JACR: MedPAC and GAO exaggerate multiple procedure efficiencies

Efficiencies in physician work resulting from providing multiple services to the same patient during the same imaging session vary significantly both between and within modalities, and may not exist at all, according to a study published in the September issue of the Journal of the American College of Radiology.

Bibb Allen, Jr., MD, of Trinity Medical Center in Birmingham, Ala., and colleagues also said a blanket application of multiple procedure payment reductions (MPPR) to the physician work component of imaging services, as has been suggested by the U.S. Government Accountability Office (GAO) and Medicare Payment Advisory Commission (MedPAC), is “unnecessarily simplistic and methodologically flawed.”

Allen and colleagues analyzed Medicare Physician Fee Schedule data from the American Medical Association Resource-Based Relative Value Scale Data Manager for 2011 to quantify preservice, intraservice and postservice physician work when providing diagnostic imaging services. An expert panel then reviewed the data, looking for efficiencies in preservice and postservice work when multiple services are provided within the same session. A representative collection of commonly performed services were analyzed including radiology and fluoroscopy codes, CT codes, nuclear medicine codes, ultrasound codes and MRI codes.

The study revealed few efficiencies in the analyzed services, and certainly not enough to offset a significant MPPR, as has been suggested by the GAO and MedPAC, according to Allen et al.

“Although potential efficiencies in physician work may occur when multiple services are provided to the same patient during the same encounter, in many situations, such services are actually more complex and less efficient,” wrote Allen and colleagues.

Imaging procedures for trauma victims, cancer patients and those with acute coronary syndromes were a few of the scenarios provided by Allen and colleagues that, due to their complexity, may actually show decreased efficiency in situations where multiple services are provided to the same patient in the same session.

Even when efficiencies were present, they were limited and highly variable, according to the study. Maximum work reduction ranged from 4.32 percent for CT to 8.15 percent for ultrasound. Large standard deviations in work reduction also existed within each modality.

Allen and colleagues said a “fundamentally erroneous understanding” of value scale methodology on the part of the GAO and MedPAC explained the differences in their conclusions. The researchers also said the GAO overvalued preservice and postservice work, focusing on a small set of examples rather than performing a comprehensive assessment and failed to recognize the high potential for variability that exists from service to service.

The authors took issue with the fact that a systematic reduction to the professional component payment would also reduce malpractice expenses and indirect practice expenses when no efficiencies exist in these areas by providing multiple services at the same time.

Harvey L. Neiman, MD, CEO of the American College of Radiology, cited the study in a recent letter to the Centers for Medicare & Medicaid Services. Neiman criticized proposed rule changes to the 2012 Medicare Physician Fee Schedule which included a MPPR of 50 percent to the professional component of MRI, CT and ultrasound services provided to the same patient during the same session.