CONGRESS PICKPOCKETS RADIOLOGY WITH DEFICIT REDUCTION ACT
Radiological societies are working fast and furiously to educate their members, as well as members of Congress, regarding a section of the Deficit Reduction Act of 2005 pertaining to a significant payment reduction for freestanding outpatient imaging services. As of press time, the bill—which was approved by the Senate 51-50 with Vice President Richard Cheney casting the deciding vote—was pending a vote in the House of Representatives, which had previously passed an earlier version. However, the efforts of organized radiology appeared to be paying off with an announcement January 25, from the office of Rep Rob Simmons (R-Conn), that he will oppose the bill, which he originally voted for. “Since then, I have met with and listened to a wide range of constituents—including AARP, American Federation of Teachers, Connecticut Voices for Children, labor unions, and radiologists—regarding the details of the proposed changes,” he said. “….Consequently, I have decided to vote against the budget on February 1.”
The cuts to freestanding outpatient radiology services stem from a capping of reimbursement for the imaging technical component paid under the Physician Fee Schedule to the frequently lower rates paid under the Hospital Outpatient Prospective Payment System (HOPPS), effective in 2007. The bill also legislates the reductions in Medicare reimbursements for multiple images on contiguous body parts by 50%—25% in 2006 and another 25% in 2007—as previously decided by CMS (see December 2005 STAT Read). According to the National Coalition for Quality in Diagnostic Imaging Services (NCQDIS), Washington, DC, CMS says this bill is proposed to save the Federal government about $8.1 billion over the next 10 years.
“We don’t believe they’ll save that,” says Cherrill Farnsworth, NCQDIS executive director. “Contiguous body parts will save something. This other development with HOPPS, it will probably cost them money.”
A cost study done by NCQDIS revealed that imaging centers have about a 7% revenue margin. “A 25% cut to revenue when existing margins are 7%, it’s going to be a killer,” she says.
“It’s our feeling that there are significant flaws in the approach that they have taken to imaging in this bill,” says James P. Borgstede, chairman of the Board of Chancellors at the American College of Radiology, Reston, Va. “They could have achieved budget savings by addressing some of the generic drug issues. They could have achieved that with addressing some of the managed care issues. But they chose not to do that, and instead they got all of their budget savings from radiologists. We think that is inappropriate.”
In response, the ACR has held meetings with Congressional members, sent letters, and is in the process of developing an impact analysis report to show what the impact of the cuts will be to specific practices.
Both the ACR and NCQDIS object to the payment adjustments because, they argue, HOPPS and the resource-based Relative Value Scale (RBRVS) represent two different systems of arriving at reimbursement rates and should not be mixed. In addition, they argue that hospitals have the capability of buying equipment and using it for more than just their outpatients—something physician offices cannot do.
“Hospitals have under-reported the charges on imaging procedures and inaccurately reported those, and therefore that system is really a flawed reimbursement methodology,” Borgstede says. “It is really a charge-based system rather than a cost-based system. It’s not that physicians were being overpaid—it’s that hospitals were being underpaid. That’s the problem.”
Both Borgstede and Farnsworth predict this bill will have a major impact on revenue for freestanding facilities, but how much of an impact depends on a practice’s case mix. The studies expected to take the hardest hit include MRI, MRA, CT, and CTA. Profitability is also expected to decline, possibly leading to imaging facilities closing and forcing patients back to hospitals for outpatient imaging.
Robert I. Grossman, MD, Louis Marx professor and chairman of the department of radiology at New York University, New York City, predicts that, if passed, this bill will change imaging market dynamics. “It’s going to make it far less profitable to invest in outpatient imaging,” he says. “It may shift the way partnerships are done so groups will sort of ally with hospitals as opposed to having an adversarial relationship with hospitals.”
MRI: FAIL-SAFE LIE DETECTOR?
Early in his career, someone asked Mark George, MD, if scanning could be used to determine if a person was lying. With people still struggling to use imaging equipment for the most basic things, George’s answer was no. But the question always remained in the back of his mind.
Flash forward to 2005, and George’s answer is much different. In a study released in the September issue of Biological Psychiatry, the professor of psychiatry, radiology, and neurosciences at the Medical University of South Carolina says MRI can be used to determine whether a person is lying.
When someone lies, he says, three things go on. The first is the emotional component. In most people, lying leads to elevated blood pressure, heart rate, and breathing rate. This is the basis for the polygraph test. Second, a lie is more complex than telling the truth—the person must multitask. Third, George says researchers have mapped the parts of the brain involved in telling a lie because when someone lies they are inhibiting an overlearned response. Imaging shows the brain regions that are involved in this process.
“With telling the truth, you just remember how it was and tell it,” he says. “When you tell a lie, you’re monkeying with the way things are connected, and you have to remember. You’re multitasking more during a lie than during telling the truth because you have to remember what things you’ve lied about and how that is going to affect other things.”
Using a 3T MR scanner and a multi-channel acquisition SENSE™ head coil, the researchers monitored the regions of the brain involved in the lying process: the singular gyrus (the area involved in multitasking), the orbital frontal cortex (the area involved in inhibiting an overlearned response), and the insula and the amygdala (two emotional areas).
“This SENSE head coil allows us to listen not with just one antenna, but with six or eight antennas,” George says. “That is kind of like turbo-charging because we have eight times more data than we used to have.”
In George’s study, 30 people were imaged after they committed a mock crime and then were told to lie about it. The subjects were scanned immediately after committing the crime. He says in more than 90% of the individuals imaged, the MRI scan was able to determine that person was lying, indicating that MRI is more reliable than a traditional polygraph test, which George says is highly operator and condition dependent. “The bottom line is that it is not that much better than chance, with high rates of false positives, and some false negatives,” he says.
George is currently working on a study sponsored by the Department of Defense Polygraph Institute that is engaging subjects in a more real-life situation before they are scanned. He says there is more time built in between the activity and the scan to see if the signal degrades over time.
“I think that the day you have the definite ability to tell whether somebody is lying or not, you transform lots of areas of our society. I think that is a very powerful tool,” George says. “It may not be used that much, but just the knowledge that it is there leaks its way into lots of things that we do: contract negotiations, diplomacy, the legal system. Just the knowledge that ultimately there is such a thing around has a big impact, so we want to make sure that we are getting it right.”
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LETTER TO THE EDITOR
Your November 2005 STAT Read included a section on “Low-Dose Radiation Poses Increased Cancer Risk,” covering a report issued by the National Academy of Sciences. Your statement that “an exposure of 100 mSv [is] roughly equivalent to 100-200 chest CTs” is incorrect. A chest CT gives an effective radiation dose of about 10-12 mSv (J Comput Assist Tomogr. 2004;28:S46-S49). Therefore, an exposure of 100 mSv, which may result in a 1% increased risk of developing cancer if the tremendous limitations of the assumptions and extrapolations used in their study are accepted, would be roughly equivalent to 10 chest CTs, not 100. Their assumption of a no-threshold model is not universally accepted, and trying to determine a 1% increased cancer risk from radiation exposure over a 42% general cancer risk is of dubious certainty.
Hadyn T. Williams, MD— Nuclear Medicine— Medical College of Georgia
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