Subspecialization in the Crosshairs: Imaging and the MPPR

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In July, CMS released its proposed 2013 Medicare Physician Fee Schedule¹ (MPFS). Contained within its pages was an unpleasant surprise for imaging: the reintroduction of the Multiple Procedure Payment Reduction (MPPR) last seen in the 2012 proposed rule. As Maurine Spillman-Dennis, MPH, MBA, senior director of economics and health policy for the ACR®, explains, “They had pulled back the group-practice provision, but now they have put it down as a proposed policy again. We got a reprieve, but now it’s back.” Matt CoxThe group-practice provision would apply a 25% reduction in professional-component reimbursement to any second study performed for one patient at the same practice on the same day. The reduction applies “even if it’s a different modality, even if the interpretation is completely different, and even if you’re dealing with two different reports and the findings need to be communicated twice,” Dennis says. Matt Cox, vice president of business development for Virtual Radiologic (vRad), adds, “We would agree with the ACR that this appears to be a blind cost-cutting initiative on the part of CMS. We think reduced reimbursement for radiologists who are, for instance, diagnosing multiple traumas in a patient’s noncontiguous body parts represents a failure to recognize the dynamic nature of radiology.” Implications of the MPPR Indeed, Dennis says, the MPPR is a cost-containment measure that appears to be founded on antiquated notions of how radiologists practice. “It seems like the agency has the idea that everyone is sitting around together in one room, when of course, they’re not,” she says. “They need to understand that this is not a situation where a cookie-cutter approach will be effective. The equipment is typically not in the same room, different technologists will work on the exams, and the exams will be interpreted by subspecialists who will each talk to the ordering physician, but not to one another.” Cox notes that this could create an improper incentive for physicians in the outpatient setting. “There may be people who manipulate this by inconveniencing the patient, which would be bad for patient care,” he says. “If you start reducing payment for secondary and tertiary interpretations, that’s the incentive you are setting forth.” In emergency settings, on the other hand, radiology practices will be financially penalized for providing comprehensive care. Dennis uses the example of a trauma patient to illustrate the MPPR’s shortcomings: “On the professional side, as well as the technical side, a head CT and a brain MRI are different exams,” she says, “but one of the two interpreting radiologists will get paid less, even though he or she did just as much work as the other radiologist.” Cox observes that focusing on cost reductions by attacking professional fees under the MPPR is not getting at the heart of the issue. “If CMS really wanted to hit costs hard, it would be better off focusing on radiology additional imaging (RAI), as noted in the 2009 study from Sistrom et al², or in-office utilization,” he says. “DRA cuts, bundling, the MPPR, reducing the conversion factor, and adjusting RVU/practice-cost factors are much easier levers for CMS to pull because they are small, incremental cuts. Added together, these small cuts are having a big impact on radiologists’ compensation.” Changes for Radiology At first blush, it might appear that the MPPR is aimed at applying the efficiencies achieved in the technical component to the professional component of reimbursement. Cox, however, points to the MPPR’s impact on the emergency setting, where cutting costs for night and weekend coverage will create even greater pressure to provide access to high-quality, experienced, subspecialty-trained radiologists, he says. “We think CMS may be viewing radiology in emergency care as a place where the on-call radiologists can simply be generalists, and that will be good enough,” he says. “As a patient in the emergency department, I would not want my radiology care compromised by reduced payment.” Cox adds, “The RAI study demonstrated that the use of experienced, trained radiologists yields better initial interpretations and lower utilization. Historically, fee reductions by CMS typically result in higher utilization or in more work RVUs per physician.” If the MPPR is implemented in the final rule, Cox says, it will raise interesting questions about how radiology groups should respond—and it is likely to lay the groundwork for reimbursement cuts in other specialties. There is little that practices can do except prepare for the worst. “If you want to know what to do, the best exercise you can go through is to model your current business at Medicare rates,” he says. “It’s an exercise that will help you better understand what you’ll need to be successful in this challenging market.” Dennis says that the ACR is continuing to fight against the MPPR; radiologists and practice executives can add their voices by sending a comment letter to CMS. “It is discouraging, but not unexpected, that CMS is trying this again,” she says. “We were somewhat successful, the first time, in getting CMS to roll back the provision, and we are hopeful that we can keep CMS from implementing it completely.” Cat Vasko is editor of Medical Imaging Review and associate editor of Radiology Business Journal.