American College of Radiology blog

Is Radiology Recession-Proof?

As more Americans are feeling the effects of the economy, it should come as no surprise that people are opting out of health care. The primary reason? Costs.

A survey of 12,000 Americans released last week found that about 20 percent of Americans have skipped medical care. About the same percentage thought they would have a difficult time paying for medical care in the future. However, only about 8 percent of those surveyed indicated skipping some form of medical imaging. More than half said they skipped a doctor’s visit.

Does that mean that Americans value medical imaging over a visit to their primary care doctor? That would be hard to determine from this one study. But it is something to think about.

The College is interested in knowing what you think.

• Has your practice or hospital experienced any effects from the economy?

• Or, have patients cancelled any imaging studies due to costs?

I look forward to hearing your thoughts.

ACR, Patient Groups, Industry Make Case for CTC Coverage

Despite significant evidence of CT colonography’s effectiveness as a screening tool for colorectal cancer, on Feb. 11, the Centers for Medicare and Medicaid Services (CMS) announced a proposed decision not to cover the exam, stating that the evidence was inadequate to conclude that CTC would provide health benefits to the average Medicare beneficiary.

In the CMS proposed decision memo, opponents to coverage cited unknown effects from radiation exposure associated with the exam, questions as to the amount of training necessary to properly read the exam, and concern that it would be difficult to generalize the results of the ACRIN CT Colonography Trial to the average practice setting and specifically to the Medicare population.

The ACR and other societies have been working together to reverse CMS’s proposal by educating members of Congress that using CTC as a screening method for colorectal cancer will help more people to get screened, aid in early detection and ultimately help save lives.

At a Capitol Hill briefing last Monday, Elizabeth McFarland, M.D., chair of the ACR Colon Cancer Committee, made a presentation to congressional and regulatory staff members on behalf of the College as to the effectiveness and importance of this exam. In response to these efforts, several lawmakers have signed on to letters written to CMS urging them to cover CTC.

In a letter to the editor published in Saturday’s New York Times, Andrew R. Spiegel, chief executive of the Colon Cancer Alliance, Ilyse Schuman, managing director of the Medical Imaging and Technology Alliance, and myself, reinforced the proven cost-effectiveness of CTC as well as its “potential to enhance colon cancer screening compliance.”

The 30-day public comment period for the proposal ended on Friday, CMS is expected to make a final (at least for the immediate future) decision on coverage by May 12.

For those of you who currently offer/perform CTC:

• Has your practice seen an increase in CTC volume since the results of the ACRIN study were published in the New England Journal of Medicine last fall or a decrease since CMS proposed not to cover the exam?

And if you do not currently offer/perform CTC:

• Will Medicare’s final coverage decision determine whether or not you add this exam to your practice or seek out training?
  
  

I look forward to your thoughts.

Radiation Exposure Back in the News

As you may know, on Tuesday, the National Council for Radiation Protection and Measurement (NCRP) issued a report stating that Americans were exposed to seven times more radiation from medical imaging exams in 2006 than they were in 1980.

Radiation exposure is always a hot topic and has garnered a significant amount of media attention over the past several years. Some of this attention can alarm patients, as did the November 2007 NEJM study which claimed that up to 2 percent of all cancers can be attributed to radiation received from CT scans.

The College immediately issued a response to the latest NCRP report advising patients to consider the information within the report in its proper context and to discuss any concerns about radiation exposure with their doctor. It is important for people to understand the undeniable benefits of medical imaging in early detection and staging of diseases, and not to forgo testing out of fear.

Although the NCRP report did not go into causes of the dramatic increase in dose, the NCRP’s executive director did, at a recent international conference, identify self-referral as a primary driver of the trend.

The ACR response and statements by College spokespersons made clear the tie between self-referral and increased imaging in a resulting Reuters Health article and in other print and broadcast news reports.

