MedPAC report on imaging volume sees glass half empty

Despite growth in medical imaging volume per Medicare beneficiary of only 0.5% in 2015, and a decline of 8% in volume since 2009, the latest report by the Medicare Payment Advisory Commission (MedPAC) warns that imaging could still be overused and concludes that Medicare should prioritize reimbursement for primary care over specialties like radiology.

Even though growth in imaging utilization has flattened over the past eight years, the latest MedPAC report, "Report to the Congress: Medicare Payment Policy," points to the rapid growth in imaging utilization between 2000 and 2009 as a cautionary tale of what could happen if imaging use is left unchecked. The commission expressed concern that use of imaging services is much higher than it was in 2000, noting that overall cumulative growth in imaging volume from 2000 to 2009 totaled 85%, compared with a cumulative decrease in imaging volume since 2009 of about 8%.

Imaging "growth was more than double the cumulative growth rates from 2000 to 2009 for [evaluation and management] services and major procedures, which were 32% and 34%, respectively," MedPAC wrote. "In addition, volume increases in 2015 were much higher for certain types of advanced imaging than other types of imaging ... and follow several years of lower volume growth."

For example, in 2015 the volume of CT for parts of the body other than the head grew by 4.2%, compared with average annual volume growth of 1.6% from 2010 to 2014 for these services. The volume of MRI for parts of the body other than the head in 2015 grew by 3.9%, compared with average annual volume growth of 0.2% from 2010 to 2014 for these services, MedPAC said.

Still, the commission acknowledged that the 0.5% imaging increase in 2015 was lower than the average increase for all healthcare services, and it follows decreases from 2010 to 2014.

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

Shift to hospital-based imaging

The new report documents the shift in imaging utilization from freestanding centers -- many of them cardiology offices -- into the hospital environment.

"In recent years, there has been a trend toward billing for some services in hospitals instead of freestanding offices," the commission wrote in the report. "This change in setting increases 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 trend has slowed the growth in volume of cardiovascular imaging in private practices, according to MedPAC. From 2014 to 2015, the number of echocardiograms per beneficiary delivered in hospital outpatient departments increased by 4.7%, compared with a 3% decline in freestanding offices, while the number of nuclear cardiology studies per beneficiary provided in hospital outpatient departments increased by 0.6%, compared with a 5.9% decline in private practices.

"These changes in billing patterns are consistent with reports of an increase in hospital-owned cardiology practices," MedPAC wrote.

The 'low-value' list

As it did in its 2016 report, MedPAC noted that imaging and cancer screening measures make up 60% 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 that the fee schedule and the nature of fee-for-service payment leads to an undervaluing of primary care and an overvaluing of specialty care. According to MedPAC, radiologists earn $560,000 per year, while primary care physicians earn $264,000.

"The commission has concerns that the resource-based relative value scale, which forms the basis for the fee schedule, includes mispriced services and that these mispriced services cause an income disparity between primary care and specialty physicians," MedPAC wrote. Fee-for-service "payment allows some specialties to more easily increase the volume of services they provide (and therefore their revenue from Medicare), while such increases are less likely for other specialties, particularly those that spend most of their time providing [evaluation and management] services."

In fact, MedPAC is proposing a per-beneficiary payment for primary care that would replace an expired incentive program that offered a 10% bonus payment on fee schedule payments for primary care visits. The monthly per-beneficiary payment would be about $2.60, and it would be funded by reducing fees for all services in the fee schedule other than primary care services, MedPAC wrote.

In any case, the bigger picture shows 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 concluded.

"Measures of payment adequacy are stable and consistent with prior years," it wrote. "Therefore, the commission does not see a reason to diverge from the current law update of 0.5% for 2018."