Radiology: Self-referral fueled continued imaging growth after DRA

In the years after the passage of the 2005 Deficit Reduction Act (DRA), which reduced Medicare payments for selected in-office imaging procedures, overall growth of Medicare noninvasive musculoskeletal imaging slowed. However, a closer examination shows the slowdown was a continuation of a trend started before the DRA, and growth of nonradiographic noninvasive musculoskeletal imaging performed by nonradiologists still grew more rapidly than that performed by radiologists, according to a study published online April 24 in Radiology.

The DRA was passed in response to criticism aimed at growing Medicare imaging costs, explained authors Scott Kennedy, MD, MBA, of New York-Presbyterian Hospital in New York City, and Howard P. Forman, MD, MBA, of Yale University School of Medicine in New Haven, Conn. Taking effect in 2007, the act reduced payments for imaging in the office setting to match payments with the outpatient hospital level.

“Although there are challenges in identifying the effect of the DRA separately from the effects of other changes that may have occurred at the same time, such as the influence of radiology benefits management companies, maturing technology, and other means of cost containment such as the use of guidelines for imaging procedures (e.g., appropriateness criteria), we were interested to analyze how physicians responded to these payment reductions,” wrote Kennedy and Forman.

The authors tracked 111 relevant procedure codes in the Medicare Part B Physician/Supplier Procedure Summary Files, measuring the imaging utilization growth rate between the pre-DRA (2004-2006) and post-DRA (2006-2008) periods.

Results demonstrated that the types of imaging tracked by the study experienced a 2 percent deceleration in the office setting and a 0.7 percent deceleration in the outpatient hospital setting between the pre- and post-DRA periods. However, the authors noted that aggregate growth of imaging had been slowing before the DRA went into effect, so the overall deceleration cannot reliably be considered a consequence of the DRA.

With that said, Kennedy and Forman wrote that these aggregate findings are still important in making policy decisions, and singled out four principal findings regarding noninvasive musculoskeletal imaging:

• In the office setting, deceleration of per-capita imaging was greater with larger payment reductions. For both nonradiologists and radiologists, deceleration was approximately 0.2 percent greater for every additional 1 percent of reimbursement reduction.

• There was no such pattern relating acceleration or deceleration of imaging and the size of payment reduction within the outpatient hospital setting.
• Even though per-capita imaging growth slowed after the DRA took effect, it still grew. There was no decline in utilization.
• Aggregate growth slowdown was three to four times higher for nonradiographic imaging as it was for all imaging.

“Given that nonradiographic imaging by nonradiologists—commonly called ‘self-referral’—results in high levels of utilization, generally without the benefits claimed for it, the desired outcome of policy changes would be a sharp reduction in imaging by nonradiologists and, thus, in unnecessary cost and radiation exposure,” wrote Kennedy and Forman. “As the DRA has not produced this outcome through its price cuts, further regulatory restrictions on imaging by nonradiologists would seem desirable.”