Broken record? MedPAC still frets about imaging use

By Kate Madden Yee, AuntMinnie.com staff writer

March 15, 2018 -- Is the Medicare Payment Advisory Commission (MedPAC) starting to sound like a broken record? The group's latest report to Congress continues to sound the alarm that imaging is overused, despite the fact that growth in imaging utilization has actually declined since 2009.

The volume of medical imaging procedures per Medicare beneficiary grew only 1.4% between 2015 and 2016, and it has declined 7% since 2009. Yet the commission's latest report focuses on the rapid growth in imaging utilization that took place between 2000 and 2009, which totaled 85% during the period.

"While volume growth for imaging in 2016 was slightly lower than the average increase for all services and followed decreases from 2010 to 2014, use of imaging services remains much higher than it was in 2000," MedPAC said. "Imaging growth was more than double the cumulative growth rates during the same period for [evaluation and management] services and major procedures, which were 32% and 34%, respectively."

MedPAC further noted that increases in imaging volume in 2016 were higher for certain types of imaging than for others, according to the commission. For example, in 2016 CT volume grew by 3.6%, compared with average annual volume growth of 1.4% from 2011 to 2015. MRI volume in 2016 grew by 2.6%, compared with average annual volume growth of 0.2% from 2011 to 2015, MedPAC said.

Lower than average

Still, the commission acknowledged that the 1.4% increase in imaging in 2016 was lower than the average increase for all healthcare services, and it follows decreases from 2010 to 2014.

Changes in Medicare imaging volume
Change in imaging volume per beneficiary, 2015-2016 1.4%
Avg. annual change in imaging volume per beneficiary, 2011-2015 -1.2%
Change in units of service per beneficiary, 2015-2016 0.4%
Avg. annual change in units of service per beneficiary, 2011-2015 -0.3%
Percent of 2016 allowed charges 11.5%
Source: MedPAC analysis of claims data for 100% of Medicare beneficiaries.

"The relatively high use of imaging and tests has led to concerns about appropriate use of these services," MedPAC noted. "Physicians have warned that diagnostic tests are often ordered without an understanding of how the results could change patient treatment. Others have found that some clinicians routinely repeat tests and diagnostic procedures."

In response to concerns about overuse, professional organizations such as the American Board of Internal Medicine (ABIM) have developed campaigns to identify overused procedures: ABIM's latest iteration of its Choosing Wisely guideline includes more than 520 tests considered overused by more than 80 specialty societies. And the U.S. Centers for Medicare and Medicaid Services (CMS) is developing a program that will require claims for CT, MRI, and nuclear medicine studies to include information about whether the services adhere to appropriate use criteria, MedPAC said.

Location shifts

Volume growth is sensitive to shifts in site of care, MedPAC noted. Relative value units (RVUs) used to calculate volume include practice expense RVUs, which are often lower for services provided in a hospital compared with those provided in a private office. In recent years, the trend has been toward billing for some services, including imaging, in hospitals instead of freestanding offices.

"This change in setting raises overall Medicare program spending and beneficiary cost-sharing because Medicare generally pays more for the same or similar services in [hospital outpatient departments] than in freestanding offices," the commission wrote in the report.

This trend has particularly slowed volume growth in cardiovascular imaging performed in private practices, according to MedPAC. From 2015 to 2016, the number of echocardiograms per beneficiary delivered in hospital outpatient departments increased by 5.4%, compared with a 1.1% decline in freestanding offices, while the number of nuclear cardiology studies per beneficiary provided in hospital outpatient departments increased by 0.3%, compared with a 4.2% decline in private practices.

Miffed about MIPS

MedPAC reiterated its concerns about CMS' Merit-Based Incentive Payment System (MIPS), which will go into effect in 2019. The program will adjust Medicare fee-for-service payments based on clinicians' performance in four categories: quality, resource use, clinical practice improvement activities, and the meaningful use of electronic health records.

"Overall, we do not believe [these] measures help the Medicare program assess high-quality physician services, and we do not believe that they are appropriate for use in a value-based purchasing program," the group wrote. "Instead, we [suggest] a population-based measure assessing avoidable hospitalizations for ambulatory care-sensitive conditions and rates of low-value care in Medicare."

Low-value care and salary inequities

As it did in its 2017 report, MedPAC noted that imaging and diagnostic and preventative testing make up 61% of the volume of low-value care per 100 beneficiaries.

"In addition to increasing healthcare spending, low-value care has the potential to harm patients by exposing them to risks of injury from inappropriate tests or procedures and may lead to a cascade of additional services that contain risks but provide little or no benefit," MedPAC wrote.

The commission also again expressed concern about salary discrepancies among generalists and specialists. According to MedPAC, radiologists earn a median of $466,000 per year, almost double the $236,000 median for primary care physicians.

MedPAC's previous research using data from the Medical Group Management Association (MGMA) showed that salary disparities exist when compensation is assessed on an hourly basis -- which accounts for variations of hours worked in a week -- and when compensation is calculated as if all services are paid under Medicare's fee schedule, the group said. These findings suggest that the fee schedule is a key source of salary disparities.

"Validation of the fee schedule's RVUs could help correct price inaccuracies and ensure that [evaluation and management] office visits are not underpriced relative to other services," MedPAC wrote. "CMS has a statutory mandate ... to validate RVUs, and the commission has provided CMS with ideas for how to do so ... [including] a per beneficiary payment for primary care that could also help rebalance the fee schedule toward primary care services."

That being said, MedPAC concluded that physician reimbursement is adequate and should be updated as usual according to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

"The commission does not see a reason to diverge from the current law update of 0.5% for 2019," MedPAC wrote.


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