The NCRP study also served as an opportunity for the to College to publicize what steps have been done thus far to lower dose, like the adoption of principles such as ALARA (as low as reasonably achievable), the Image Gently^SM campaign (www.imagegently.org), and ACR Appropriateness Criteria® (www.acr.org/ac) which can help physicians prescribe the most appropriate imaging exam for more than 200 clinical conditions.

I would like to know:

• What are your overall thoughts on this NCRP report?

• Have you had patients ask you about radiation risk as a result of the report and the associated media coverage?

• What do you tell them?

*Note: Keep in mind your comments will be in the public domain.

Savings Through Spending: Obama’s Budget Announced

On Thursday, President Obama announced his $3.6 trillion budget plan for the 2010 fiscal year. The plan would create a “health care reserve” costing $634 billion over 10 years, in an effort to provide universal health coverage. Tax increases and cuts to Medicare and Medicaid would fund the reserve.

According to the plan, increased spending on insuring all Americans upfront will save money in the long run, because patients will seek out care and engage in preventative measures to reduce the occurrence of chronic (and often costly) diseases.

The proposed plan would seek to control imaging costs through the use of radiology benefit management companies in the Medicare program. The ACR, however, has argued that the use of Appropriateness Criteria in an order entry system is a better way to monitor imaging, and ensures that patients receive the best study for their condition in a timely manner.

Other health care measures in the plan include:

• $1 billion to the FDA to improve food safety
• $6 billion for cancer research
• $76.8 billion toward EMR adoption and medical treatment comparison
• $330 million toward addressing doctor and nurse shortages

What do you think about the budget plan in terms of health care reform?

What do you think are the strengths and shortcomings of the plan?

I look forward to your comments.

How We’ll Tackle 2009

Get organized …
Lend a hand …
Listen more …

These may seem like your basic list of New Year’s resolutions, but they’re actually taken straight from our colleagues in the field.

In the latest edition of ADVANCE for Imaging and Radiation Therapy Professionals, I offered my vision for what the ACR would put forward in 2009. You can read what I (and others) had to say here.

It’s no secret that we will face another round of hard issues in the year ahead. With the Obama Administration taking office in just a few days, there are already items on the table that will affect us. Prior authorization is one of them; changes to how Medicare reimburses for the technical component of imaging exams is another.

Education and advocacy remain at the heart of the College’s mission, and we will continue to strengthen our presence in the face of the forthcoming health care legislation.

There are a great many items on the agenda for 2009. New courses will be added to the ACR Education Center over the next few months. ACR staff is working to tailor your membership to your needs, using the newly launched Practice of Radiology Environment Database (PRED), and much more.

Despite any challenges we encounter this year (and there will be challenges), the ACR will remain at the forefront to lead the way. Please write in with what you think radiology’s biggest challenges are for the coming year and how you think the ACR can help.

I very much look forward to your input.

MedPAC to Augment Primary Care Physician Reimbursement: Will That Attract More Doctors or Just Hurt Others?

The Medicare Payment Advisory Commission (MedPAC) has proposed an increased reimbursement to primary care physicians treating Medicare patients. The recommended increase, which is scheduled to reach Capitol Hill in June, is due primarily to recent data that suggest some Medicare beneficiaries may have difficulty finding a primary care doctor, and that fewer medical students are entering primary care.
                              
However, Sen. Max Baucus (D-Mont.) plans to submit Medicare legislation to the Senate in May which could include the proposal to increase primary care physician reimbursement in addition to another delay to the 10 percent cuts scheduled to hit all physicians July 1. The increase to primary care may come at the expense of other specialties.

If Congress follows MedPAC’s recommendation, the budget neutrality rules in Medicare’s budget will offset an increase to primary care doctors with a cut to others. The ACR is educating Congress that radiology cannot absorb another round of cuts to pay for increases to other specialties and offering more effective, targeted measures such as accreditation and the use of Appropriateness Criteria that can actually help eliminate unnecessary costs and raise quality of care.

