The Bill Box
Price Transparency: Movement Gains Momentum Amid Doubts
CMS Proposes 55% Cut to Mammography CAD Reimbursement
NIA/Magellan to Begin Pilot Program for Coronary CTA Patient Handling Protocols

The Bill Box

Vetoed California Bill Exposes Fault Line Between Parties

On September 22, Governor Arnold Schwarzenegger (R) vetoed SB 840, which would have created a government-run single-payor health care system, eliminate private medical insurance, and establish in its place a statewide system for all residents.

SB 840 passed the California Assembly 43-30, and consternation over the proposal has exposed a clear fault line running between the Democratic and Republican parties where health care is concerned.

State Senator Sheila Kuehl (D-Los Angeles), who wrote the bill, told the San Francisco Chronicle, “It creates [health care] access for all Californians by steeply reducing administrative overhead and emphasizing preventive and primary care instead of endlessly cutting coverage and access to care or increasing consumer spending.”1 She added, “I hope that the people of California will hang the albatross of bad health care around the governor’s neck.”

Assemblyman Greg Aghazarian (R-Stockton) told the Chronicle, “This [bill] creates a government-run system akin to the Department of Motor Vehicles. Do we want health care taken care of by another bloated bureaucracy?”1

Pennsylvania Bill to Establish Universal Children’s Health Coverage

Lawmakers in Pennsylvania have agreed to pass a bill establishing universal children’s health insurance. The plan, called Cover All Kids and initiated by Governor Edward G. Rendell (D), will provide coverage for dental and vision care, emergency department care, prescription drugs, hospital and home care, mental health treatment, and some other services. Cover All Kids mirrors a similar program in Illinois that went into effect last month, potentially offering coverage to 253,000 uninsured children; approximately 133,500 uninsured children live in Pennsylvania.

“I think Pennsylvania has a good idea,” William O’Hare, head of the Kids Count program to track the well-being of US children, told the Philadelphia Inquirer.2 “Investment in the health care of young children pays off down the road in so many ways.”

All children under 18 will be covered by Cover All Kids, regardless of income. Premiums will be calculated on a sliding scale, with wealthier families paying as much as $145 a month and lower-income families paying as little as $20. The program will start with 15,000 children in 2007 and add an additional 75,000 within 5 years; it will cost Pennsylvania $4.4 million for the first year with an additional $10 million provided by the federal government. By its fifth year, the program will cost the state an estimated $50 million.

In April, Massachusetts passed a law requiring adults to buy health insurance or face a penalty; New Jersey is considering a plan similar to Pennsylvania’s.

Cat Vasko is associate editor of  Axis Imaging News.


  1. Gledhill L. Assembly approves universal health care. San Francisco Chronicle. August 29, 2006:A1. Available at: Accessed September 22, 2006.
  2. Sullivan J. Uninsured Pa children to all get state coverage. Philadelphia Inquirer. August 11, 2006. Available at: Accessed September 22, 2006.

Price Transparency: Movement Gains Momentum Amid Doubts

By Cat Vasko

A 2005 telephone poll, conducted by Harris Interactive, Rochester, NY, at the behest of Great-West Healthcare, Greenwood Village, Colo, found that most Americans can guess the price of a new Honda Accord within $300—but were $8,100 off when guessing the cost of a 4-day stay in the hospital. A full 63% of those who had received medical care in the 2 years prior to the survey did not learn what it cost until their bill arrived. And 105 never found out at all.

The trend toward health care pricing transparency is undeniable, and with more democratized access to technology than ever, the time seems right for hospitals and providers to go public with their prices. Some do so voluntarily, like insurance provider Aetna Inc, Hartford, Conn, which offers online access to the rates it pays physicians in select markets as well as information on clinical quality and efficiency. Others do so as mandated by state legislation: 32 states require that some hospital information be made public, like South Dakota, where median prices for the 25 most common inpatient procedures at every hospital in the state are posted online.

