CMS Says Evidence is Sufficient to Expand Medicare Coverage for Low-dose CT Lung Cancer Screening
By Marty Stempniak | November 18, 2021
The Centers for Medicare & Medicaid Services believes there is sufficient evidence to warrant expanding eligibility for lung cancer screening via low-dose CT, the agency announced on Wednesday.
Under the proposal, Medicare beneficiaries between the ages of 50 to 77 would be eligible, a drop from the previous starting age at 55. CMS also plans to reduce the threshold from 30 pack-years down to 20—meaning 20 cigarettes smoked per day for the past two decades. The new coverage guidelines align with recently updated recommendations from the U.S. Preventive Services Task force, released in March.
In explaining the decision, the agency said cancer of the lung and bronchus has accounted for 130,000 deaths in 2021, more than colon, breast and prostate cancer combined. It also cited results from high-profile lung cancer trials, demonstrating CT screening’s benefits.
“The evidence is sufficient to conclude that broadening the eligibility criteria for lung cancer screening with low dose CT is reasonable and necessary for the prevention or early detection of illness or disability and appropriate for Medicare beneficiaries under conditions established in this [national coverage determination],” CMS said Nov. 17.
Other eligibility criteria include displaying no lung cancer symptoms, being a current smoker or one who has quit in the last 15 years, and receiving an order for LDCT. Prior to the first screening, Medicare beneficiaries must schedule an appointment to help determine eligibility, discuss decisions in the process, and receive counseling on smoking cessation. CMS said the clinical evidence is “insufficient” to extend the age range beyond 77 to 80. Meanwhile, radiologists can participate if they are board-certified (or eligible) and have documented participation in continuing medical education.
The agency first announced it was launching its coverage review back in May and said it hoped to have a decision in November and complete the process by February 2022. A study in JAMA Network last month estimated that broadening LDCT recommendations to match the USPSTF’s guidelines could spell a 54% surge in eligibility. CMS also recently announced plans to raise the rate for outpatient lung cancer screening by more than 37%.
To read more, go to Radiology Business.
Congressional Doctors Lead Bipartisan Revolt Over Policy on Surprise Medical Bills
By Michael McAuliff | November 17, 2021
The detente that allowed Congress to pass a law curbing surprise medical bills has disintegrated, with a bipartisan group of 152 lawmakers assailing the administration’s plan to regulate the law and medical providers warning of grim consequences for underserved patients.
For years, people have faced these massive, unexpected bills when they get treatment from hospitals or doctors outside their insurance company’s network. It often happens when patients seek care at an in-network hospital but a physician such as an emergency room doctor or anesthesiologist who treats the patient is not covered by the insurance plan. The insurer would pay only a small part of the bill, and the unsuspecting patient would be responsible for the balance.
Congress passed the No Surprises Act last December to shield patients from that experience after long, hard-fought negotiations with providers and insurers finally yielded an agreement that lawmakers from both parties thought was fair: a 30-day negotiation period that would be followed by arbitration when agreements cannot be reached.
The rule, which would take effect in January, effectively leaves patients out of the fight. Providers and insurers have to work it out among themselves, following the new policy.
But now many doctors, their medical associations and members of Congress are crying foul, arguing the rule released by the Biden administration in September for implementing the law favors insurers and doesn’t follow the spirit of the legislation.
“The Administration’s recently proposed regulation to begin implementing the law does not uphold Congressional intent and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and potentially force small practices to close thus limiting patients access to care,” Rep. Larry Bucshon (R-Ind.), who is a doctor and helped spearhead a letter of complaint this month, said in a statement to KHN.
Nearly half of the 152 lawmakers who signed that letter were Democrats, and many of the physicians serving in the House signed it. But the backlash has not won the support of some powerful Democrats, including Rep. Frank Pallone (N.J.), chair of the Energy and Commerce Committee, and Sen. Patty Murray (Wash.), chair of the Senate Health, Energy, Labor and Pensions Committee, who wrote to the administration urging officials to move forward with their plan.
Some members of Congress who are also doctors held a conference call with the administration late last month to complain, according to aides to lawmakers on Capitol Hill, who could not speak on the record because they did not have authorization to do so. “The doctors in Congress are furious about this,” said one staff member familiar with the call. “They very clearly wrote the law the way that they did after a year, or two years, of debate over which way to go.”
The controversy pertains to a section of the proposed final regulations focusing on arbitration.
The lawmakers’ letter — organized by Reps. Thomas Suozzi (D-N.Y.), Brad Wenstrup (R-Ohio), Raul Ruiz (D-Calif.) and Bucshon — noted that the law specifically forbids arbitrators to favor a specific benchmark to determine what providers should be paid. Expressly excluded are the rates paid to Medicare and Medicaid, which tend to be lower than insurance company rates, and the average rates that doctors bill, which tend to be much higher.
