Radiology Reacts to MedPAC Recommendations

From left: Cherrill Farnsworth and James Borgstede, MD, present statements to the Subcommittee on Health of the House Committee on Ways and Means on March 17, 2005.

In its March 2005 report to Congress, Medicare Payment Policy, the Medicare Payment Assessment Commission (MedPAC) provided suggestions to address the rapid increases in Medicare spending for diagnostic imaging services and the lack of quality assurance in diagnostic imaging performed in the physician office setting. On March 17, 2005, representatives from several associations and societies, including the American College of Radiology (ACR), and the American College of Cardiology (ACC) responded to MedPAC’s recommendations.

“MedPAC’s June 2004 and March 2005 reports to Congress share the College’s concerns, stating that diagnostic medical imaging is the fastest growing type of medical expenditure within the category of physician services in the United States,” said James Borgstede, MD, FACR, chairman of the ACR Board of Chancellors, in his address to the House Ways and Means Subcommittee on Health. “The ACR, as well as lawmakers, federal regulators, and private payor insurers, recognize that this trend line, which is growing exponentially every year, is unsustainable and that the growth of imaging utilization, some of which may be inappropriate, must be controlled.”

Other testimonials to the House Ways and Means Subcommittee on Health were given by: Mark Miller, executive director of the Medicare Payment Advisory Committee; Kim Allen Williams, MD, professor of medicine and director of nuclear cardiology at the University of Chicago, Chicago, on behalf of the ACC; Cherrill Farnsworth, chairperson for the National Coalition for Diagnostic Imaging Services and CEO of HealthHelp Inc, Houston; and David Rollo, MD, chief medical officer, Philips Medical Systems, Milpitas, Calif, on behalf of the National Electrical Manufacturers Association.

Citing successful privileging strategies implemented by Tufts Health Plan and Highmark, Farnsworth stated that Medicare should incorporate the innovations of the private sector to promote quality standards.

“Empirical evidence demonstrates that private sector privileging strategies promote high-quality care,” said Farnsworth, in her testimony. “We firmly believe that private sector quality standards should also be available to Medicare beneficiaries.”


One of the changes suggested in the MedPAC report for payment policy reform targets an intensely debated topic—the adjustment of technical component payments made to providers who bill for multiple imaging services performed on contiguous body parts. Since Medicare currently calculates physician fee payment rates for imaging services under the assumption that each service is done independently, the rates do not take into account the efficiencies that may be gained when multiple studies are done in tandem. MedPAC’s recommendation is that the Centers for Medicare and Medicaid Services (CMS) apply a separate adjustment to technical component payments for multiple services performed during the same visit when there are efficiencies. Expanding coding edits for imaging services will help control the rapid growth in imaging spending by allowing Medicare to better detect improper billing by providers and to reduce payments for imaging procedures that use fewer resources when performed together, states the MedPAC report. The ACR, however, does not support this recommendation.

“The Practice Expense Advisory Committee, which is a subcommittee of the Relative Value Update Committee, recently reviewed the technical component reimbursement for all CPT codes including the imaging codes. The results of this review will go into effect on January 1, 2006,” says Borgstede. “The reason we do not endorse the MedPAC recommendation for the adjustment of the technical component is that we might get a double cut with both the MedPAC and Practice Expense Advisory Committee revisions.”


Setting quality standards for imaging services is just one of the ways that the MedPAC report states would encourage providers to offer efficient quality care to Medicare beneficiaries. Other strategies include measuring resource use by physicians in comparison with that of their peers and creating incentives for individual physicians to control unnecessary volume.

According to MedPAC, less money could be spent on health care without sacrificing quality if physicians who used numerous resources reduced the intensity of their practice by providing fewer diagnostic services, using fewer subspecialties, using hospitals and intensive care units less frequently as a site of care, and performing fewer minor procedures. To realize how much can be saved, physician resource use needs to be measured over time and the results must be shared back to the physicians. By being made aware of the results, physicians would be able to assess their practice styles, evaluate whether they tend to use more resources than their peers, and revise their practice style. During its research, MedPAC found that nearly all health plans and purchasers mentioned resource use measurement as central to their cost-containment and quality improvement strategies. Some plans collected information and gave it back to patients or providers, others used it as a basis for bonus payments to providers, and some used it to select providers to be in preferred tiers or limited network plans.

To create new incentives in the physician payment system, MedPAC recommends that Medicare shift from having one national spending target to multiple spending targets and presents four ways to attain this goal: create an alternate pool based on membership by organized groups of physicians; divide the United States into regions and adjust the annual conversion factor based on changes in the volume of services provided in each region; set targets based on the performance of hospital medical staffs; or develop volume targets for specific services or types of services.