Providers are quick to point out, however, that health care pricing cannot be examined in a vacuum. Carmela Coyle, senior vice president for policy at the American Hospital Association (AHA), Washington, DC, told the Chicago Tribune, “We run a risk of doing a disservice to consumers by simply dumping data,” stressing that various factors, such as quality, efficiency, or whether the hospital in question supports teaching, can come into play.1

Critics of the transparency efforts note that posted prices do not reflect the true price of health care after insurers come into play. In one market, however, this hurdle was easily jumped when payor Humana Inc, Louisville, Ky, entered into an agreement with the Business Health Care Group of Southeast Wisconsin LLC (BHCGSW) to disclose its negotiated prices with physicians and hospitals, allowing BHCGSW to display bundled data, which is more useful to consumers, online. Larry Rambo, chief executive for Humana’s Wisconsin and Michigan markets, told the Tribune that he agreed to the project because it will strengthen his company’s relationships with area businesses.1

It does not stop there. Transparency has now gained traction on the federal level. On August 22, President Bush signed an executive order requiring the Department of Health and Human Services (HHS), the Department of Veterans Affairs, the Department of Defense, and the Office of Personnel Management to collect information about the cost and quality of the health care that they provide, then share that data—with each other and with beneficiaries. The order also calls for the agencies to use interoperable electronic medical records, work to identify methods by which to foster better care, and have these changes under way by January 1, 2007, though it does not state how all of this should or could be funded.

“I guess if I had to summarize how I view it, I would say there’s a choice between having the government make decisions or consumers make decisions,” Bush told The Washington Post.2 “Health care policy ought to be aimed at bolstering the consumer, empowering individuals to be responsible for health care decisions.” The President also noted that health savings accounts (HSAs) could encourage individuals to be more invested in the price of their own health care; the push for pricing transparency is perceived by many as the first step toward widespread adoption of HSAs.

A number of voices—including Representative Michael C. Burgess (R-Tex), who gained attention earlier this summer for introducing a bill supporting Quality Improvement Organizations and mandating a 1-year moratorium to the imaging cuts proposed in the Deficit Reduction Act (DRA) of 2005—joined a chorus in support of the order. In a statement on his Web site, Burgess said, “The President’s executive order applied to the federal government closely mirrors the principles I am addressing at the state level through the bill I intend to introduce this fall.”3 The bill—HR 6053, introduced on September 13—would require insurers to give patients an estimate of their costs for health services. America’s Health Insurance Plans and the National Association of Manufacturers also stepped forward in support of the measure.

Are price transparency measures an easy fix for soaring health care costs? A sobering note came from Robert Berenson, health policy fellow at the Urban Institute, Washington, DC. On the PBS Nightly Business Report on August 22, he noted, “Most health care costs are associated with people with chronic conditions. Five percent of people in Medicare generate 50% of the costs. And so if you make some consumers more cost conscious, and that’s a desirable thing to do, we’re still not going to dent the cost problem, which is associated with people with very high health spending.”4

Cat Vasko is associate editor of  Axis Imaging News.


  1. Graham J. Pricing health care? It’s not that easy. Chicago Tribune. August 10, 2006. Available at: Accessed September 22, 2006.
  2. Fletcher MA. Bush signs order on health care. The Washington Post. August 23, 2006:A13. Available at: Accessed September 22, 2006.
  3. Burgess MC. Statement on Bush’s push for health care transparency. Michael C. Burgess Web site. August 22, 2006. Available at: Accessed September 22, 2006.
  4. President Bush gives patients the power of information [transcript]. Nightly Business Report. PBS television. August 22, 2006. Available at: Accessed September 22, 2006.

CMS Proposes 55% Cut to Mammography CAD Reimbursement

The Centers for Medicare and Medicaid Services (CMS), Washington, DC, has proposed (docket ID CMS-1512-PN), cutting the technical compensation rate for the use of computer-aided detection (CAD) with mammography by almost 55%, according to an analysis by the Stanford Washington Research Group, Washington, DC.

The current reimbursement rate, set at $15.92, would become $14.02 in 2007, then plummet nearly 50% to $7.20 by 2010, for a total reduction of 54.77%. CMS says the proposed change is based on the amount of physician work required to perform mammography CAD; however, the proposal does not note any differentiation between the use of CAD with full-field digital mammography and the use of CAD with film-screen mammography, which requires digitizing.

According to the American College of Radiology, Reston, Va, the number of facilities using full-field digital mammography is on the rise, but not all facilities are completely digital; many continue to use CAD with the traditional, more labor-intensive analog mammography.

The comment period for the document, which closed August 21, yielded 321 opinions, most from internists supporting its proposed hike in reimbursement for evaluation and management services.

—C. Vasko

NIA/Magellan to Begin Pilot Program for Coronary CTA Patient Handling Protocols

By Tor Valenza

National Imaging Associates Inc (NIA), Cordova, Calif, a radiology benefits manager and a division of Magellan Health Services, Avon, Conn, soon will begin a pilot program to evaluate the diagnostic use of 64-slice coronary CT angiography (CCTA). Thomas G. Dehn, MD, FACR, executive vice president and chief medical officer at NIA, ultimately hopes to discover whether it is more efficient to begin a coronary artery disease (CAD) assessment with a traditional nuclear study, such as stress myocardial perfusion imaging (MPI), or with CCTA.

