| February
10, 2005
The Coalition for Patient-Centered Imaging
(CPCI) represents the undersigned healthcare organizations
committed to ensuring that patients have full access to high
quality, convenient, and up-to-date imaging technology. The
Coalition organized in response to efforts to limit the availability
of imaging services provided in physicians’ offices.
As the use of imaging services has increased,
some medical organizations and health plans have sought to
place the “blame” for this change on physicians,
such as obstetricians/gynecologists, neurologists, orthopedic
surgeons, cardiologists and urologists, to name a few, who
use these technologies in their office practices. Because
these physician services are included under the volume considerations
of the sustainable growth rate, they are clearly relevant
to today’s hearing on physician payments.
Office-based imaging services offer three important
advantages to patients. First, office-based imaging speeds
correct diagnosis and treatment of the patient’s medical
condition. For example, a patient who visits an orthopaedic
surgeon with knee pain will almost certainly need an image
of the knee for proper diagnosis. If the orthopaedist provides
these services in the office, examination, diagnosis and initiation
of therapy can be done in one encounter with the patient.
If the physician were not able to provide the service, diagnosis
and treatment would be delayed until the patient was seen
by the radiologist and that physician sent the report back
to the orthopedist. Another patient visit to the orthopaedist
would be needed to review the findings and determine the appropriate
therapy. This results in unnecessary delays in treatment and
added costs as noted below.
Second, as can be seen from the preceding scenario,
in-office imaging is very convenient for the patient. This
is especially important for elderly Medicare beneficiaries
who may have limited transportation options or mobility problems.
The fact that their physician is skilled in both the imaging
aspect and physiology of their ailment increases patient confidence
as well.
Third, in-office imaging can limit Medicare
spending by reducing the number of office visits and other
physician encounters that are billed to the system. By providing
“one stop shopping” the orthopaedic surgeon has
reduced the number of office visits required to complete the
diagnosis and treatment decisions for the patient. The alternative
requires one visit to the physician to determine that an image
is needed. This is followed by the encounter with the radiology
practice. Finally, the patient must return at least once to
the physician’s office for review of the image and treatment
decision. All of these encounters engender a separate billing
to Medicare. In-office imaging reduces the number of billed
encounters, thereby reducing spending for evaluation and management
services.
The Medicare Payment Advisory Commission (MedPAC)
is in the process of finalizing its March report to Congress
that will include recommendations relating to imaging services.
They fall into two main categories: 1) safety and quality
and 2) billing and payment. CPCI has cautioned MedPAC to frame
any recommendations carefully to ensure that they are not
interpreted in a manner likely to impede patient access to
high quality physician imaging services.
Furthermore, we have urged the Commission to
assure that any statistics cited in the final report regarding
utilization of imaging services do not overstate actual growth
due to shifts in site of service. According to MedPAC, about
20 percent of the overall 8.6 percent growth in imaging services
are attributable to shifts in site of service, rather than
new volume. If these shifts in site of service were appropriately
accounted for, the actual overall growth rate for imaging
would be about 6.9 percent by our estimates. Because some
interests will urge Congress to respond to the increase in
imaging services, we believe it is important not to overstate
that number. Congress needs greater certainty in the data
on increased use of imaging services than now exists. It is
also important to understand that the greatest increases are
in the higher technologies, such as CT and MRI, areas already
dominated by radiology.
The public needs to understand the extraordinary
contributions of diagnostic imaging to physicians’ ability
to diagnose and treat illness quickly and accurately. We do
not believe that the issue of whether or to what extent the
increase in diagnostic imaging utilization is medically unnecessary
has been fully explored, and, therefore, we believe any action,
such as mandatory accreditation and privileging, that could
result in arbitrarily limiting diagnostic imaging utilization
would not be appropriate.
Opponents of office-based imaging have challenged
the competence of the physicians who provide such services,
as if only they possess the knowledge required to safely perform
and interpret diagnostic imaging. The ability of a physician
to interpret a diagnostic image cannot be determined based
exclusively on the physician’s specialty. In fact all
specialties include as a part of their training the education
and experience needed to use the imaging technologies that
have become an essential component of their practice. If Congress
looks to the use of accreditation programs as a means of assuring
safe and appropriate use of imaging, it is critical that those
organizations that explicitly or implicitly authorize only
radiologists to perform or interpret imaging studies not be
the sole source of accreditation. To the extent that specific
accreditation organizations are named, we urge that a number
of such organizations be included, to avoid any implication
that Congress endorses any particular set of standards.