Also, while adjusting reimbursements is one way to attract more students, it won’t diminish all of the perceived drawbacks to a career in medicine. Take Monday’s article in Forbes Magazine for example: Reasons Not to Become a Doctor. Citing increased practice costs versus lower reimbursement rates, cost of malpractice insurance, preauthorization, and student debt, it’s no surprise students are fearful of physician careers. See my post from last December about attracting more medical students to radiology for more on this topic.

Some hospitals are compensating by adding a new position to their workforce: the hospitalist. I read last Tuesday’s Wall Street Journal article on hospitalists with great interest, as it described the up-and-coming physician generation as seeking a work-life balance — and they’re getting it.

There are many issues here. Some will affect us imminently and others will be more impactful in the future. But I wonder, is there an alternate way of addressing this physician shortage while not pitting one physician specialty against another? What do you think is causing fewer Americans to become physicians?

I look forward to your thoughts.

ACR Actions Regarding Financially Motivated Self-Referral

One issue that obviously needs more discussion here is about what specific initiatives the ACR is undertaking regarding financially motivated self-referral. Frankly, it has been astonishingly difficult to get this concept across to people in Congress and their staffs as well as CMS. From the point of view of many of them, it  seems logical that if Dr X determines one of his/her patients needs a CT scan that he/she provides it in their office, in similar fashion to a flu shot or anything else. Many also perceive this to be a matter of patient convenience. This is the perception fostered by self-referring physicians that the ACR has been fighting for over two decades.

There are reasons now, however, to think that perhaps, just perhaps, the tide may be turning and policymakers in Washington are taking a fresh look at the role ownership may play in the prescribing of certain physician services.

One reason both Congress and their policy advisory body, MedPAC, are taking a fresh look at self-referral is that they are running out of other reasons to explain why some physician services grow exponentially faster than others. In this vein, it seems most certain that Congress, this year, will prohibit physician ownership in specialty hospitals. While we have tried for years to link the arguments of our concerns in imaging to the specialty hospital ones, it now appears some on Capitol Hill are listening. Also, MedPAC, the highly influential advisory body to Congress has now listed “ownership” and the use of certain services as a major policy they will study. Their interest is primarily driven by their concerns about the growth of imaging services, and we have been meeting with them, closely, for several years to educate and illuminate their understanding of the complexities of this problem.

Another sea change in Washington is that the dominant political philosophy in Congress changed in the last elections and is poised for further changes in the upcoming 2008 elections. The former Republican majority believed in a market-driven health care environment and government edicts about ownership was not a popular or well-liked philosophy. The new majority Democrats are much more supportive of a government-centered, regulatory health care model. This may indeed help us in our arguments against self-referral but we need to be cognizant that in other policy decisions, we may not like this kind of control.

So, what else can we do? In the long run, there is nothing better than data, objectively developed and relentlessly applied, to turn people's outlooks around. However, it is extraordinarily difficult to develop the kind of information that is now helping turn the tide. Our primary obstacle is that no payer, Medicare or private insurer, looks at ownership as a factor in determining coverage or payment for a particular service. As a result, input data must come from insurance billing records that are controlled by corporate and government entities with their own agendas. Data analysis requires sifting through millions of patient records to group services into episodes of care that are then further analyzed to see whether the same kind of specialist who billed for the office visit also billed for the imaging study or whether the imaging study was billed by a radiologist.

The ACR has always recognized the importance of this kind of analysis and has funded research on the relationship of utilization and self-referral by Scott Gazelle M.D., Ph.D., and similar research by an internal research group lead by Dr. Jonathon Sunshine, an economist.

These activities are bearing fruit. Dr. Gazelle recently published a major study in Radiology and the ACR staff has had the opportunity to present our data to leaders at the Centers for Medicare and Medicaid Services (CMS) within the past month. The data are eye opening and clearly indicate that where referral is linked to financial incentives, the utilization of imaging skyrockets. CMS is now planning its own analysis, stimulated in part by data supplied through these ACR initiatives.

