Radiology Groups Slam MAC’s Local Coverage Determination, Claiming It’s Irrational, Lacks Evidence
By Marty Stempniak | September 20, 2023
Radiology groups are slamming a Medicare Administrative Contractor’s recent local coverage determination for one key pain treatment approach, claiming its irrational and unsupported by scientific evidence.
Noridian Healthcare Solutions recently announced the proposal, which pertains to an interventional surgical procedure used to treat chronic lower back pain emanating from the vertebrae. The MAC is proposing to exclude coverage for this nerve ablation procedure if the patient has any nonvertebral pathology that could contribute to their symptoms.
The American Society of Neuroradiology and others are expressing “significant concern” around this restriction. A second change also would require patients to undergo screening, evaluation and diagnosis by a multidisciplinary team that includes a psychologist prior to undergoing the interventional procedure.
“Neither of these requirements is rational or evidence-based,” ASNR, the American College of Radiology, the American Society of Spine Radiology and the Society of Interventional Radiology wrote to Noridian, which covers Jurisdiction E including California, Hawaii and Nevada.
“The studies, appropriately cited by the [local coverage determination], that have demonstrated the procedure’s effectiveness did not preclude the treatment of patients with nonvertebral pathology that could contribute to symptoms or complaints, nor did they require extensive screening, evaluation, and diagnosis by a multidisciplinary team and implementation of a psychological assessment.
The radiology groups are “strongly” suggesting that the MAC revise the language in its proposal. This would ensure that the patient’s pain is most likely vertebrogenic in nature, so if imaging findings suggest otherwise, providers can consider other more appropriate treatments. ASNR et al. also asked Noridian to quash any mentions of psychological evaluations for patients requiring such intraosseous basivertebral nerve ablation treatments.
“Requiring screening, evaluation and diagnosis by a multidisciplinary team is not reasonable and serves only as a barrier to treatment,” the societies wrote. “A psychological assessment in these patients is unnecessary as these patients have chronic pain (>6 months); have already undergone extensive conservative, nonsurgical management; and have Type 1 or Type 2 Modic changes on MRI. For this patient population, the treatment is highly effective. There simply is no basis for a psychological assessment in these patients.”
You can read the full letter here and the local coverage determination from the Medicare Administrative Contractor here.
To read more, go to Radiology Business.
AHIP, Health Systems on Opposite Sides of No Surprises Act Debate
By Rylee Wilson | September 20, 2023
Payers and providers don’t agree on much when it comes to the No Surprises Act dispute resolution process.
In a Sept. 19 hearing held by the House Ways and Means Committee, Jeanette Thornton, executive vice president for policy at AHIP, the trade association representing insurers, said the independent dispute resolution process, or IDR, overwhelmingly favors the “initiating party,” — hospitals and air ambulance companies.
“Between an overwhelming number of disputes and repeated litigation from the Texas Medical Association that has created regulatory uncertainty and repeated starts and stops, the Departments have been hindered in developing an IDR process that works,” Ms. Thornton said in her opening statement. “The IDR process should be fair to all parties, with consistent rules, transparency into decisions, and ultimately used rarely.”
As of Sept. 1, all federal dispute resolutions are on pause after a Texas judge ruled in favor of the Texas Medical Association, which argued the dispute resolution process favors insurers.
In testimony to the committee, Jim Budzinski, CFO of Marietta, Ga.-based Wellstar Health System, said the dispute resolution process disincentivizes payers to keep health systems in their networks, instead relying on dispute resolution to receive higher payments.
“Wellstar has seen firsthand the actions by large health insurers who refuse to negotiate with us, insist on going out of network and rely on the independent dispute resolution process. We see this as a prime example of how flawed the No Surprises Act implementation has been,” Mr. Budzinski said.
Ms. Thornton said the success of the payer business model “largely depends on having large networks of high-quality, high-value healthcare.”
“The idea that health insurance providers are intentionally withholding required payments to healthcare providers defies our fundamental business model,” Ms. Thornton said. “While we advocate for a regulatory structure that incentivizes network participation over IDR, when a provider is owed additional amounts after IDR, because we aim to bring more providers in-network, we have every incentive to view that provider as a potential partner and make timely payments.”
To read more, go to Becker’s Payer Issues.
