CAC News
MANAGED CARE COMMITTEE REPORT
As in 2005, the focus of managed care with respect to radiology in Massachusetts has been the spiraling cost of high tech imaging (CT, MRI, Nuclear Cardiology, PET).
This has led the major health insurance providers in Massachusetts (Blue Cross, Tufts Health Plan, and Harvard Pilgrim) to implement pre-authorization plans for high tech imaging. The first preauthorization program was implemented by Harvard Pilgrim in early 2005. Blue Cross and Tufts followed in late 2005 with full implementation of their plans in 2006. There are some differences in all three pre-authorization programs with some being more punitive than others. In addition most of the peripheral insurers (CIGNA, Aetna for example) in this state have programs in place as well. After initial vocal opposition, the medical community has come to accept these programs as a way of life.
The initial data on the preauthorization programs as presented to the Task Force on Cost Control of the Massachusetts Medical Society by Harvard Pilgrim, Blue Cross and Tufts suggests that the desired effect is being achieved and that there is a slowing of the costs assigned to high tech imaging. As such, one can assume that the preauthorization programs are here to stay, at least for the near future.
The other significant issue for radiology is Cardiac CTA. Eight new category 3 CPT codes relevant to Cardiac CTA were approved in 2006. NHIC (the Centers for Medicare and Medicaid Services (CMS) carrier in New England) approved payment for 7 of the 8 codes for Cardiac CTA in September. At this point in time, none of the major insurers in Massachusetts has a policy that allows for payment of Cardiac CTA but as experience accumulates and more evidence based literature is published, this should change. The timing of that is uncertain as all three major insurers are concerned about the financial impact this could have on the cost of health care.
Lastly, there is little good news on the Federal front. Most of us are aware of the impact the Deficit Reduction Act will have on the technical component of non hospital based out patient imaging in 2007. In addition, the CMS has frozen the conversion factor for the physician schedule for 2007 but the RVUs have been adjusted with a redistribution of funds towards E & M coding. The net result of this is a decrease of the CMS Physician Fee Schedule for Radiology for 2007 of approximately 8%. On the plus side, CMS has agreed to limit the contiguous body part reduction in payment to 25% for 2007 (was slated to be 50%).
Looking to the future, I think it is clear that the focus on the cost of imaging will increase and the changes we have seen over the last few years will continue. The Radiology community in general will need to be vigilant to ensure we are paid fairly for the services that we provide to our patients.
Respectfully submitted,
Philip Rogoff, MD
Chair