Medicare Compliance & Reimbursement

More use might not mean overuse, some say.

The Medicare Payment Advisory Commission says Medicare should set national standards of expertise for providers who bill the program for performing and interpreting diagnostic imaging studies.

Ways and Means Health Subcommittee chair Nancy Johnson (R-CT) is skeptical.

Testifying before Johnson's panel on March 17, MedPAC Executive Director Mark Miller outlined the concerns that led MedPAC to advance its provider-credentialing proposal - which would also include standards for the machines themselves - as well as other recommendations designed to control imaging utilization.

Miller said the volume of imaging services paid under Medicare's physician fee schedule grew 45 percent between 1999 and 2003, twice as fast as the 22 percent growth for all other physician services. Medicare spending on imaging grew 60 percent, from $5.7 billion to $9.3 billion, over the same period.

Miller: Imaging Amount Doesn't Affect Quality

Miller noted that less than one-fifth of the increase in imaging procedures billed under the fee schedule is explained by a shift of such services to physicians' offices from hospital outpatient departments, where they are billed under the hospital outpatient prospective payment system. He also noted the quality of imaging procedures varies considerably by provider and the quantity varies by region, but that regions with higher imaging volumes do not exhibit better outcomes.

Johnson: It's Not That Simple

Johnson objected to Miller's assertion, given that "imaging has grown so integrated into both diagnostic and treatment procedures, it's very difficult to rely on figures showing increased use to draw any conclusions about overuse."

Miller agreed that "in this volume growth, we can't very well distinguish between appropriate and inappropriate" uses of imaging; he explained that "in part that's what drives us to the quality standards," rather than attempting to delineate specific situations where imaging should or should not be used.

Later, in response to a question from Rep. John Lewis (D-GA), Miller said MedPAC did not directly measure whether increased use of imaging had reduced the number of patients who required surgeries and other types of invasive procedures.
 
"We are aware that there are clinical studies that say there is such a relationship" in specific cases, Lewis said, but the proposition is more dubious in the aggregate. He noted that John Wennberg, MD, and his collaborators on the Dartmouth Atlas of Health Care have found that when utilization is high in one area, "it's high on everything: high imaging, high testing, high admission to the hospital, high surgery - high everything."

As a precedent for MedPAC's proposed imaging standards, Miller cited a 1992 law that set similar standards for mammography providers. Johnson said that, as the prime House sponsor of that legislation, she obviously thought these types of structures made sense then. Now, however, she said she was reluctant to add "a whole new group of structures" in a system that had already grown "structure heavy."

Imaging Inspection May Be Start Of Service Scrutiny

The dollar amounts and quality-of-care issues involved in the imaging debate are significant in their own right, but the same type of debate could extend to other areas as well.

Rep. Pete Stark (CA), the senior Democrat on the Health panel, asked Miller whether "imaging services uniquely require [competency] standards, or should we begin requiring standards for other areas of Medicare?"

Miller's response: "I would not close the door that we could be back talking to you about other services. For example ... while imaging is growing very rapidly, so is diagnostic testing. Diagnostic testing has some of the same supply-driven characteristics that imaging has, and I don't think it's out of the question that we could come back and talk to you about that."