Nonradiologist Imaging Report Does Not Address Lawmaker Concerns Over Explosive CT, MR, PET Utilization Growth in Medicare System
April 7, 2005
Contact: Shawn Farley
(703) 648-8936
E-mail: shawnf@acr.org
RESTON, Va – A recent analysis of Medicare imaging data, paid for by the American College of Cardiology and members of their coalition, does not adequately address policy makers' concerns that the profusion of in-office high-tech modalities such as CT, MR, and PET are setting the base for a Medicare cost explosion and ignores a decade of data regarding increased volume of medical imaging procedures in self-referral situations by nonradiologists.
The group attempts to make imaging growth appear more in line with growth in other Medicare Part B expenditures by comparing it to a Part B baseline which included services such as durable medical equipment, clinical labs, and ambulance services that are not part of the physician fee schedule, the most appropriate comparison, on which MedPAC and CMS base their independent reports on imaging growth.
Medicare data prove that diagnostic imaging is the fastest growing type of physician service expenditure in the United States, with an annual growth rate twice that of other physician services. The coalition report claims that this is not primarily due to self-referral because "some of the fastest growing imaging services are primarily done by physicians that receive referrals." However, Medicare data show that imaging utilization growth among nonradiologists is up to more than twice that of radiologists, particularly in the in-office setting. Therefore, at current growth rates, nonradiologists will soon do the majority of nonhospital CT and MRI where there are few established quality oversights.
Medicare data clearly show that medical imaging has increased significantly in both hospital and in-office settings since 2000. The ACC coalition analysis claimed that a significant portion of the increase in in-office imaging was due to a shift in site of service from hospital to in-office sites, but does not refute MedPAC estimates that only 20% of the drastic rise in in-office imaging utilization is due to shift in site of service. The ACC coalition report does not account for the other 80% of the overall rise in in-office utilization.
The report also claims that the rise in imaging is offset by the reduction in more invasive techniques that imaging replaces, but does not show which costs are offset. ACR finds that (a) all Medicare costs are growing, so it is not clear what is offset; (b) growth in nonradiologist imaging is much greater than that of radiologists and there is no need for this difference if the only driver of utilization is a general trend towards using imaging to replace other procedures; (c) MedPAC-commissioned research showed that large differences in imaging utilization were not related to significant differences in health outcomes; and (d) a procedure is not cheaper than the alternative if the alternative is no procedure.
The ACC coalition report also claims that the dramatic increase in in-office imaging is justified by the "convenience" of having the equipment in-office for an immediate analysis and treatment of patient condition. Yet, independent analysis of Medicare data demonstrate that only 3% of imaging procedures done by nonradiologists are billed on the same claim as the office visit. Further, convenient access to potentially poor quality or unnecessary services is not a patient benefit. Additionally, a recent Blue Cross Blue Shield study showed that nearly a third of all imaging done by nonradiologists is unnecessary. Unnecessary tests needlessly expose patients to radiation and additional costs.
The coalition report also claims that studies showing lower quality imaging done by nonradiologists reflect the use of older technology such as x-rays and does not reflect a lack of imaging education and training on the part of nonradiologists. However, the report does not offer independent data to the contrary or explain how the quality of nonradiologist imaging has improved by utilizing newer, far more complex, technologies with no significant additions to mandatory imaging training in nonradiologist medical specialties. Radiologists are required to undergo 4 to 6 years of unique, specific, post–medical school training in radiation safety, advanced medical physics, the performance of radiological procedures, and interpretation of medical images. Other medical specialties require as little as 2 days to a maximum of 10 months of imaging training, if specifically mandated at all.
ACR analyses show that if Congress follows through on the MedPAC commissioners' recommendations and enacts facility accreditation and personnel certification requirements, Medicare can save up to $4 billion over the next decade. This would be a major step in protecting the solvency of this important taxpayer-supported program and ensuring that Americans are receiving the highest quality care from the physicians most qualified to provide imaging services.
To arrange an interview with an ACR officer, please contact ACR Public Relations Manager Shawn Farley at (703) 648-8936 or shawnf@acr.org.
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The ACR is a national professional organization serving more than 32,000 diagnostic radiologists, radiation oncologists, interventional radiologists, nuclear medicine physicians, and medical physicists, with programs focusing on the practice of radiology and the delivery of comprehensive health care services.