Why It Matters: the Recent News on the PC MPPR and PALS
Two recent legislative victories made a serious impact on the future of the specialty. Here’s what these events mean for radiologists and their patients.
The Professional Component (PC) Multiple Procedure Payment Reduction (MPPR)
In 2012, CMS used the Medicare Physician Fee Schedule rulemaking process to enact a professional component multiple procedure payment reduction on select advanced diagnostic imaging services, specifically CTs, MRIs, and ultrasounds. For radiologists, this results in significantly reduced payments for interpreting studies performed on the same patient on the same day during a single session. Although ultrasound is not traditionally recognized as an advanced imaging modality, CMS made the unconventional decision to include it within this flawed reimbursement policy. A similar MPPR on the technical component (TC) was previously enacted by CMS in 2006.
Whether applied to the PC or TC, CMS uses MPPRs to decrease imaging utilization by imposing a reimbursement cut on studies performed on the same patient on the same day during a single session. The Medicare Payment Advisory Commission and CMS argued that interpreting multiple imaging studies on the same patient requires less effort. The MPPR is designed to capture these perceived efficiencies.
In a scenario in which a patient underwent multiple imaging studies, the initial MPPR proposal issued by CMS in 2012 would have resulted in full payment for the most expensive advanced diagnostic imaging procedure. Additionally, it would apply a 50 percent reduction to reimbursement associated with any subsequent study performed on the same patient during the same session on the same day and interpreted by the same radiologist.
Through the tremendous efforts of the ACR, CMS altered the PC MPPR proposal so that radiologists would only experience a 25 percent cut in PC reimbursement under the MPPR. CMS, however, used a separate Medicare Physician Fee Schedule rulemaking cycle to expand the PC MPPR in 2013 so that it applies the 25 percent cut to multiple radiologists interpreting imaging studies from the same patient on the same day, irrespective of practice setting. The practices most affected by the policy were those providing the benefits of subspecialty reads to our patients requiring multiple imaging studies, often those individuals struggling with serious conditions or trauma. Effectively, practices were being financially punished for providing more efficient care.
Thanks to the ongoing efforts of ACR’s physician leadership and members working in concert with the Economics and Government Relations Departments, in April 2014 Congress passed legislation requiring CMS to publicly disclose the data the agency theoretically consulted when it first implemented the 25 percent PC MPPR. ACR routinely utilized a 2011 peer-reviewed JACR® article to demonstrate that any professional component efficiencies varied by modality and were no greater than 5 percent. Unfortunately, CMS ignored this statutory mandate and refused to publicly disclose any supporting data.
In light of CMS’s unwillingness to release the necessary data, on Dec. 18, 2015, Congress passed and the president signed into law H.R. 2029, the Consolidated Appropriations Act of 2016. This bipartisan legislation includes provisions that decrease the PC MPPR from 25 percent to 5 percent. This new rate, which more accurately reflects the empirical evidence related to PC MPPR efficiencies, will go into effect Jan. 1, 2017. Successful enactment of this legislation was, once again, in large part due to the tireless efforts of the physician volunteers and staff of the ACR.
USPSTF Screening Mammography Draft Guidelines
As we’ve discussed in this article, the Affordable Care Act requires private insurers to cover preventive services given a grade of B or higher by the U.S. Preventive Services Task Force (USPSTF) without any form of cost sharing. Unfortunately, the USPSTF proposed a C grade for women 40–49 and a B recommendation for mammograms every other year for women 50–74. In addition, the task force proposed an I grade for digital mammography or MRI instead of film mammography as screening modalities for breast cancer, meaning the evidence for or against the procedures was insufficient. According to a May 2015 analysis released by Avalere Health, the draft USPSTF recommendations would have placed approximately 17 million women in jeopardy of losing guaranteed access to annual mammograms.
With this information in hand, ACR, in conjunction with a number of other physician and breast cancer screening advocacy groups, worked to introduce the Protecting Access to Life Saving Screenings (PALS) Act. This bipartisan legislation sought to place a two-year moratorium on the imposition of the April 2015 USPSTF breast cancer screening draft recommendations and to expand the definition of screening mammography to include any digital modality of such a procedure.
Although the USPSTF has not yet issued its final recommendations, Congress did include some legislative language from the PALS Act in H.R. 2029, the Consolidated Appropriations Act of 2016. As a result, private insurers will continue to be required to provide women ages 40 and over with an annual screening mammogram without any form of cost sharing until Jan. 1, 2018.
The ACR is constantly working for its physician members and patients. These two major legislative victories are just a few examples of the hard work by the physician volunteers and staff of the ACR. Thank you to all the members for their support. And if you are not a member, please consider joining.
By Colin Segovis, MD, PhD (@colinsegovis), RFS secretary and resident at Wake Forest University