Options to Improve Quality and Efficiency Among Medicare Physicians
Statement for the Record of the American College of Radiology Before the House Ways and Means Subcommittee on Health
May 10, 2007
The American College of Radiology (ACR), representing more than 32,000 radiologists, radiation oncologists, and medical physicist members, is pleased to submit this statement for the record regarding the hearing on options to improve quality and efficiency among Medicare physicians.
Fundamental First Steps
There are fundamental steps that need to be taken as Medicare strives to achieve the level of efficiency needed in order to maintain solvency into the future. First, the federal government must encourage and provide incentives for physicians to acquire the necessary health-information technology systems in order to deliver integrated care across multiple provider settings. The upfront expense for many physician practices to purchase, integrate, and operate these systems is often too great an undertaking, resulting in little or no financial benefit for the physician compared to the benefit realized by Medicare and other insurers. In addition, while Medicare takes steps toward greater efficiency in the delivery of physician services, it must move away from the current methodology for reimbursing physicians under the Sustainable Growth Rate (SGR) formula. However, we caution Congress not to make major changes to the payment system without solid evidence-based solutions that have been proven to resolve the existing problems. Only with stable and predictable payments can doctors begin to invest resources in the technology and processes that lead to greater efficiency.
Growth in Volume of Imaging Services
The ACR believes that as the stewards of the Medicare program, Congress must ensure that beneficiaries continue to have access to the highest quality physician care and that this care is delivered in an efficient and safe manner. In the case of diagnostic imaging and image-guided therapy, increased volume and intensity have been shown, in specific clinical circumstances, to lower overall cost by reducing unnecessary hospital admission and surgery. Overall growth in volume and intensity of imaging in the 21st century is appropriate, and may be appropriate at a higher level as compared to the average growth of all medical services, because that growth represents a natural evolution of health care delivery in which diagnosis and treatment are made more rapidly and more accurately. (See Attachment A)
Accreditation Requirement and Standards for Physicians Performing Imaging
There is no doubt that inappropriate growth of imaging exists and we share Congress's desire to make certain that the Medicare dollar is spent wisely. The Medicare Payment Advisory Commission (MedPAC) has put forth numerous recommendations over the years on ways to improve quality and efficiency in the delivery of medical imaging services. In 2005, the Commission recommended that standards be implemented for physicians who perform and interpret imaging studies. MedPAC mentions how much of the recent growth in imaging has taken place in physician offices where there is less quality oversight than in the hospital or independent diagnostic testing facility (IDTF) setting. The ACR believes that in order to ensure that imaging services provided outside the hospital are appropriate, safe, and cost effective, Medicare should require that complex procedures, such as those in nuclear cardiology, MRI, CT, and PET, are performed by experienced and qualified physician specialists working with well-trained technical staff in an accredited facility or physician office. Private insurers requiring accreditation for facilities providing advanced diagnostic imaging have witnessed an increase in quality of care and patient safety, as well as a reduction in repeat tests that have led to cost savings for their programs. In fact, UnitedHealthcare has recently announced that beginning in March of 2008 all beneficiaries receiving advanced medical imaging (MRI, CT, PET, nuclear medicine, and nuclear cardiology) must go to an accredited facility for those services.
Use of Appropriateness Criteria and Feedback for Physicians Ordering Imaging
Beyond patient safety and quality measures such as accreditation, Medicare should implement programs to ensure that seniors are receiving appropriate imaging — the right test, at the right time, for the right reason. Private insurers have found that a disproportionate number of imaging studies are being ordered by a relatively small number of physicians. To that end, the ACR encourages the consultation of Appropriateness Criteria when determining if and when a patient should receive an imaging study. Over the years, the ACR has developed Appropriateness Criteria® for use by primary care physicians, as well as specialists, consisting of evidence-based, expert criteria for selecting the most appropriate imaging for patients depending on the symptoms they present and their medical history. Programs developed by Medicare should include a reporting and feedback component where referring physicians can see how their ordering patterns compare to their colleagues. When using Appropriateness Criteria within a program such as a Radiology Order Entry system (ROE), the ordering patterns of referring physicians can be successfully shifted through educational feedback reports, with the potential result of savings for the payer. In the end, timely and appropriate imaging can produce better patient outcomes through more precise treatment and lowered morbidity and mortality.