Arbitrators would be instructed to consider the median in-network rates for services as one of several factors in determining a fair payment. They would also have to consider items such as a physician’s training and quality of outcomes, local market share of the parties involved where one side may have outsize leverage, the patient’s understanding and complexity of the services, and past history, among other things.
But the proposed rule doesn’t instruct arbiters to weigh those factors equally. It requires them to start with what’s known as the qualifying payment amount, defined as the median rate the insurer pays in-network providers for similar services in the area.
If a physician thinks they deserve a better rate, they are then allowed to point to the other factors allowed under the law — which the medical practitioners in Congress believe is contrary to the bill they wrote.
The provisions in the new rule “do not reflect the way the law was written, do not reflect a policy that could have passed Congress, and do not create a balanced process to settle payment disputes,” the lawmakers told administration officials in the letter.
To read more, go to Kaiser Health News.
Primary Care Docs Order Fewer Imaging Exams When Seeing Patients Via Video or Phone
By Marty Stempniak | November 16, 2021
Primary care visits conducted via video or the phone result in fewer imaging orders, according to new research published Tuesday in JAMA Network Open.
Telehealth use has exploded over the past few years amid the COVID-19 pandemic as patients seek to stay home and limit exposure to the virus. Previous research has shown that direct-to-consumer virtual primary care offerings may result in overprescribing and other differences in follow-up care.
Kaiser Permanente researchers aimed to explore this concern at the Oakland, California based institution using pre-pandemic data from more than 1.1 million patients. They found that primary care docs ordered imaging or lab tests in about 59% of office visits compared to 29% of video encounters and 27% of appointments handled over the phone.
The study did not assess why the variances occurred, but authors speculate that sicker patients may seek in-person primary care.
“It is possible that these differences in treatment might be driven by the types or seriousness of concerns that patients chose for each visit type, or by the degree to which physicians could assess the patient in each visit type,” Mary Reed, DrPH, a Kaiser Permanente research scientist, said in a statement. “We need to explore these details further in future research.”
Reed and colleagues analyzed data from all completed primary care appointments booked at KP in Northern California between 2016 to mid-2018. All told, the study included nearly 2.2 million appointments. Along with imaging orders, video (39%) and telephone visits (35%) resulted in fewer medications prescribed compared to office-based encounters (52%). About 25% of video visits had a follow-up within the next week, with similar numbers for telephone (26%) and in person encounters (24.5%). Meanwhile, there was no notable difference between the three for emergency department visits or hospitalizations.
Those involved believe their work underlines the usefulness of telemedicine during the pandemic and beyond.
“In contrast to prior studies of direct-to-consumer telemedicine, we did not find evidence of over-ordering or over-prescribing among patients using telemedicine to visit their own primary care doctors,” Reed et al. wrote. “Video or telephone visits may be a convenient and safe way for patients to address some primary care needs without generating a substantial number of follow-up office visits or experiencing health events.”
To read more, go to Radiology Business.
Report: Reimbursement Drives Adoption of AI Software for Stroke
By Erik L. Ridley | November 15, 2021
The start in 2020 of Medicare payments for artificial intelligence (AI) software to detect large vessel occlusion (LVO) stroke on CT scans has precipitated a sharp increase in utilization, according to a new report from group purchasing organization Vizient.
After analyzing its Vizient Clinical Data Base, the company found that 130 hospital members were using the designated code for AI software in LVO detection — ICD-10-PCS procedure code 4A03X5D — in the second quarter of 2021, up from 63 hospitals in the fourth quarter of 2020. And the number of procedures also more than doubled.
“AI-assisted stroke triage and workflow platforms appear to be in the early stages of innovation adoption,” the authors wrote in volume 4 of Vizient’s Medical Device Tech Watch publication. “Currently, hundreds of U.S. hospitals use the technology and thousands of scans are analyzed weekly with AI.”
Vizient attributed the rapid adoption to the U.S. Centers for Medicare and Medicaid Services (CMS) decision in September 2020 to implement a new technology add-on payment (NTAP) for AI-based detection of LVO stroke on CT angiography exams. Taking effect on October 1, 2020, the NTAP enabled reimbursement up to $1,040 if the total inpatient cost of care exceeds the diagnosis-related group (DRG) payment, Vizient said.
“Depending on volume and other local factors, NTAP reimbursement may provide substantial revenue to offset technology subscription costs,” the authors wrote. “AI usage may also drive revenue growth by increasing the number of mechanical thrombectomies.”
Crucially, AI was reported to have played a diagnostic role in approximately 38% of the procedures that resulted in mechanical thrombectomy, according to Vizient.
Five stroke detection algorithms have received U.S. Food and Drug Administration (FDA) clearance for LVO stroke detection:
• Viz LVO (Viz.ai), February 2018 via the FDA’s de novo pathway
• LVO detection algorithm (Aidoc), December 2019
• Cina Head (Avicenna.ai), June 2020
• Rapid LVO (RapidAI), July 2020
• StrokeViewer LVO (NiCo.Lab), November 2020
To read more, go to Aunt Minnie.