123 Organizations Come Out in Support of FIND Act Aimed at Strengthening Diagnostic Imaging Pay
By Marty Stempniak | September 20, 2023
A total of 123 organizations have endorsed a legislative proposal aimed at strengthening Medicare payment for diagnostic imaging agents.
Supporters include societies representing radiologists and nuclear medicine professionals, device manufacturers, patient advocacy groups and pharmaceutical companies.
Bipartisan members of the U.S. House and Senate reintroduced the Facilitating Access to Innovative Diagnostics, or FIND, Act earlier this year.
Currently, Medicare only reimburses for radiopharmaceuticals through a packaged system. But this can create a barrier for those who need newer nuclear imaging agents, advocates note. The FIND Act would eliminate this obstacle by requiring HHS to issue separate payment for such agents, using a per-day cost threshold of $500.
Those announcing (or restating) their support Monday included the American College of Radiology, Society of Nuclear Medicine and Molecular Imaging, Medical Imaging & Technology Alliance, the Michael J. Fox Foundation and Eli Lilly & Co.
“It is time for Congress to expand access to these procedures and address flawed payment policy through passage of the FIND Act,” Ali Manson, VP of government relations and advocacy for ZERO Prostate Cancer, said in a Sept. 18 announcement from the supporters.
Meanwhile, theHouse Energy and Commerce Health Subcommittee held a hearing Tuesday to discuss the FIND Act along with several other proposals aimed at improving seniors’ access to treatments.
“In addition to novel therapies, we now have diagnostic tools that can help us detect diseases sooner, such as multicancer screening diagnostics, leading to improved patient outcomes and savings to the healthcare system,” Subcommittee Chair Brett Guthrie, R-Ky., who is not currently listed among co-sponsors of the FIND Act, said in his opening remarks. “These tools represent another opportunity to ensure our Medicare policies strike the appropriate balance of increasing access while driving higher quality care.”
Others supporting the legislation include the American College of Nuclear Medicine, the American Society of Radiologic Technologists, the American Society of Neuroradiology, Bracco Diagnostics, GE HealthCare, the Mayo Clinic Department of Radiology and Siemens Healthineers.
To read more, go to Radiology Business.
Hospital Prices Online Are Not Aligned With Prices Offered Via Telephone
By Victoria Bailey | September 19, 2023
Hospital prices posted online for vaginal childbirth and brain magnetic resonance imaging (MRI) did not match the prices offered to a secret shopper via telephone, indicating poor price transparency.
The Hospital Price Transparency Rule requires hospitals to publish a machine-readable file with prices for all services and a consumer-friendly tool with prices for 300 shoppable services. The regulation aims to improve transparency and allow consumers to compare prices across hospitals.
The study published in JAMA Internal Medicine focused on whether hospitals’ prices posted online correlated with the prices they gave over the phone.
Researchers looked at self-posted online cash prices for vaginal childbirth and brain MRI at 20 top-ranked hospitals, 20 safety-net hospitals, and 20 non-top-ranked, non-safety-net hospitals in 2022. They then contacted the hospitals via telephone using a secret shopper approach to request the lowest cash price for each service.
The ability to provide prices for vaginal childbirth and brain MRI varied among the three hospital cohorts. For vaginal childbirth, 63 percent of top-ranked hospitals, 30 percent of safety-net hospitals, and 21 percent of non-top-ranked, non-safety-net hospitals provided both online and phone prices. For brain MRI, 85 percent of top-ranked hospitals, 50 percent of safety-net hospitals, and 100 percent of non-top-ranked, non-safety-net hospitals provided online and phone prices.
For both services, safety-net hospitals had lower online prices than the other two cohorts, but telephone prices were similar for all three groups.
Additionally, there was significant variation between the lowest-priced and highest-priced hospitals for vaginal childbirth and brain MRI across the three hospital groups. Among non-top-ranked, non-safety-net hospitals, the lowest online price for brain MRI was $457, while the highest was $166,994. Meanwhile, among safety-net hospitals, the lowest phone price for vaginal childbirth was $3,882, while the highest was $100,000.
The correlation between online and telephone prices for the services was poor, researchers found. Non-top-ranked, non-safety-net hospitals had the highest correlation between prices for vaginal childbirth, while safety-net hospitals had the highest price correlation for brain MRI. Top-ranked hospitals had the poorest correlation between prices for both services.
To read more, go to Revcycle Intelligence.