MedPAC Recommendations At-a-Glance

  • The Secretary should use Medicare claims data to measure fee-for-service physicians’ resource use and share results with physicians confidentially to educate them about how they compare with aggregated peer performance. The Congress should direct the Secretary to perform this function.
  • The Secretary should improve Medicare’s coding edits to detect unbundled diagnostic imaging services and reduce the technical component payment for multiple imaging services performed on contiguous body parts.
  • The Congress should direct the Secretary to set standards for physicians and providers who bill Medicare for interpreting diagnostic imaging studies. The Secretary should select private organizations to administer the standards.
  • The Secretary should include nuclear medicine and PET procedures as designated health services under the Ethics in Patient Referrals Act.
  • The Secretary should expand the definition of physician ownership in the Ethics in Patient Referrals Act to include interests in an entity that derives a substantial proportion of its revenue from a provider of designated health services.

King Tut Undergoes Full-Body Scan

Experts in Egypt used a mobile CT system to examine the mummy of Tutankhamun (King Tut), which was discovered in Egypt’s Valley of Kings in 1922. King Tut was rumored to have been murdered; however, these latest CT tests cast doubt on that theory.

Based on images generated from a total of 1,700 slices, some researchers believe that the young Pharaoh suffered from a broken thigh shortly before his death at the age of 19 and died from an infection of this wound. The CT scans revealed embalming resin inside the wound and no sign of a healing process. Other scientists on the team, however, maintain that injury was not the cause of the king’s death, but the result of a wound inflicted on the mummy from careless examination by earlier archeologists. They point to the fact that there was no evidence for hematoma, which should be there if the injury was inflicted in the Pharaoh’s lifetime.

The study is part of a research project conducted by Egypt’s Supreme Council of Antiquities. The project also involves examining CT scans of a large number of other Egyptian mummies.

MRI Improves Cancer Detection in BRCA Carriers

In a study designed to assess the best method of breast cancer detection among women who carry the BRCA1 and BRCA2 gene mutations, breast MRI was found to be the most sensitive modality, followed by mammography, ultrasound, and clinical breast examination (CBE).

The study, by Warner et al for the September 15, 2004, edition of the Journal of the American Medical Association, enrolled 236 female BRCA1 and BRCA2 mutation carriers in southern Ontario and Montreal, Canada, between the ages of 25 and 65. All underwent screening over a five and a half year period, from November 3, 1997, to March 31, 2003. During this time, one to three annual screenings, consisting of MRI, mammography, and ultrasound, were performed on the women, while CBE was performed semiannually.

According to Warner, lead investigator, the following women are eligible for genetic testing under Canada’s single-payor health system: all breast cancer patients diagnosed at age 35 or lower; diagnosed before age 50 and either Jewish or having a first or second degree relative with breast cancer before age 50 or ovarian cancer at any age; with two or more additional relatives with breast or ovarian cancer on the same side of the family; any male breast cancer patient; or any epithelial ovarian cancer patient.

Results showed that out of the 236 women who participated in the study, a total of 22 cancers were found in 21 women. Of these 22 cancers, 2 (9.1%) were detected by CBE, 7 (33%) by ultrasound, 8 (36%) by mammography, and 17 (77%) by MRI. Cancer detection sensitivity by mammography was significantly higher when combined with MRI and ultrasound (95%) than when mammography and CBE alone were performed (45%).

The authors concluded that MRI is likely to become the mainstay of screening BRCA1 and BRCA2 carriers, who have an 85% lifetime risk of developing breast cancer. They also concluded that further research is necessary to determine whether surveillance regimens that include MRI will reduce breast cancer mortality in high-risk women, and the funding is in place to carry out such a study.

The authors noted that the use of breast MRI for surveillance of high-risk women is relatively scarce outside trials, due in part to its high cost and relatively low specificity compared to mammography (93% for MRI as compared to 99.6% for mammography in year one of the study). For this reason, they highlighted the fact that the recall rates in the study decreased considerably from 26% in the first round of screenings to 13% on the second round and 10% on the third round.

