Endocrinologists are bracing for deep cuts in outpatient imaging services slated to be phased in over the next few years.
If nothing is done to stop the spiraling decline in payment under Medicare, some endocrinologists say they may have to stop providing services such as dual-energy x-ray absorptiometry (DXA) in their offices.
Though the Medicare payment cuts began in January, the impact will be felt over the next few years, said Dr. Nelson B. Watts, director of the Bone Health and Osteoporosis Center at the University of Cincinnati and a past president of the International Society for Clinical Densitometry.
And the situation is somewhat unpredictable because some private insurance plans are planning cuts as well, while others have not announced whether they will follow Medicare's lead in this area.
“The news is filtering down slowly. There are physicians who are hard hit but don't know it yet,” Dr. Watts said.
Dr. Watts, who splits his time between clinical trials and patient care, said he might have to stop performing DXA in the office outside of clinical trials. The loss in revenue from DXA scans also could mean further disruption to his practice since that money currently allows him to keep a nurse practitioner on staff.
The cuts to imaging services under Medicare are coming largely from two areas—cuts mandated under the Deficit Reduction Act of 2005 (DRA) and changes made to practice expense methodology under the physician fee schedule. Under the DRA, Medicare is required to set the fee for the technical component of an imaging service at the hospital outpatient department rate as long as that rate is lower than the Medicare physician fee schedule payment rate.
The combined effect of these cuts is an immediate 40% decline in DXA reimbursement in 2007, dropping payments from about $139 to $82 for a DXA scan (77080). However, by the time the cuts are fully implemented in 2010, the reimbursement for DXA will drop a total of about 75% to $35, according to estimates from the International Society for Clinical Densitometry. Similar cuts are scheduled for payment for vertebral fracture assessment (77082), which will drop from $39 to $33 this year and to $19 in 2010.
In the area of thyroid imaging, the DRA has triggered approximately a 35% cut in payment for ultrasonic guidance for biopsy (76942) in 2007. Thyroid ultrasound (76536) is not cut this year under the DRA provision because the physician fee schedule payment already is lower than the hospital outpatient department payment rate, according to the American Association of Clinical Endocrinologists (AACE).
Those who already have made the investment in equipment may choose not to spend the money for upgrades or replacement, said Dr. Daniel S. Duick, an endocrinologist in Phoenix, and president-elect of AACE.
Over time, it will become a problem of patient access. “Physicians are going to kind of balk” at continuing to provide these services in their offices, Dr. Duick said.
As more physicians refer patients to hospitals or freestanding radiology clinics for imaging services, it also will become a quality of care problem, endocrinologists say.
Dr. Victor L. Roberts, an endocrinologist in Winter Park, Fla., does only a limited amount of imaging in his office and refers patients outside his practice for the rest. Besides the inconvenience for patients, the technical quality varies, he said.
However, when imaging services such as thyroid ultrasound are performed by the endocrinologist, they are done at the bedside by someone who is familiar with the patient's history. “It's better if it's done by the physician who knows the patient,” Dr. Roberts said.
But there may some relief on the horizon for endocrinologists and other physicians who provide in-office imaging services.
Rep. Carolyn McCarthy (D-N.Y.) recently introduced legislation calling for a 2-year moratorium on the imaging cuts included in the DRA. The Access to Medicare Imaging Act (H.R. 1293) also would require the Government Accountability Office to study the impact of the payment reductions in the DRA to see how they affect patient access and service issues. A similar bill was introduced in the last Congress but failed to gain traction.
This year's version of the legislation is slightly different because it also includes a provision that would permanently exempt the imaging procedures commonly performed in endocrinologists' offices from the DRA cuts. If the legislation passed, the DRA cuts would be applied to only “advanced diagnostic imaging services” such as MRI, CT, PET, and nuclear cardiology procedures.
The legislation already has garnered the endorsement of the Endocrine Society. AACE officials were reviewing the legislation but did not have an official position at press time.