Preparing For Transitions
The work of the Commission on Economics is one of several major ways we provide value to its members and our specialty.
Since its establishment in 1927, the commission has influenced many transitions in federal physician payment structure and helped members adapt to the challenges of change. In 1965, we responded to the development of the federal Medicare program by advocating radiologists be paid under Part B physician payment system and not Part A. Assuring radiologists were paid separately from hospitals has provided the opportunities for the technological and academic advancements that have allowed our specialty to flourish.
Medicare Part B physician payments were initially based on usual and customary charges. However, the late 1980s brought about another significant payment policy transition. In response to Medicare's rising costs, policymakers proposed legislation requiring that physician payments be made using a resource-based relative value scale (RBRVS), and again proposed that radiologists be paid under the hospital payment system and its diagnosis-related groups. Fortunately, the Commission on Economics was able to influence the developing payment policy, and radiologists were not required to become employees of the hospitals. In the process, the ACR agreed to develop a relative value scale (RVS) for radiology, which was adapted in its entirety for the Medicare RBRVS in 1992. This made the transition from usual and customary charges to the RBRVS much smoother for radiology than other specialties, and the ACR's proactive posture in developing its own RVS assured appropriate relativity among imaging services.
Managing the Ups and Downs in Reimbursement
Since 1992, the commission has maintained a high profile in payment policy issues. Our physicians have served as members and advisors to the Current Procedural Terminology® (CPT®) Editorial Panel, assuring there are adequate and accurate CPT codes to describe and report our services. Additionally, our representatives to the AMA-Specialty Society RVS Update Committee (RUC) and the RUC's Practice Expense Subcommittee have worked for the best possible reimbursement for those services. Furthermore, the commission has a network of local radiologists that promotes proper coverage of imaging services by Medicare and private payers.
From 1995 to 2005, technological advances in imaging services and minimally invasive image-guided procedures provided new opportunities for imaging to positively impact patient care in previously inconceivable ways. During that decade, the demand for our services grew, the top medical students were attracted to our specialty, and the business of radiology thrived. Commission activity focused on the creation of CPT codes, seeking appropriate valuation, and assuring appropriate coverage for the wealth of new procedures developed as the result of advances in technology and minimally invasive techniques. This was indeed among the best of times for the commission and our specialty.
However, with this success came the inevitable scrutiny of how much it costs to provide imaging services. In 2005, as the federal health-care system became starved for resources and concerns developed over income discrepancies between primary-care providers and specialists, governmental agencies began examining Medicare's payment policies and became tenaciously focused on the rapid growth in volume and spending on imaging services. Our advocacy efforts correctly explained to legislators that the causes of imaging growth were due to important technological advances that greatly benefit patient care. We also argued that the causes of inappropriate growth could be largely mitigated by employing ACR Appropriateness Criteria® for ordering physicians and by eliminating economic conflict of interest and defensive medicine. Unfortunately, policymakers concluded that the growth in imaging services was primarily caused by the overvaluation of imaging services in the payment system and have proposed numerous payment policy changes — many of which have been enacted and have negatively influenced imaging reimbursement.
Beginning with the Deficit Reduction Act of 2005, a series of legislative and regulatory policies, such as changes to the equipment usage assumption, practice expense payment methodology, and the bundling of CPT codes including CT of the abdomen and pelvis, have decreased Medicare spending on imaging services by billions of dollars. Such governmental agencies as the Government Accountability Office, MedPAC, and CMS, as well as Congress and the White House, continue to propose targeted policies designed to limit or decrease payments for imaging services. Defending this onslaught has led to a higher level of integration and coordination between the College's Commission on Economics and the Government Relations Department and its Congressional advocacy efforts. In addition, in 2004 the Economics and Health Policy departments were put under the direction of the assistant executive director for Government Relations to assure this coordination occurred at the highest levels.
The commission's response to the challenges to imaging reimbursement have bene Herculean, well-coordinated, and, whenever possible, data driven. Although these efforts were not always successful, many of the challenges to reimbursement have been successfully defended, delayed, or significantly mitigated as a result. These years also have seen a dramatic increase in member involvement in economics and government relations. Member responses to RUC survey requests, as well as calls and letters to Congress and CMS, have all increased.
