We’re about to take another slap if the recent deliberations of MedPAC become real. They’re bound and determined to kill off in-office imaging for all specialties, not just cardiology. To force by public policy all imaging to hospital sites is going to cause quite a problem for patients, both in inconvenience and in increased overall cost. (ACC President Fred Bove has a great President’s Page on the democratization of imaging in the next issue of JACC; watch for it.) Nonetheless, our current version of the IPAB (Independent Payment Advisory Board) is MedPAC, and here’s what they’re doing:

MedPAC staff recently made a presentation to the MedPAC commissioners regarding the “in-office ancillary services” exception (commonly known as the “group practice” exception) to the Stark Law (see the MedPAC slides).  It is this exception that enables private practice cardiologists to provide echocardiography services to their patients.

At the meeting, MedPAC staff suggested that the Commissioners consider three options for addressing the increased utilization that ostensibly results from this exception, especially in the area of clinical lab services, radiation therapy services and diagnostic imaging:

1. Excluding certain services from the group practice exception, such as outpatient therapy and radiation therapy and diagnostic tests that are not usually provided at the time of the office visit.  (According to data presented by MedPAC staff, ultrasound is provided on the same date as the office visit less than 30 percent of the time, so echo likely could not be provided by group practices if this test were adopted.)
   
   
2. Payment tools such as reducing payments for self-referring physicians, packaging services and bundling services.
   
   
3. Establishing a prior authorization program for physicians who self-refer.

In case you’re not watching closely, I need to alert you to the fact that the entire payment system — in both the public and private sector — is in severe disarray. If most doctors are working for hospitals in order to remain viable in the near future, which might be administratively simpler for Medicare and the insurers, the need for payment reform and for physician involvement in it will become even more pressing, because hospital-based costs are going to drive health care costs up. And then, next year, the thrust will be to slash hospital reimbursements. The status quo of the current payment systems, as exemplified by this entry, needs to be changed. Price controls don’t work. When do we wake up here? This is a bad dream.

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