ChatGPT Knows a Lot About PET Scans, but Its Advice is Inconsistent
By Chad Van Alstin | September 15, 2023
ChatGPT remains inconsistent when it comes to dishing out medical advice, but that does not mean it is necessarily useless. In another study analyzing the reliability of the popular large language model application from OpenAI, researchers from Germany posed 25 questions to ChatGPT focused entirely on PET/CT scans, rating each answer for accuracy, helpfulness and consistency. The results of a study were published in the Journal of Nuclear Medicine. 
Questions asked to ChatGPT ranged from basic (“Is a PET scan harmful?”) to more complicated (“I’m a caregiver to a toddler. Are there any precautionary measures after a PET scan?”), and overall, the AI did fairly well with its responses, with 23 of the answers ranked as appropriate by the researchers.
ChatGPT scored particularly poorly on only two questions – “I’m a caregiver to a toddler. Are there any precautionary measures after a PET scan?” and “What’s my lymphoma stage?” – with researchers rating the responses as “quite inappropriate.” No answers from ChatGPT earned the lowest rating of “highly inappropriate”.
Complicating the results are the ratings given for consistency. Some responses were rated favorably for appropriateness, but the chatbot was inconsistent with how it responded when asked multiple times, calling its reliability into question.
To read more, go to Health Imaging.
Radiology Groups Urge CMS to Retool the Flawed Merit-based Incentive Payment System
By Marty Stempniak | September 15, 2023
Radiology groups are urging the federal government to retool the Merit-based Incentive Payment System, or MIPS, amid concerns that it’s too difficult for the specialty to participate.
Both the American College of Radiology and Radiology Business Management Association encouraged CMS to make changes to the quality-reporting program in comments submitted this month. As one point of contention, ACR highlighted the agency’s plan to raise the “performance threshold” from 75 to 82 points next year. Providers falling below this level would be automatically penalized.
However, radiologists already are struggling to participate in MIPS, given several barriers. Those include the specialty’s ineligibility to earn maximum incentive adjustments, despite perfect performance in the program.
“The ACR strongly opposes CMS’s proposal to raise the performance threshold to 82 points until the effects of topped out quality measures on non-patient facing clinicians and the barrier for introducing new measures is addressed,” CEO William T. Thorwarth Jr., MD, wrote to the agency on Sept. 8. “It is important to acknowledge that due to declining measure availability and an increased fraction of topped out measures for some specialties, such as radiology, as well as the removal of bonus points, there is not equivalency between past and present years,” he added later. “As a result, past performance is not reflective of the current challenges. We thus strongly urge CMS to use the flexibility provided in the statute to maintain the threshold until these issues are successfully addressed.”
CMS also has indicated that it plans to sunset the MIPS program in favor of alternatives, though no timeline has been set. The college asked the agency to hold off on such a change for now.
“The ACR acknowledges that the MIPS program is burdensome and imperfect at effectively measuring clinician performance,” Thorwarth wrote. “However, we encourage CMS to commit to not sunsetting MIPS until there is an option available which is viable to all specialties.”
The Radiology Business Management Association also voiced opposition to certain aspects of MIPS, as spelled out in the 2024 fee schedule. RBMA is “extremely concerned” about the impact on radiology practices after reimplementing cost measures for the 2022 performance period. The association believes there are no meaningful opportunities for clinicians to impact performance, and CMS has not provided cost data since 2019, RBMA noted.
There also is no interim reporting during the performance period, leaving clinicians unable to understand how they are performing.
“It defies logic to expect clinicians to impact costs for patients who cannot be readily identified, for unknown services with unknown costs, ordered and rendered by unknown providers and suppliers for unknown reasons,” RBMA Executive Director Bob Still wrote Sept. 11. “Given the fact that the meager data is not provided until after the end of the reporting period, no one can expect it to impact program costs. Many radiology practices have reported being scored on the Medicare Spending per Beneficiary measure. They express frustration with this, since radiologists rarely admit patients to the hospital, and even more rarely manage post-discharge care.”
Radiologist Richard Heller, MD, MBA, also recently editorialized on the inherent flaws in MIPS. He urged Congress to consider quashing the program, as the Medicare Payment Advisory Commission recommended five years ago.
“Eliminating the MIPS program, or at least hitting pause while an alternative approach is developed, would not only reduce the burden on providers and stop the costly gamesmanship of managing a broken system, but it would also clear the way for meaningful reform,” Heller, who is associate chief medical officer for health policy and communication at Radiology Partners, wrote Sept. 9 in a MedPage opinion piece. “Let’s hope Congress takes the easy win.”