Congress should not assume that there is consensus
in the physician community regarding the training, experience,
and other requirements for interpreting physicians in each
modality. In fact, standards of practice are always evolving
and it is not uncommon for there to be disagreement regarding
the appropriate training and experience standards among different
specialties or even within a particular specialty. We seriously
doubt whether sufficient credible data exists to determine
which standards are appropriate. In addition, we do not believe
it is practical or prudent to place CMS in the position of
arbiter in this arena, nor do we believe that it is appropriately
within the purview of the federal government to review each
interpreting physician’s particular credentials.
CPCI also cautions Congress from accepting
the notion that significant cost savings to the Medicare program
can be achieved by mandating accreditation and physician qualifications
without a thorough analysis into why growth in imaging services
is occurring and who is responsible for that growth.
Those who purport significant cost savings
claim that the growth in imaging services is due to inappropriate
utilization. However, the few studies that MedPAC has cited
during its public discussions to justify its recommendations
for accreditation and privileging are insignificant and overtly
biased. For example, MedPAC has referenced a 1998 study by
Verrilli for Blue Cross Blue Shield of Massachusetts that
suggests 2 percent savings in imaging services were realized
when physician privileging and facility accreditation standards
for diagnostic imaging services were combined. However, MedPAC
has failed, in public discussions, to acknowledge that the
study found a higher failure rate among chiropractors and
podiatrists than among medical and surgical specialists during
site inspections. We suggest that MedPAC’s claim of
cost savings should not be based on a study that found a higher
failure rate among non-physician providers that have limited
ability to bill Medicare for imaging services. In another
study frequently cited by MedPAC (Moskowitz), the findings
were based solely on an examination of radiography, or X-rays,
and did not outline any clear cost savings. While quality
improvement is a goal shared by all physicians, to assume
savings from such studies is inherently risky.
Congress should be cautious about statements
that raise issues of imaging safety in the absence of credible
and impartial studies documenting that medical imaging raises
serious public safety concerns. Data cited on this issue in
prior MedPAC reports is based on an unpublished survey conducted
in Utah by a company that sells radiology benefits management
services to insurers and authored by a radiologist who is
one of the most vocal opponents of in-office diagnostic imaging.
Various aspects of medical imaging equipment safety are already
regulated by the Nuclear Regulatory Commission, the Food and
Drug Administration, the Occupational Safety and Health Administration
and by state authorities. In the absence of credible, published,
peer-reviewed literature documenting safety concerns arising
from the use or misuse of diagnostic imaging, we urge Congress
to shy away from the conclusion that these agencies are not
performing their designated functions adequately.
MedPAC has proposed changes to coding edits
and billing practices that could reduce the number of individual
imaging services that can be billed by physicians. As imaging
technology has evolved, it is appropriate that Congress review
current billing rules to determine if they are still relevant
for current use. It is not yet clear to what extent savings
might be found. We believe that further analysis is needed
before Congress directs CMS to incorporate new billing rules.
CPCI appreciates the opportunity to provide
these comments to the Subcommittee on the subject of the current
use of imaging technology in medical practice. We urge caution
in the examination of MedPAC's recommendations and encourage
Congress to assure that any actions it takes in this area
reflect the consensus of a broad and balanced group of affected
organizations and are done in the best interests of Medicare
beneficiaries.
American Academy of Family Physicians
American Academy of Neurology
American Academy of Ophthalmology
American Association of Clinical Endocrinologists
American Association of Orthopaedic Surgeons
American Association of Neurological Surgeons
American College of Cardiology
American College of Obstetricians and Gynecologists
American College of Surgeons
American Gastroenterological Association
American Medical Group Association
American Society for Gastrointestinal Endoscopy
American Society of Breast Surgeons
American Society of Echocardiography
American Society of Neuroimaging
American Society of Nuclear Cardiology
American Urological Association
Congress of Neurological Surgeons
Heart Rhythm Society
Medical Group Management Association
Society for Cardiovascular Angiography and Interventions
Society for Cardiovascular Magnetic Resonance
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