC), testified that the growth in the volume of imaging services such as PET scans, CT scans, and MRIs performed on Medicare beneficiaries “is growing at twice the rate of all physician services.” And what worries MedPAC, he continued, is that increasing the amount of imaging being done doesn't necessarily mean the quality of care is getting any better.
“There is a threefold variation in the use of these services among the Medicare population, and it's not linked to health care quality,” Dr. Miller said. “It's more [related to the] availability of services and practice style.”
MedPAC also is concerned about the wide variability in imaging quality, he said. “There is variation in the quality of the images produced and in the quality of image interpretation.” He said the 17 MedPAC commissioners would like to see the Department of Health and Human Services set quality standards for imaging providers, referring to recommendations submitted to Congress earlier this year (CARDIOLOGY NEWS, March 2005, p. 6).
“Some people characterize this recommendation as directed toward limiting imaging to radiologists only and billing for imaging to radiologists only,” Dr. Miller said, alluding to the perceived “turf war” going on between radiologists and other imaging providers. “That is not correct. We believe the standard should apply to all physicians” who do imaging.
Subcommittee member Rep. Jim Ramstad (R-Minn.) said he was happy to hear that imaging would not be restricted to radiologists. “I would hate to see this become nothing more than a turf battle,” he said. “It seems to me that overutilization is a complex issue, involving factors like defensive medicine, provider preference, and consumer demand for the best test.”
The subcommittee also heard from representatives for cardiology and radiology groups, each of which took opposing positions on the increase in imaging volume. “We are deeply concerned with the exponential growth in office-based imaging by those who may lack the education, training, equipment, and clinical personnel to safely and effectively use these studies,” said James Borgstede, M.D., chair of the American College of Radiology's board of chancellors. “For this reason, the ACR supports many of the MedPAC recommendations that link Medicare reimbursement to quality, safety, and training standards for physicians and facilities which provide medical imaging services.”
Kim Williams, M.D., speaking on behalf of the American College of Cardiology, said there was “no credible evidence” to support the idea that office-based imaging was of poor quality. “Patients are really the issue, not the turf wars frequently discussed in the literature of the American College of Radiology,” he said. “Office-based medical imaging performed by well-trained specialists is good patient care.”
Cardiologists are especially concerned about a MedPAC recommendation involving ownership of imaging equipment. Under the current laws against physician self-referral, physicians cannot refer patients to an imaging center in which they have direct ownership. Dr. Williams urged the subcommittee not to remove a provision in the law that exempts nuclear medicine.
The subcommittee also considered the issue of whether to lower reimbursement for multiple imaging procedures performed in the same visit—specifically, lowering the amount paid for each subsequent image after the first one. Dr. Borgstede noted that the American Medical Association's CPT Editorial Panel has recommended such a reduction, but it will apply to the first image as well. That change will take effect next January, he said.
“We're at a stage where we have to rethink the way we pay physicians,” Rep. Johnson said to the two physicians on the panel. “Think about it, and get back to us about what you'd like to see in terms of … steps in the quality ladder.”