Diagnostics & Imaging Week Washington Editor

The subject of the amount of money spent on Medicare imaging in doctor's offices continues to be a chart-topper, and the recent Government Accountability Office report dealing with this subject did not disappoint in this context, drawing quick and vehement response from industry. The report indicated, however, that beneficiary access was not hampered, a fact that did not seem to mollify critics of the policy, some of whom had previously argued that access would indeed be problematic.

The topic has not avoided the scrutiny of the Medicare Payment Advisory Commission (MedPAC), which recently heard testimony that Congress should allow the Centers for Medicare & Medicaid Services to require pre-authorization to tamp down on the overuse of the various imaging modalities. Nonetheless, MedPAC members seemed disinclined to pass along such a recommendation to Congress.

The Sept. 26 GAO report noted that total Medicare Part B expenditures "are expected to increase over the next decade at an average annual rate of about 8%," a good deal faster than the projected growth of gross domestic product of 4.8%. GAO also noted the 13% annual growth rate in Part B imaging between 2000 and 2006, "from about $7 billion to about $14 billion." Two thirds of Part B imaging is said to have taken place in a physician's office.

The report said that the aligning of technical fees for physician office imaging to hospital outpatient department fees embodied in the Deficit Reduction Act of 2005 (DRA) "sparked intense reaction from the imaging provider community," which argued that access could suffer. However, the GAO report indicated this was not the case. Technical fees are those charged for performing scans, not for interpreting scans.

GAO examined changes in Part B imaging that took place between 2006 and 2007, and concluded that imaging spending "fell to $12.1 billion, a decline of 12.7% from 2006." All the same, the report noted "an increase in per-beneficiary volume of imaging services," which was not enough to offset the reduction in overall imaging spending. This came at a time when the number of beneficiaries under fee-for-service declined by 2.5%, but "the volume of tests increased from 1.99 to 2.05" per beneficiary.

Regarding the GAO report, acting CMS administrator Kerry Weems wrote a Sept. 12 letter to Vincent Ventimiglia, Jr., the assistant secretary of legislation at the Department of Health and Human Services that neither industry nor MedPAC have been able to "definitively explain the growth and geographic variation in imaging spending." Weems also suggested that the rapid increases in such imaging and the geographic variation "raised questions about whether such growth is appropriate and whether all imaging services are used appropriately."

Weems also said that CMS is "pleased that GAO's findings suggest that overall beneficiary access ... was maintained under the DRA payment system."

As one might expect, industry took a less favorable view. In a Sept. 30 statement, Stephen Ubl, president of the Advanced Medical Technology Association (AdvaMed; Washington) described the DRA reduction in fees as "draconian" and made the case that "the use of advanced imaging – used to detect and guide physician treatment decisions for cancer and heart disease, both deadly and pervasive diseases – is slowing." However, Ubl did not address the question of whether access had been affected.

The American College of Radiology (ACR; Reston, Virginia) took a similar tack in a Sept. 30 statement by James Thrall, MD, chairman of ACR's board of chancellors, who said the effect of the DRA cuts ran "far deeper than the Congressional Budget Office (CBO) initially stated" and that ACR "supports recent legislation passed by Congress to curtail inappropriate utilization of imaging studies by implementing mandatory accreditation of imaging providers."

However, ACR previously made the argument that access was an issue. In an undated statement obtained from the ACR website, Arl Van Moore, MD, the previous chair of the ACR board of chancellors said Congress ought to repeal the DRA provisions "before these drastic cuts irreparably damage patient access to care."

ACR spokesman Shawn Farley told Diagnostics & Imaging Week that accreditation of imaging centers would help blunt overuse because it would work with appropriateness criteria because accredited clinics are more likely to use appropriateness criteria. "The thing we think is not helpful is these across-the-board imaging cuts that put everyone in one boat," Farley said, adding "when people have applied [appropriateness] criteria, it has turned out that" inappropriate imaging went down.

Tuberculosis admissions down in '06

The Agency for Healthcare Research and Quality reports that hospital admissions for tuberculosis (TB) were down in 2006, but the disease is still a costly one.

According to the Healthcare Cost and Utilization Project report, dated only as October 2008, TB was described as the primary reason for a hospitalization a total of 8,800 times in 2006, which is down sharply from 1995, when roughly 15,000 were admitted with a primary diagnosis.

However, the bacteria involved, Mycobacterium tuberculosis, is still a large factor as a pathogen, showing up as a secondary diagnosis in almost 50,000 hospital stays in 2006, down from 55,500 in 1995.

According to AHRQ's numbers, hospital admissions related – primarily or otherwise – to TB ran up a tab of $752 million, and hospital stays for primary diagnoses of TB cost an average of more than $20,000, a testimonial to the persistent nature of the bacterium. True to form, the regional variance was conspicuous, with the Midwest accounting for an admission rate of 1.4 stays per 100,000 while the Northeast topped the list at 3.6 per 100,000. These are both statistics for primary diagnoses. The report did not include speculation as to whether high population densities are part of the reason that the numbers for the Northeast are so high.

Public health programs paid for almost half the primary diagnosis cases, with Medicaid paying 24.4% of all such hospital stays "even though Medicaid covers only 12.3% of non-maternal, non-neonatal stays," the report notes. Medicare handled another 22% of primary diagnosed cases. Private payers reimbursed almost 22% of these cases.

As for payment for secondary diagnoses of TB, Medicare handled more than 52% and Medicaid 19%. Private insurance handled less than 16%.

The primary diagnosis most likely to be associated with a secondary diagnosis of TB was, not surprisingly, pneumonia at a bit more than 10%, followed by chronic obstructive pulmonary disease at 7% of all cases. Acquired immune deficiency syndrome was third at 5.3%, while congestive heart failure accounted for 2.9% of all secondary diagnoses of TB.

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