Cancer Scanning Curbed as Cascading U.S. Pay Cuts Take a Toll
Cancer Scanning Curbed as Cascading U.S. Pay Cuts Take Toll
An employee at a General Electric production facility assembles magnetic resonance imaging devices in Beijing, on July 22, 2011. Photo: Nelson Ching/Bloomberg
An employee at a General Electric production facility assembles magnetic resonance imaging devices in Beijing, on July 22, 2011. Photo: Nelson Ching/Bloomberg
Two years ago, Robert Rapoport, a radiologist in Albany, New York, spent about $1 million to replace a 10-year-old open MRI machine, the only one available within a 30-minute drive.
It’s an expense his imaging centers wouldn’t be able to recoup today, he says.
Rapoport, reeling from the effects of $6 billion in federal reimbursement reductions since 2007, says he’s reached the point where he can’t buy equipment for his patients that will be more effective or safer without taking a loss. And this year, he faces a new ruling: The U.S. has set a limit on how much it will pay for more than one scan per patient in a day.
Regulators say the reductions ensure that testing is efficient and necessary. Doctors, though, are pushing a lobbying effort in Washington to peel the cuts back, saying they’ve forced centers to close, limiting how many MRI’s and CT scans are available to cancer patients and trauma victims, particularly in underserved rural areas.
“There will be extreme delays for procedures, delays that could mean a removable mass turns into an incurable cancer,” Rapoport, 47, said in a telephone interview.
Since Jan. 2007, the number of mammography centers in the U.S. has shrunk by 209 to 8,624 on Feb. 1, leaving 1,319 fewer breast cancer scanners in place, according to U.S. data. While the U.S. doesn’t track data on how many facilities have MRI’s and CT scanners, radiologists such as Rapaport say the data reflects what’s happened with all imaging centers.
2007 Change
Reimbursement for imaging centers first became an issue after Medicare spending on the services almost doubled to $13.7 billion between 2000 and 2005. That spurt prompted concern by Medicare officials and U.S. legislators that doctors who owned the equipment, and many of the centers, were doing unnecessary medical scans to boost their profits.
In reaction, the 2005 Deficit Reduction Act trimmed Medicare spending for imaging by $1.7 billion, or 12.5 percent, to $12 billion, starting in 2007. Since then, successive congresses have reduced the amount further and by 2010, reimbursement levels for Medicare spending had fallen to $11.5 billion, the lowest since 2003, according to the Centers for Medicare and Medicaid Services.
Now, radiologists and their Washington-based trade groups are pushing back. They’ve enlisted the backing of 196 U.S. House members for legislation introduced by Representatives Pete Olson, a Texas Republican, and Betty McCollum, a Minnesota Democrat, that would undo the January policy limiting multiple same-day scans while requiring independent cost analysis using a method defined by radiologists to justify any further reimbursement reductions.
Patient Welfare
The cascading cuts shouldered by radiologists since 2007 do more than punish doctors for possible excesses, said Sandra Schneider, a radiologist in Rochester, New York. They are negatively affecting the welfare of patients, particularly those in rural areas, she said.
“We rely on CMS and other agencies to do these measures in the best interest of patient care, not on payment,” said Schneider, formerly the president of the American College of Emergency Physicians. “They’re doing everything they can to show they’re cutting costs without looking at the unintended consequences downstream.”
Government measures to identify what services are inappropriate also are under fire. A new efficiency measure developed by CMS to reduce CT scans in emergency rooms was only 17 percent accurate in assessing which patients should get a scan, according to a study published today in Annals of Emergency Medicine.
Health-Care Spending
Health-care spending in the U.S. reached almost $2.6 trillion in 2010, more than ten times the $256 billion spent in 1980, according to CMS. By 2019, national health spending is expected to reach $4.5 trillion and comprise 19.3 percent of GDP, the center said.
Starting this year, CMS will cut doctors reimbursements by 25 percent each time a Medicare patient undergoes more than one scan in a given day. The policy would save about $100 million that the government wants to use to beef up reimbursements for primary care and other medical services, according to CMS.
The rule may discourage doctors from treating patients after serious accidents or strokes, or limit options for cancer patients whose disease has spread, Schneider said. Such cases may require scans on several parts of the body or repeat imaging to confirm a diagnosis, she said.
Trauma Patient
“The most obvious is a trauma patient who breaks bones in the face and body,” Schneider said. “They’re going to be pushing to not do both studies on the same day.”
Medicare says radiologists can be more efficient, and that limiting payments ensures that more tests are only done when needed.
Doctors say the policy is unfair and doesn’t take into account processing time. Rapaport cites the example of a patient with brain and chest injuries who may need 100 images of each body part. It may take two doctors with different specialties to pore over the data, and it doesn’t make sense for the second physician will be paid less, he said.
In 2006, Herb Kuhn, who was director of the Center for Medicare Management at the time, said the initial cuts were included in the 2005 Deficit Reduction Act because the previous rates provided “inappropriate incentives for growth in volume and intensity of services with limited clinical benefit.”
From 2009 to 2010, as the cuts were rolled out, the volume of imaging services decreased by 2.5 percent, according to CMS.
Skewed Incentives
The old fee schedule “got skewed in favor of specialty services,” said Judith Feder, a fellow at Washington-based Urban Institute, which analyzes social and economic policy.
“Now the schedule needs to be rebalanced,” said Feder, who is also a professor of public policy at Georgetown University in Washington. “We need to reinvest appropriately in primary care as we work to be more efficient and mindful in the way we’re paying specialists.”
The cuts are prompting radiologists to close practices or take hospital jobs, creating gaps in coverage in outlying areas, said Bibb Allen, chairman of the American College of Radiology Economics Commission. Hospitals are reimbursed more for imaging work than the private practices, meaning CMS may end up paying more per patient over the long run, he said.
‘More Expensive Venue’
“In their zeal to try to reduce payments for imaging in the physician fee schedule, they’re really just pushing that work over to a more expensive venue,” Allen said.
The radiologists reference a 2009 study by the National Bureau of Economic Research, showing increased use of imaging is linked with longer life expectancies. A January report in Annals of Emergency Medicine said head injury patients treated with blood thinners to prevent clots should be CT scanned twice in a 24-hour period before they are discharged, to check for delayed hemorrhages.
“Every year we’ve fought one more battle against payment reduction,” Allen said. “We’ve been asked to make an apology for a very valuable tool in the health care enterprise.”
To contact the reporter on this story: Sarah Frier in New York at sfrier1@bloomberg.net
To contact the editor responsible for this story: Reg Gale at rgale5@bloomberg.net
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