The cost-effectiveness of the regimen will be closely linked to any decrease in the fatality rate among BRCA carriers. “Wholesale MRI costs $600 per study,” says Warner. “Assuming the retail cost plus additional studies and biopsies is double that, in a crude estimate, it’s about $24,000 per quality adjusted life year (QALY), if we assume that the case fatality rate drops from 30% to 10%.” —Nicolle Harrity

Mammography Practice Audit Trends

In a study designed to examine the practice of community-based mammography in the United States, researchers surveyed 45 screening centers in three geographically distinct locations of the country and published the results in the February 2005 issue of the American Journal Roentgenology. More than 80% of the mammography facilities surveyed generate audit reports that include the number of screening examinations, the number of diagnostic examinations, and the number of cancers diagnosed by each radiologist. Forty percent of the facilities reported audit data back to radiologists once a year; 31% provided reports twice annually; and 7% offered quarterly updates. In addition to examining audit systems, survey questions probed mammography practice settings, services offered, charges for screening and diagnostic mammography, and interpretation methods.

Reprinted with permission: Hendrick RE, Cutter GR, Berns EA et al. Community-based mammography practice: services, charges, and interpretation methods. AJR Am J Roentgenol. 2005 Feb;184(2):433-8.

Industry News

GE Healthcare, Wausheka, Wis, and Intermountain Health Care, Salt Lake City, have signed a letter of intent under which they will jointly develop a clinical information system that Intermountain will market to hospitals and large group practices nationwide. According to the proposed deal, GE will incur the bulk of the research and development costs associated with developing the system and Intermountain will spend about $100 million to buy and install pharmacy, radiology, and other departmental clinical systems at its 21 hospitals and 92 clinics…FujiFilm Medical Systems USA, Stamford, Conn, is offering its educational scholarship for a PACS administrator-in-training to attend the Society for Computer Applications in Radiology (SCAR) Annual Meeting and the special 1-day preconference SCAR PACS Administration Overview Course; the application deadline is April 22, 2005…CoActiv Medical Business Solutions, Ridgefield, Conn, received FDA approval for its EXAM-PACS® for primary reads and archival storage of digital mammography examinations…InSight Health Corp, a subsidiary of InSight Health Services Corp, both located in Lake Forest, Calif, has earned the Gold Seal of Approval™ from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), for its mobile diagnostic imaging units…Siemens Medical Solutions, Malvern, Pa, and CTI Molecular Imaging Inc, Knoxville, Tenn, have entered into a merger agreement under which Siemens will acquire CTI. The acquisition includes all the businesses of CTI Molecular Imaging, including CTI PET Systems, PETNET Solutions, CTI Mirada Solutions, CTI Molecular Technologies, and CTI Concorde Microsystems. Siemens has received 510(k) clearance from the FDA to market its new Acuson AcuNav™ 8F ultrasound catheter, which is 33% smaller in the cross-sectional area than the existing AcuNav 10F catheter. Siemens also received FDA 510(k) clearance for its mammography soft-copy reporting workstation, MammoReport(Plus), allowing for the processing of digital CAD images and mammograms from approved vendors, expanded indications for multimodality viewing, and use with FDA-cleared monitors for the interpretation of lossless compressed images…Mallinckrodt, Hazelwood, Mo, a division of Tyco Healthcare, Mansfield, Mass, announced the successful completion of two Phase II studies using the OptiMARK® imaging agent to determine safety and effectiveness in identifying the presence, location, and extent of myocardial infarctions; the study data identified the optimal dose to use in patients with suspected heart attack…

The American Society for Therapeutic Radiology and Oncology (ASTRO) has adopted a new logo in an effort to give the Society a more global identity…Communications Synergy Technology Inc (ComSynTech), Rochester, NY, has partnered with MedPay USA, Austin, Tex, to expand the workflow functions in ComSynTech’s InFORM RIS with MedPay’s billing verification software.


David H. Hussey, MD, FACR

David H. Hussey, MD, FACR, of the American Society for Therapeutic Radiology and Oncology (ASTRO), Fairfax, Va, has been elected president of the Radiological Society of North America for 2005. Hussey served as president of ASTRO in 2000, and he is currently active in ASTRO’s history and maintenance of certification committees…Scott Longacre, of Gamma Medica Inc, Northridge, Calif, has been named vice president of finance and chief financial officer and Kevin Parnham has been named vice president of engineering…John Douglass of Konica Minolta Medical Imaging, Wayne, NJ, has been named director, corporate accounts…John Chiminski has been promoted to the position of vice president and general manager of GE Healthcare’s Global Magnetic Resonance business…The Radiation Therapy Oncology Group (RTOG) announced the following appointments: Walter J. Curran, Jr, MD, reelected for a third term as chair of the RTOG; David K. Gaffney, MD, chair of the RTOG gynecology cancer working group; Howard Safran, MD, medical oncology chair of the RTOG gastrointestinal cancer committee; and Harvey Pass, MD, thoracic surgery chair of the RTOG lung cancer committee.