Bundled Payments
In its mandated report to Congress on alternatives to the SGR, MedPAC presented the option of bundling physician payments in order to reduce overuse of services. The Commission’s logic is that a larger unit of payment puts physicians at a greater financial risk and provides the incentive to order services judiciously. However, the ACR believes the strategy of bundling payments to physicians has the potential to lead to more problems than it would solve as was witnessed when the private sector experimented with capitation in the 1990s. Questions remain as to how services rendered by a physician in a consulting role, such as is the case with diagnostic radiology, would fit into the concept of bundling. It is not clear that the incentive for a physician to judiciously order images is provided under this option, and in fact it may have the opposite effect. Furthermore, to extend the concept of bundled payments beyond a single episode of care and fully integrate it into the general population of outpatients, in the multitude of complex patient care situations occurring over variable time courses, at multiple locations, and involving multiple and often independent provider decision makers would require a system design so complex that it would likely be administratively unmanageable. The ACR asks that the Health Subcommittee explore this alternative only after careful evidence-based deliberation and in consultation with all provider stakeholders. It is our belief that improving health care efficiencies must be approached from the standpoint of quality with a focus on utilization controls based on appropriateness of care and physician collaboration, with the ultimate goal of improving outcomes rather than having the primary focus on achieving savings.
The ACR looks forward to working with Congress this year towards the shared goals of improving quality and efficiency through ensuring that Medicare pays for the safest, highest quality, appropriate imaging services for beneficiaries.
Attachment A
1. Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. NEJM. 1998;338(3):141-146.
The authors evaluated 100 patients who had CT for suspected appendicitis. Fifty-three had appendicitis; 47 did not. After the cost of CT, overall savings was $447 per patient ($44,731).
2. Jordan JE, Donaldson SS, Enzmann DR. Cost effectiveness and outcome assessment of magnetic resonance imaging in diagnosing cord compression. Cancer. 1998;75(10):2579-2586.
This article is both a retrospective review and literature review. The authors found that with the use of MR in imaging patients with diagnosed cord compression, costs were reduced by 65 percent. Imaging studies utilized prior to MRI for diagnosis included myelography, CT, plain film, and nuclear medicine. The average cost for diagnosis in these groups dropped from $3,664/patient to $2,283/patient. The lack of hospitalization costs with myelography contributed significantly to the reduced cost with MRI diagnosis.
3. Garcia Pena BM, Taylor GA, Lund DP, Mandl KD. Effect of computed tomography on patient management and costs in children with suspected appendicitis. Pediatrics. 1999:104:440-446.
CT was obtained with three strategies: 1) obtain on all patients and discharge if nl, 2) obtain on all pts and admit all, and 3) selectively obtain CT if wbc>10,000.
All strategies decreased the number of hospital days, negative laparotomies, and the per-patient cost. Savings for strategy 1 was $2,018/patient, for strategy 2, $554/patient, and for strategy 3, $691/patient.
4. Rhea JT, Rao PM, Novelline RA, McCabe CJ. A focused appendiceal CT technique to reduce the cost of caring for patients with clinically suspected appendicitis. AJR. 1997;169:113-118.
Use of focused CT reduced both variable and total cost by $23,030 and $ 45,556 respectively per 100 patients. Costs were reduced through decreased number of negative laparotomies and decreased number of hospital days (cost of one negative appendectomy equals the cost of 18 appendiceal CT scans).
5. Rosen MP, Sands DZ, Longmaid HE 3rd, Reynolds KF, Wagner M, Raptopoulos V. Impact of abdominal CT on the management of patients presenting to the emergency department with acute abdominal pain. AJR. 2000;174:1391-1396.
This is a review of 57 patients who presented to the emergency room with acute abdominal pain of a nontraumatic origin. CT added significantly to the confidence level of the emergency room physician's diagnosis evaluated subjectively. The use of CT averted the admission of 10 of 42 of these patients, approximately 24 percent. Furthermore, patient management was altered in 60 percent of patients.
6. Rosen MP, Siewert B, Sands DZ, Bromberg R, Edlow J, Raptopoulos V. Value of abdominal CT in the emergency department for patients with abdominal pain. Eur Radiol. 2003;13:418-424.
Patients with abdominal pain who presented to a teaching facility were evaluated with CT when appropriate. This article demonstrated that 17 percent of hospitals admissions and 62 percent of surgeries were avoided based on the CT findings. There was also a significant benefit derived by the treating physician, markedly improving their confidence level with their diagnoses.
