Part of the Solution

As the health care system shifts, radiologists are on the frontlines of patient care — but ongoing reimbursement cuts from CMS are hampering physicians and will ultimately affect patients.in search throwarth

As radiologists, we’re all well aware of, and fully on board with, the need to deliver highvalue health care at a lower cost. We’ve been singing from the quality hymnal for years through our leadership in accreditation and evidencebased imaging.

We’ve worked hard to develop relevant quality measures and a decision support tool that can drive appropriate imaging utilization and improve care while reducing costs. We’re dedicating our smartest health policy and economics minds to thinking about how to make sure radiologists can fit and function within bundled-payment models.

Imaging utilization is not even growing. In fact, it is declining significantly.

So why does CMS continue to make huge cuts to imaging services in the name of “revaluing potentially misvalued services”? Not a single “potentially misvalued service” has seen an increase in value, so you’ll forgive me for being a little cynical about the true intent of the process.

Particularly frustrating is the issue of the payments that radiologists receive for performing CT and MRI examinations (called the technical component). A portion of this payment recognizes the cost of buying the piece of equipment. The cost is recognized in two main ways, both of which have been cut drastically, creating a double jeopardy scenario.

The first way that payments have been cut is by CMS refusing to pay for the total time the machine is being used by a particular patient. CMS states that it should only have to pay for the time that the patient is actually lying on the MRI table having images obtained. It maintains that it should not have to pay for the time taken for the technologist to greet the patient, perform vital lastminute safety checks, and position the patient on the table. Nor is CMS willing to pay for the time that the technologist takes to edit, reconstruct, and package the raw images for optimal interpretation. I don’t think CMS actually believes in this imaginary scenario — that the patient is teleported onto the table from the reception area and the technologist wiggles his nose a la Samantha in the 1960s television show “Bewitched” so that all the image reconstructions appear in a flash. I think CMS knows that work is done; it just doesn’t want to pay for that work. This has resulted in doubledigit- percentage reductions for many services, most notoriously last year to 73721 (MR lower extremity).

You have to admire CMS’s chutzpah. Next time I go to a restaurant, I think I will tell the waiter that I will only be paying for the food, not the cost of cooking or serving it. I’ll let you know how that goes.

To add insult to injury, the assumptions about the amount of time imaging equipment is in use have been ratcheted up through provisions of both the Affordable Care Act of 2010 and the American Taxpayer Relief Act of 2012. Simply put, the more the machine is assumed to be in use, the lower the technical component payment portion, which reflects the cost of buying the unit. This utilization rate assumption has gone from 50 percent to 90 percent, with the last 15 percent imposed this January. This most recent increase in the utilization rate assumption has resulted in an average of 10 percent additional reductions to CT and MRI technical reimbursements. Think about what a 90 percent utilization rate assumption means. In an eight-hour day, the machine is assumed to be running for 7 hours and 12 minutes. CMS pays for one technologist per machine, so that leaves 48 minutes for your technologist to warm up the unit, do quality control, get lunch, and take the odd bathroom break. Heaven forbid there is a study that needs to be re-edited or a phone call to be made. Our technologists are amazing, but in the real world we all know that between patients who don’t show or don’t have their authorization and common glitches that slow down the day, a 90 percent utilization rate is simply not realistic. Our colleagues at the RBMA actually surveyed and found that the old 50 percent rate was closer to the truth when one factored in scanners in rural areas. Those scanners may not see as much use, but they provide a valuable and convenient service to Medicare beneficiaries that threatens to go away with these cascading cuts.

Combine the two issues I’ve outlined above and that’s where it really gets bizarre. Help me understand this, CMS: I’m supposed to use my machine 90 percent of the time, but you’ll only pay for the actual time that images are being acquired?

We are not dumb. We know where healthcare is going, and we want to be part of the solution. We know the contribution that imaging can make to diagnosing cancer while it is still curable, reducing hospital admissions and length of stay, and getting to the diagnosis more quickly and less invasively. It’s hard to focus on the positive though, when you’re worried about paying your staff and making the payments on your equipment. In the end, it’s our patients who will suffer through not having convenient access to high-quality imaging.

So, CMS, please let us use our powers for good. We have so much to offer, and if you’ll stop cutting our reimbursement indiscriminately, we are more than happy to step up and embrace value-based payments.


article 2 headshotBy Geraldine B. McGinty, MD, MBA, FACR, Chair

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