Healthcare reform launches new era for nuclear medicine

While healthcare reform has been slowly evolving as a result of many acts of Congress during the past decade, it is the Affordable Care Act of 2010 (ACA), that is driving major changes in healthcare coverage, the economics of the medical industry and quality of care. The latter is being carried by a series of reporting and incentive programs that have a direct impact on the practice of nuclear medicine and molecular imaging, according to a review published March 1 in the Journal of Nuclear Medicine Technology.

Kristi R. Mitchell, MPH, from Avalere Health, Washington, D.C., and colleagues outlined recent and future changes in public health policy as it relates to nuclear medicine and molecular imaging.

Costs associated with healthcare are estimated at 18 percent of U.S. gross domestic product and continue to rise. The ACA focuses on quality and appropriate use as a means of improving healthcare and reducing costs. The U.S. is lacking compared to other countries in areas pertaining to quality--including breast cancer survival rates and diabetes-related amputations, all of which led to the current reform.

“In an attempt to place outcome measurement at the center of health reform, there has been a renewed effort to shift away from volume payment and toward value,” wrote Mitchell et al. “No longer will physicians be rewarded solely for providing more care, but for providing high-quality care as defined by meeting and in some cases exceeding performance standards set by public and private payers. These recent efforts represent another way to rectify the inappropriate, perverse incentives wreaking havoc in our health-care system.”

However, there is not a great deal of information available about heathcare costs and the quality of care needed to stimulate growth and competition in what is still a consumer market. Electronic health records and other innovations that speed up the flow of such information are expected to slowly begin bridging that gap; 54 percent of all medical offices have adopted the technology.

“There is insufficient data on what works best, with treatment varying from community to community and pervasive safety and quality concerns. The infrastructure necessary to gather and share such information is only at the very beginning stages for imaging.”

One of the most significant and controversial changes in health reform is the creation of the Independent Payment Advisory Board, which heads cost cutting. Bundled into this is the Patient-Centered Outcomes Research Institute (PCORI) that is designed to provide the information needed to develop appropriate reform based on comparative-effectiveness research. Millions of dollars have already been supplied by the Treasury to fund this endeavor. Every year, $150 million is slated to fund PCORI and starting in October a new source of income will be coming from individual fees of $1 from every insured person. This will provide an additional $200 million in funding for research. The fee is scheduled to increase to $2 in 2014 and through 2019, providing another $500 million in the effort to define new measures of healthcare reform.

“However, application in nuclear medicine and molecular imaging has been limited largely by the lack of consensus around what defines quality,” wrote the authors.

The ACA has implemented the hospital inpatient quality reporting program, which sets the stage for the hospital inpatient value-based purchasing program beginning this fiscal year 2013, and data will be reported by CMS via an online portal called Hospital Compare, but it is the hospital outpatient quality reporting program that will have the greatest impact on the imaging industry.

“The hospital outpatient quality reporting program, modeled after the hospital inpatient quality reporting program, is a quality data reporting program implemented by CMS for outpatient hospital services. Currently there are six imaging efficiency measures included in the hospital outpatient quality reporting program; one additional measure will be added for the 2014 payment determination.”

These 2012-2013 measures pertain to MRI of the lumbar spine for low back pain, use of brain CT in the emergency department for atraumatic headache, mammography follow-up, use of contrast for abdominal and thoracic CT, cardiac imaging for preoperative risk assessment for noncardiac low-risk surgery and simultaneous use of brain CT and sinus CT. Five new measures related to optimizing and thereby lowering radiation dose are scheduled to roll out in 2014.

Data reporting is being made possible by the Physician Quality Reporting System (PQRS) incentive program, which encourages individual healthcare professionals to report 2012 data about quality measures through the electronic health record, Medicare Part B claims, an eligible PQRS registry or data submission vendor. Successful completion of this awards qualified professionals 0.5 percent of their total estimated charges according to the Medicare Part B physician fee schedule for that set reporting period. Incentives will turn to penalties beginning in 2015.

“Also starting in 2015, CMS will implement the physician value-based payment modifier, also known as the VBPM, for groups of 100 or more providers,” the researchers wrote. “This modifier will be based on participation in PQRS, performance on quality measures reported through the PQRS, and cost measures that have been specified in the final rule for the 2013 Medicare Part B physician fee schedule. Starting in 2017, the payment modifier will apply to all providers regardless of specialty or whether they are individual providers.”

Lack of meaningful use of the electronic health record will result in a 1 percent penalty from Medicare by October 14, with the exception of four categories of hardship for eligible professionals and limited to five years. 

Medical societies such as the Society of Nuclear Medicine and Molecular Imaging (SNMMI) have been working to develop online tools to help physician adoption of these platforms. In addition to data reporting, one of the major focuses of ACA is on appropriate use of medical technology. Appropriate use will most likely be evaluated based on hospital clinical decision support systems instead of performance-based payment systems. SNMMI recently received $300,000 to devise strategies using interactive media to be promoted toward professionals in oncology, who frequently order advanced diagnostic imaging during the course of cancer care. 

“This implementation will most likely be in the form of popups on the screen when a physician tries to order an examination and will serve as a mechanism to support ongoing provider education,” wrote the authors.

Another juggernaut in the era of appropriate use is the emergence of amyloid imaging, which has the potential to revolutionize dementia care, but in the current environment of healthcare reform, it is uncertain how coverage will take shape.

“Since the spring of 2012, SNMMI has worked with the Alzheimer’s Association to develop a set of appropriate-use criteria for [beta-amyloid] imaging,” the researchers wrote. “The issue of the role of imaging in dementia remains unclear to many physicians, and with the advent of new radiopharmaceutical agents the opportunity for the profession to take a leadership role to define the appropriate patient and clinical scenario has become imminent.”

Critics of healthcare reform say that the Congressional Budget Office cost estimate understates cost due to flaws in Medicare’s sustainable growth rate payment formula for physicians, which creates hefty costs in the interim toward a permanent revision.

“If Congress were to wait until 2016 to do away with the sustainable growth rate, the estimated combined cost for providing temporary patches through 2016 and then eliminating the sustainable growth rate approaches $600 billion,” wrote the authors.

Nuclear medicine and molecular imaging professionals will have to wait and see what impact new data from incentive programs and registries will have on reimbursement and guidelines for quality of care for this specialty.