Following the passage of the DRA in 2005, a new front was added to the ACR's efforts to support the practice of radiology. We helped organize a broad based coalition of manufacturers, patient groups and other medical specialties to create the Access to Medical Imaging Coalition (AMIC) to protect the outpatient practice of radiology. For the specific issues involved, the ACR has worked well with other organizations that we have not always been close to and with the imaging device industry. A tangible good outcome of the work done by AMIC is the recent letter addressed to the Senate Finance Committee leadership signed by 30 Senators stating their opposition to further cuts related to imaging. A powerful statement and indicator that the ACR message is being heard on Capitol Hill.

James H. Thrall, M.D., FACR

Chair, RADPAC

Vice Chair, American College of Radiology Association (ACRA)

RADPAC® and Radiology’s Efforts to Eliminate Economically Motivated Self-Referral

I was recently asked by a member if RADPAC, radiology’s political action committee, is formidable enough to affect change in Washington, particularly in regards to economically motivated self-referral.

In response, I would say that RADPAC has been very effective in helping radiology gain access to Congress but it could use more support from the membership. Right now, about 6 percent of members contribute each year, and we are being out spent by several other specialties. To be most effective, we need to collectively increase our commitment. Nonetheless, RADPAC contributed over $1 million to members of Congress in the last election cycle.

After years of RADPAC contributions to candidates and radiology’s lobbying of both Congress and CMS regarding the abuses of economically motivated self-referral without the kind of response we want, we are actually now seeing a broad-based awakening — radiology’s message has been heard.

Several provisions in the Centers for Medicare and Medicaid Services (CMS) proposed rule call for implementing aspects of the Stark legislation from years ago to reduce the abuses of self-referral — for example, closing loopholes such as sham leasing arrangements.

Beyond that, CMS is undertaking a study based on insurance claims data to calculate the impact of self-referral by comparing imaging utilization rates in self-referral versus non-self-referral situations. We already know what they will find!

Moreover, Congress appears to be developing a better understanding of self-referral abuses, and insurance companies are increasingly stipulating that imaging facilities be accredited by the ACR (or other entities), which eliminates the worst offenders using outdated equipment.

So back to the basic question — is RADPAC strong enough to win? I believe it can be, and we have a terrific team in Washington but it will require ongoing financial support and the involvement of radiologists with our lobbyists to help tell our story to legislators, regulators, and the payer community.

If we as radiologists all invested as little as one or two dollars a day — $365-$730 per year — we would have the resources in RADPAC to be the number one funded medical political action committee (PAC) and guarantee that our message gets across with maximum impact.

The tide is with us. Now is the time to strengthen our efforts to support RADPAC and keep up our momentum.

James H. Thrall, M.D., FACR
Chair, RADPAC
Vice Chair, American College of Radiology Association (ACRA)

ACR Member Interaction with Elected Officials

This week, the House of Representatives passed legislation to provide a $35 billion expansion of the children's health insurance program. The Senate is expected to pass this same legislation later this week. The bill does not include any Medicare provisions, including any cuts in medical imaging reimbursement.  

The fact that Medicare provisions, particularly the imaging cuts, were not included in the final bill means that the House will set aside those provisions, originally contained in the House passed Children’s Health and Medicare Protection (CHAMP) Act, until the Senate is ready to address Medicare later this fall. Rest assured, the ACR will continue to work on improving the House Medicare language and addressing the imaging cuts contained in CHAMP.

In the past, the ACR has asked members to educate their Members of Congress on the importance of medical imaging and how imaging reimbursement cuts can hurt quality of care and patient access to care. We have provided materials on the ACR Web site to help our members do this, but it might be helpful for members who, perhaps, have not spoken with their legislators before to hear from other members who have. 

Please share your experiences of interacting with your local, state, and federal lawmakers and share any tips you might have for other ACR members on how they might do this more effectively.

I look forward to your feedback and I think your fellow members will appreciate it as well!

Cynthia R. Moran
Assistant Executive Director for Government Relations and Economic Policy
American College of Radiology

---

To leave a comment, click the "Comments" link below. Scroll down through the posted comments to find the comment form. Fill in the form and click the "Post" button. If you need more detailed instruction, click here.