Health Care Reform
Proposed Medicare Cuts for Imaging Services will Impact Early Diagnosis of Deadly Diseases
Sep 13, 2009 - 12:15:39 AM

( - Speaking to a joint session of Congress and the American people this week, President Obama made very clear his belief in the important value of routine check-ups and preventative health care in the context of overall health care reform, noting “…there’s no reason we shouldn't be catching diseases like breast cancer and colon cancer before they get worse.”

The President knows that early detection saves money and lives, which is why he wants to require private insurance companies to cover these screenings. For the benefit of our nation’s seniors, the same test should be applied to the Medicare program.

Unfortunately, health reform proposals in Congress fail that test by erecting needless barriers that impede physicians’ ability to diagnose disease, such as cancer and heart disease, early -- when they are most treatable. Billions of dollars in proposed cuts to Medicare reimbursements, on top of billions more made just three years ago, will stand in the way of seniors’ ability to access vital diagnostic imaging tests, such as computed tomography (CT) and magnetic resonance imaging (MRI) scans, in the outpatient setting.

Under these new proposed Medicare reimbursement cuts, physician practices just won’t be able to stay in business. Those that do will be forced to pull back services, stop or limit accepting Medicare patients, stockpile patients in their waiting room, and force seniors to wait long periods of time to schedule appointments. Because of the nature of these Medicare cuts, these problems would be greatly magnified in rural areas of the country.

Meanwhile, what will this mean for preventive diagnostics and early detection of diseases among the Medicare beneficiary population? Many times it will mean they will forgo a test that could detect cancer when it’s treatable. Other times, diagnostic tests will be delayed, allowing a cancer to grow or plaque to build up in an artery. At best, it will mean seniors will be forced into the hospital for CTs and MRIs, possibly increasing their risk of infection and most definitely costing both patients and the Medicare program more money.

Voters clearly understand medical imaging’s value in early diagnosis of disease, and so they oppose efforts to cut Medicare spending for imaging. A Zogby Interactive opinion survey of 4,426 likely voters released on the eve of the President’s speech reveals that 71 percent of voters oppose making further Medicare cuts to advanced imaging tests and screenings as a means to pay for health care reform. The truth is that advanced medical imaging such as CT, MRI, and positron emission tomography (PET) allow physicians to better detect disease, diagnose patients and determine the proper course of treatment. Yet even in the face of widespread opposition to imaging cuts, a number of reform proposals circulating in Congress would limit access to these vital tests.

The proposed cuts stem from a dramatic change in the utilization assumption (the amount of time in a 50 hour work week a CT, MRI or PET machine is assumed to be in use) that is plugged into Medicare’s formula to determine the price the program pays for an imaging scan. Proposals put forth by the Obama administration would dramatically increase the utilization rate assumption for advanced imaging equipment from 50 percent to 95 percent. The House Tri-Committee’s bill proposes increasing the utilization rate assumption to 75 percent. An increase of either amount would severely reduce reimbursements and limit Medicare patients’ access to diagnostic tests that save lives.

Harmful in and of themselves, these proposed cuts are in addition to Medicare cuts to medical imaging reimbursement that resulted from enactment of the Deficit Reduction Act of 2005 (DRA). These cuts are already impacting the availability of imaging services, especially in rural practices, and resulting in the loss of vital healthcare jobs. Data from the Government Accountability Office (GAO) show that, in 2007 alone, $1.64 billion was cut from reimbursements for vital advanced diagnostics, such as CT scans and MRIs.

An independent analysis conducted in 2009 by The Moran Company, one of the nation’s most respected health policy organizations, supports the GAO finding. The Moran analysis shows that spending on imaging has not been skyrocketing as some wrongly maintain. In fact, the data show that Medicare spending on advanced imaging was reduced by 19.2 percent from 2006 to 2007, and volume of service grew only a modest 1.9 percent. Additional drastic cuts, such as those proposed by Congress and the Obama Administration, will further reduce access to imaging and impair physicians’ ability to detect diseases when treatment is most likely to achieve the best clinical outcomes.

There is good reason to believe that the rationale behind these proposed cuts is nothing more than an attempt to extract money from the Medicare program. The problem is that current proposals would reduce Medicare reimbursements too drastically, moving the utilization assumption to an unrealistic level. The 90 percent utilization assumption being considered by members of Congress is based on a flawed survey commissioned by the Medicare Payment Commission (MedPAC).

In making its recommendation, MedPAC itself cautioned against using its survey to determine equipment use rates, saying in an April 2006 meeting, “This survey is a first step…It was not nationally representative and it was not designed to determine equipment use rates. Its intent was to assess the feasibility of getting use rate data from the survey.”

The Centers for Medicare and Medicaid Services (CMS) also agreed that the MedPAC’s survey was unsound, stating in its 2007 proposed physician rule, “We do not believe we have sufficient empirical evidence to justify an alternative proposal [to the 50 percent utilization assumption.]”

Better evidence of actual use rates is available. According to data collected earlier this year by the Radiology Business Management Association (RBMA), the amount of time imaging equipment is in use in outpatient settings does not approach use rates the Obama Administration, Congress and MedPAC have proposed. In fact, RBMA’s data show that imaging equipment in rural regions of the country operates only 48 percent of the time an office is open for business, while equipment in non-rural areas operates 56 percent of the time a center is open.

Yet the flawed 90 percent utilization assumption recommended by MedPAC serves as the basis for current legislative proposals. Before signing any such proposals into law, we urge the administration to direct the Department of Health and Human Services to launch a public-private partnership tasked with collecting more comprehensive and accurate data from equipment scanning logs that measure the actual time an imaging machine is in use.

Limiting access to advanced medical imaging such as CT and MRI is worrisome enough. But there are larger implications as well. It’s not only access to CT and MRI that is threatened by deeper cuts. Access to mammography and dual energy x-ray absorptiometry (DXA) will also be limited. With reduced reimbursements for CT and MRIs, outpatient practices cannot offer tests, such as DXA, that are poorly reimbursed.

Fortunately, there is a better way. Rather than proposing utilization rate increases, which would undercut the value of preventive health care to which President Obama himself subscribes, the medical imaging community supports sensible reform efforts such as the use of appropriateness criteria in ordering imaging services, accreditation of imaging facilities, and physician education and feedback programs to reduce costs and ensure proper utilization of imaging, without compromising patient access. Defensive medicine also contributes to unnecessary costs to our health care system and must be addressed. These measures, if adopted, will ensure that patients have access to high quality care and can receive the right scan at the right time.

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