Recently, the thousands of member responses to CMS and Congress regarding the professional component (PC) Multiple Procedure Payment Reduction (MPPR) policy were likely the key reasons CMS lowered the percentage reduction from 50 to 25 percent; we now have nearly 200 co-sponsors for the Diagnostic Imaging Services Access Protection Act (HR 3269) in Congress.
In the Obama Administration's budget for fiscal year 2013, as in years past, more targeted cuts are proposed for radiology in the form of increases to the equipment usage assumption and the institution of radiology benefit management companies (RBMs)-administered prior authorization programs for Medicare. Additionally, CMS may elect to expand the MPPR to other modalities or increase the percentage of reduction. While we have been successful in keeping these changes out of legislation and CMS rulemaking during these past few years, Congress may view these policies as trade-offs for other spending. MedPAC also continues to propose the use of RBMs for prior-authorization of imaging in the Medicare program and proposes significant Medicare payment reductions for specialists while maintaining payments for primary care at current levels. MedPAC also continues to have imaging on their agenda as part of their project to look at the costs associated with repeat testing.
Despite having to use substantial resources to defend the governmental assault on imaging, the commission has also been able to grow and assume a more proactive role for our specialty. In 2008, we established the Future Trends Committee (FTC), which has allowed the commission to also focus on areas where we can be proactive with policymakers and provide information about potential changes in imaging economics, including novel payment models, to members. A key recommendation from the FTC was the development of evidence-based research that shows the value of imaging in the health-care enterprise. To this end, the research arm of the College has been reinvigorated by moving the Research Department into the Economics and Government Relations Division, the hiring of a new Ph.D.-level health economist to lead the department and the establishment of the Committee on Imaging Health Policy and Economics Research (CIPER).
Already, research from CIPER has been instrumental in mitigating the MPPR, producing graphs and charts showing the flattening of imaging utilization, and developing a series of research projects that correlate the performance of imaging studies with an increase in patient complexity. The commission has also been working to prepare the specialty and our members for future payment models if traditional fee-for-service payments are eliminated.
In addition to providing members updates about how imaging might fit into accountable care organizations (ACOs), the Managed Care Committee has developed a capitation handbook to prepare members for this potential payment model. The commission is also working with the AMA, the Brookings Institution, and other groups to develop appropriate solutions for imaging payments in bundled episodes of care.
Policymaker goals of rewarding valuable care over quantity of care present another challenge for imaging reimbursement. The ACR Commission on Quality and Safety has established the ACR as the leader in facility accreditation, promoting radiation safety and appropriate utilization of imaging services. Of these services, utilization management has the ability to provide a way for radiologists to be involved in gain-sharing projects with payers. The ACR Appropriateness Criteria are universally recognized as the most extensively vetted and evidence-based utilization management rules available. However, they have not previously been available as a distinct decision-support tool for referring physicians. Current work at the College has created decision-support algorithms based exclusively on appropriateness criteria rules that can be integrated into computerized order-entry software or available as a cloud-based, stand-alone product that will hopefully be a basis for members to participate in gain-sharing projects with payers or within ACOs to manage imaging in a capitation payment model.
So, this is where we stand today. But the future is certain to bring even more challenges to our profession. I have been a member of the commission for 15 year and we have always been ready to take on challenges of the day. I am confident this will continue into the future. We have the best physician volunteer economics team and specialty society staff in organized medicine, and it has been a true privilege to serve as the chair of the commission for the past four years.
Beginning in late April, I take on new responsibilities for the College as vice chair of the Board of Chancellors, and I am delighted to report that Geraldine B. McGinty, M.D., M.B.A., who is currently the vice chair of the commission, will become the next chair. She has been a long time commission member and is a proven leader and advocate for our specialty. I am confident in her knowledge, leadership ability, and political savvy and am very pleased to have her leadership as we navigate the rough seas ahead.
By Bibb Allen Jr., M.D., FACR