Recent studies have shown a 99% negative predictive value for CAD using 64-slice scanners.1 At the same time, payors are uncertain whether CCTA is being used as a duplicative CAD screening test—used to confirm a false positive in a stress nuclear study. Consequently, most insurance companies code the procedure as investigational and minimally reimburse for the procedure, typically paying between $400 and $700, depending on the region. Medicare does pay for CCTA in select cases, but its reimbursement can be as little as $250.17 for CPT code 0144T, plus the physician’s contracted professional fees. Physicians participating in the NIA pilot program will receive approximately $1,000 per procedure, including professional and technical fees. The CPT codes that will be used for the pilot program are 0148T (cardiac CT) and 0151T (CCTA), which were recently approved by the American Medical Association. In most cases, these two codes will be used together.

The NIA pilot program will allow symptomatic CAD patients, as well as asymptomatic patients with significant CAD risk factors, to utilize either CCTA or a more traditional nuclear study, such as stress MPI. If patients choose the CCTA, a designated pilot program radiologist or cardiologist must perform the procedure. The outcome of the CCTA or nuclear study will be recorded in an online registry. Postprocedure data will trace whether the CCTA or nuclear study revealed insignificant CAD, significant CAD, or that it was indeterminate. In addition, the data will indicate whether the patient required a further invasive diagnostic study, such as a coronary catheterization. The protocol also will include various approaches for CAD treatment, which will be based on the patient’s Agatston calcium score and/or stenosis diameter.

Dehn proposed the pilot program in April of this year after NIA staff reviewed more than 500 CCTA images. The staff evaluated the claims and call center experiences, including thousands of CAD episodes.

If the pilot program demonstrates to NIA that CCTA can be employed as an efficient negative predictor for CAD, Dehn estimates that diagnostic coronary catheterizations could be reduced by 30% to 35%. At that point, diagnostic coronary catheterizations will be recommended only when there is a high probability that an angioplasty or stent also will be performed. Dehn also believes that the general acceptance of CCTA by payors will significantly reduce—if not replace—stress nuclear studies, such as MPI.

In addition to comparing the efficiency of CCTA, the pilot program includes following up with patients after the procedure. At least a portion of the treatment plan for patients with insignificant to moderate CAD will consist of cardiac counseling. “It’s believed by some that the resources for doing good cardiac counseling are not available in the community, and we’re going to ask some of those questions, questions that are related to the socio aspects of coronary artery disease and lifestyle counseling,” Dehn says. “Our postulate is that if the reimbursement rates were better for cognitive services, [cardiac counseling] would probably be better. But we don’t know. We’re going to find out.”

Currently, the planned participants of the NIA pilot program are Blue Cross/Blue Shield of Idaho, Blue Cross/Blue Shield of Hawaii, Health New England, Independent Health (New York), and Blue Shield/Blue Cross of Western New York. NIA offered the program to its insurance clients across the nation. It also advised participating health plans to select providers based on the American College of Cardiology and American College of Radiology credentialing criteria for CCTA.

Anthony Foti, MD, a radiologist with Windsong Radiology Group, Buffalo, NY, is looking forward to participating in the program. Foti says that if CCTA proves to be successful, the medical system will benefit through lower costs and early detection of CAD. He also concurs with Dehn that CCTA may significantly decrease the number of diagnostic coronary catheterizations.

Similarly, William Morris, MD, an interventional cardiologist with Buffalo Medical Group and codirector of cardiac CT at Mercy Hospital of Catholic Health System, welcomes the pilot program. Morris says that the pilot program will allow more of the local community to make use of CCTA. Until now, his CCTA procedures have been performed on volunteers, Medicare cases approved on appeal, and Canadian patients paying cash.

As of this writing, the pilot program is set to begin implementation in Western New York sometime this month with 20 cardiologists and 20 radiologists participating. The other regions are expected to start the pilot program by the end of 2006.

Tor Valenza is a staff writer for Axis Imaging News.


  1. Hoffman MHK, Shi H, Schmitz BL, et al. Noninvasive coronary angiography with multislice computed tomography. JAMA. 2005;293:2471-2478. Available at: Accessed September 22, 2006.