To read more, go to Radiology Business.
Good News, Bad News for Physicians
By Patsy Newitt | September 14, 2023
Here are three pieces of good news and three pieces of bad news for physicians:
1. Physician pay is declining
CMS is floating a 3.34 percent conversion factor decrease in its proposed Medicare physician fee schedule for 2024 released July 13.
The average physician compensation declined by 2.4 percent in 2022, according to Doximity’s 2023 “Physician Compensation Report.”
“People wonder why our healthcare system is in such a turmoil. Poor access to doctors, and emergency rooms are so overcrowded with trivial problems,” Sheldon Taub, MD, gastroenterologist at Jupiter (Fla.) Medical Center told Becker’s. “Who wants to go into medicine when your reimbursement goes down every year? I pay more for my plumber or electrician than I make per hour… Our healthcare system is a travesty, and I have to blame much of it on the government. Big business is running medicine and that’s a shame.”
Additionally, more physicians and practices could be hit with a penalty with the Merit-Based Incentive Program based on the 2022 performance feedback. These penalties can reduce Medicare payments up to 9 percent, according to a Sept. 11 news release from the American Medical Association.
2. Physician shortages are getting worse
The overall shortage of physicians in the U.S. could reach 124,000 by 2034, according to Physician Thrive’s 2023 compensation report. Of those, up to 48,000 could be in primary care and 76,000 will be specialists, surgeons or hospitalists, according to the report. These shortages will burden already-burnt out physicians and further affect access to care.
“The extraordinary rate of provider burnout is the most concerning healthcare disruptor to me. When combined with physician shortages, America’s healthcare workforce is under enormous strain as the population ages and the demand for healthcare services increases,” Luis Argueso, partner at InHealth Advisors, told Becker’s. “There are no quick solutions to this problem given the time to train new practitioners, although increases to the number of resident slots are a good start. Provider shortages will lead to delays in care and increased costs, at a time when healthcare is already hard to find and difficult to afford. This concern doesn’t just impact patients; given the way healthcare is financed (through taxes for government payers or forgone compensation for employees), we all bear the financial cost.”
Areas with an aging population, such as Midwestern and Southern states, along with rural areas, will see exacerbated shortages in the next decade, according to the Physician Thrive report.
3. Physicians are losing autonomy
Only 44 percent of physicians owned their practice in 2022, compared with 76 percent in the early 1980s, according to a report from the American Medical Association. Additionally, the number of physicians working in private practices decreased by 13 percent between 2012 and 2022.
Some leaders feel that this is affecting physician autonomy.
“Physicians remaining independent are going to be few and far between. They’re either going to go with these large equity groups or hospitals or something like that,” Dr. Taub told Becker’s. “You still have a quote, unquote, ‘private practice,’ but you have guidelines and rules that you have to conform to so it meets their criteria. So right away, you feel a little bit of your autonomy being compromised, and then the bigger the group gets, the more restrictions they have on what you can do to stay in the group and conform to what they want you to do. On top of that, the government throws in their regulations too. The private practitioner is a dying breed.”
1. Payers, legislators are cutting prior authorizations
In 2022, 39 percent of physicians spent one to nine hours on prior authorizations weekly, according to Medical Economics’ “94th Physician Report,” but payers and legislators are making increasing efforts to cut down these requirements.
In the last two months, Humana, Cigna and Blue Cross Blue Shield plans have cut prior authorization requirements. Additionally, UnitedHealthcare began a two-phased approach to eliminate prior authorization requirements for several procedure codes, aiming to cut prior authorization by 20 percent.
“Many gastroenterologists are concerned about prior authorization and advanced notification processes causing delays in cancer diagnosis for patients with alarm symptoms and medical management in general,” Benjamin Levy, MD, a gastroenterologist at University of Chicago Medicine, told Becker’s. “As a physician community, we breathed a sigh of relief when the proposed new prior authorization requirements were changed to advanced notification.”
States have also made efforts to limit prior authorizations. Last year, Texas passed a law where physicians who have a 90 percent prior authorization approval rate over a six-month period on certain services are exempt from prior authorization requirements for those services. In June, Michigan launched new prior authorization rules that aim to make the process faster, more effective and more transparent.
To read more, go to Becker’s ASC Review.