Hand Trauma Patients Requiring Radiology Services Face Much Higher Odds of Receiving Surprise Bill
By Marty Stempniak | November 12, 2021
Hand trauma patients who require radiology services face significantly higher odds of receiving a surprise medical bill, according to new research.
The emergency department is one of the most common sources of such unexpected IOUs, with upward of 43% of visits resulting in a surprise bill. And upper hand extremities are a frequent reason for ED encounters that sometimes require transfers to higher-level care centers, despite a patient’s intent to use an in-network facility.
Experts with the Baltimore-based Curtis National Hand Center—one of the largest of its kind in the world—sought to unearth factors that might increase one’s odds of receiving a surprise bill. Among physicians, radiologists and pathologists had the highest association, both presenting a 132% higher risk of producing unanticipated debt for their encounter, experts wrote in the Journal of Hand Surgery.
“Although the incidence of surprise billing decreased over time, the wide geographic variation across states suggests that the problem persists,” Chao Long MD, a research fellow at the hand center and plastic and reconstructive surgery resident at Johns Hopkins, wrote Nov. 8. “The source of surprise bills is widely varied, including both physician and nonphysician providers, and placing hand trauma patients requiring multidisciplinary care at high risk. Hand surgery as a specialty can advocate for comprehensive policies to better protect our patients from financial exploitation.”
For the study, Long et al. used IBM MarketScan commercial claims covering care spanning from 2010 to 2017. They landed on a final sample of nearly 711,000 encounters, with almost 98,000 (or 14%) involving a surprise medical bill. Such instances decreased from 26% at the study’s start down to 11% by its conclusion. Average coinsurance payments were higher for surprise billing encounters, with double the growth over the seven years compared to those without an unexpected tab. Facility transfers occurred in only about 0.5% of patients who received a surprise bill, while radiologist services occurred most frequently at 21%.
The authors also discovered that other nonphysician providers, such as therapists (147%), also increased the odds of receiving a surprise bill. And the practice is widespread, existing “to varying degrees” in every U.S. state, despite 21 having legislation to address this concern at the time of the study, which likely contributed to decreases in the study. As of February, 33 states have enacted surprise billing laws and the federal government is now working on a national version.
“Altogether, these findings are particularly concerning because patients with hand or upper extremity trauma frequently require a multidisciplinary team. As such, the odds and resultant magnitude of surprise billing accumulate,” the authors advised.
To read more, go to Radiology Business.
When Patients are Satisfied, Outpatient MR Imaging Volumes Increase, New Study Finds
By Marty Stempniak | November 12, 2021
When patients are pleased with their radiology care, outpatient imaging volumes increase, according to new research published Thursday.
Previous studies have demonstrated the impact satisfaction can have in spurring return visits and positive word-of-mouth. But analyzing this issue can be difficult in the specialty, experts detailed in Current Problems in Diagnostic Radiology. Individuals often do not meet face-to face with their radiologist, and other uncontrollable factors such as claustrophobia in the MRI machine potentially impact satisfaction scores.
Ohio State researchers recently set out to explore this topic, retrospectively reviewing outpatient MRI volume trends across 10 sites and matching them up with Press Ganey outpatient surveys. They found a clear correlation, with median satisfaction score changes trending higher at facilities reporting rising visit numbers.
“Patient satisfaction and patient volume at MRI imaging sites are interrelated, and patient experiences or perceptions of quality of care have the potential to influence what imaging sites are preferentially utilized,” Amna Ajam, MD, with OSU College of Medicine’s Department of Radiology, and co-authors wrote Nov. 11. “Significant associations between favorable satisfaction survey trends and increasing MRI volume suggest that patient satisfaction is not only a quality metric but has operational importance in predicting or impacting imaging volume.”
Altogether, the analysis covered nearly 40,000 patient visits logged over a one-year period ending in March 2016 in which OSU experienced systemwide MRI declines. A three-month period ending June 30, 2015—when Ohio State witnessed a peak in volume—served as the baseline for the study. Quarterly volume stayed stable across six of the study sites, climbed at a seventh by 18%, and fell 20-24% at the other two.
Ajam et al. discovered a notable association between volume trends and changes in all five Press Ganey score domains. Statistical significance was highest for “overall assessment” (how well staff worked together, rating of care delivered, etc.) and “test or treatment” (instructions received, time spent waiting, friendliness of staff who provided care). Meanwhile, the newest, most visually appealing sites saw volume fall, “diminishing the argument for major design investment as means of enhancing patient volume.”
With rising consumerism in healthcare, the authors believe imaging leaders must pay attention to the “economic consequences” of patient satisfaction.
“Given that a relatively high proportion of operating costs in MRI are fixed costs, profitability at an MRI site is strongly dependent on patient volume,” Ajam and colleagues advised. “Taking patient volume as an indicator of increased profitability, our findings corroborate the positive association between client satisfaction, loyalty and profitability described for inpatient care, the hospitality industry and banking services.”
To read more, go to Radiology Business.