Regulatory Update: September 2010

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CMS plans to implement a two-year Medicare Imaging Demonstration Project [PDF] that will test whether decision-support systems can promote the appropriate ordering of imaging services using criteria established in current medical-specialty guidelines. The project will focus on MRI, CT, and nuclear-medicine diagnostic-imaging services. The 11 targeted services chosen within these modalities—CT of the brain, sinuses, thorax, abdomen, lumbar spine, and pelvis; MRI of the brain, lumbar spine, shoulder, and knee; and nuclear imaging of the heart—have high expenditures and utilization among Medicare fee-for-service beneficiaries.

The decision-support system “captures a physician attestation that the data to determine appropriateness and recommendations were reviewed by the physician and confirmed with the beneficiary,” according to the CMS solicitation for proposals. Decision-support systems include point-of-order systems, which are defined as computerized provider order entry systems that require supporting information at time of referral; also included are point-of-service systems, which are defined as electronic or paper forms that allow physicians to certify that data were collected and confirmed with the beneficiary before an imaging service is provided.

CMS is currently seeking up to six conveners, or organizations that will recruit physicians for the demonstration and handle other responsibilities such as collecting data and ensuring that the decision-support system meets current medical-specialty criteria. Each convener will be responsible for recruiting 200 to 1,000 physicians.

Applications to become a convener are due by September 21, and more information can be found on the CMS website [PDF]. “Physician practices apply through a convener,” according to the agency; physician practices must also meet other requirements, including having appropriate access to the Internet, as well as other capabilities for transmitting and receiving data.

As part of the demonstration project, conveners and physician practices will receive additional payments for reporting the data necessary to determine the appropriateness of an order for one of the 11 imaging services targeted for study. The ACR® “advocated for this project during the health care reform debate in order to demonstrate that future savings in imaging could be derived through increasing quality and decreasing utilization rather than implementing broad across-the-board cuts to advanced imaging services,” according to its statement.

MedPAC Reviews Options for Addressing Growth in Ancillary Services

The Medicare Payment Advisory Commission http://www.medpac.gov/ (MedPAC) highlighted concerns in its Aligning Incentives in Medicare [PDF] report about the growth of services—such as imaging, radiation therapy, home health, durable medical equipment, physical therapy, and others—provided in physicians’ offices under the in-office ancillary services (IOAS) exception.

Jonathan W. Berlin, MD, MBA, clinical associate professor of radiology at the University of Chicago Pritzker School of Medicine, says, “This report marks a growing trend by the government actually to notice self-referral increases in imaging. For a long time, that wasn’t the case. We can say that it’s great they’re noticing it, but we also have to look at what’s happening as a result of the government noticing it.”

Berlin notes that many radiologists might think that the government will simply eliminate the IOAS exception, but the report actually presents lawmakers and regulators with several different options, including some that might result in simply cutting fees.

In its report, MedPAC reviews three broad options available to curb the growth of ancillary services: limiting the types of services or physician groups covered by the IOAS exception; developing payment tools (such as bundling services or parts of the payment rates together) to lessen incentives that promote volume growth; or requiring self-referring physicians to participate in a prior-authorization program.

The Coalition for Patient-Centered Imaging (CPCI) strongly opposed MedPAC’s report, noting that it does not reflect current data or reimbursement policies. Policies recently adopted in the Patient Protection and Affordable Care Act, for example, will already begin to move the current payment system away from volume and toward appropriate, high-quality care. “While the physician community continues to diligently work to