Pinpointing the source and path of disease inside the human body has been one of the most essential advancements of modern medicine. From multi-slice CT scanners, advanced MRI readings and PET (positron emission tomography), radiologists are able to identify critical areas of disease for more targeted treatment. Yet the cost of using such innovative equipment continues to soar, making it more difficult to provide imaging services. Medical imaging is a $100 billion a year industry, and the federal government is keeping tabs. According to a March 2005 Medicare Payment Advisory Commission (MedPAC) report to Congress, high-end medical imaging (CT, PET and MRI) is the fastest-growing type of physician services expenditure in the United States, with an annual growth rate that is more than twice that of other physician services. The latest cutbacks, which were slipped into the Deficit Reduction Act of 2005 (DRA) in February, take direct aim at outpatient radiology and imaging. The DRA calls for drastic Medicare reimbursement cuts for out-of-hospital medical imaging procedures. The crowning blow is the technical imaging component reimbursement, which will be determined from the lesser of two fee schedules, either the Hospital Outpatient Prospective Payment System (HOPPS) or the Medicare Physician Fee Schedule payment. As of January 1, 2007, cuts of 38 to 69 percent will be implemented on high-end imaging procedures. The cuts are to reduce reimbursement for imaging services by $2.8 billion in five years. The American College of Radiology (ACR), which is dedicated to working with Congress and CMS to define quality control guidelines for proper imaging utilization, has a preliminary analysis revealing that the cuts actually amount to nearly $1.2 billion annually or $6 billion over five years. Leading-edge technologies such as the 64-slice CT scanner, which allow physicians to target problems without more invasive techniques, are on the reimbursement chopping block and could leave many doctors financially unable to purchase such updated equipment. The proposed reimbursement cuts may force radiologists, radiation oncologists and other qualified physicians who have made considerable investments in imaging equipment to stop offering services that benefit patients and to limit the number of Medicare patients they receive. The cuts will also likely discourage investment into the research and development of new technologies, which are progressively replacing more invasive procedures. Ultimately, the ACR believes the patient pays the price. "These cuts will keep physicians from investing in equipment that would save or extend lives and deny patients the opportunity to receive the highest quality, least invasive care," explains Dr. James P. Borgstede, FACR, chair of the ACR Board of Chancellors. "Medical imaging is serving an increasingly large role in patient care. This bill is undercutting new technologies that can be of great benefit to current patients and denying future generations of less invasive procedures that may benefit all of mankind." These cuts, which have come in tandem with the November 2005 cuts for imaging exams on contiguous body parts, are a radical response to decrease overall Medicare reimbursement spending. The contiguous body part cutback will reduce that reimbursement by 25 percent this year and 25 percent in 2007. The DRA forces radiologists to disproportionately absorb the burden of reducing reimbursement spending. In fact, the ACR and other medical organizations, manufacturers and patient advocacy groups, who have sent letters to Capitol Hill opposing the DRA imaging cuts, contend the provision singles out imaging services to shoulder more than one-third of all Medicare payment reductions in the DRA. What's more, this policy does not differentiate between diagnostic services and treatment planning services needed for cancer patients. "Clearly medical imaging is in the short sights of the members of Congress and CMS, and it's our opinion a large reason for that is economically motivated self-referral, but we have to address the issue of Congress essentially reducing the technical component reimbursement to incentivize physicians from performing imaging," contends Borgstede. "That's not the way to solve the problem. They solve the problem here with a meat axe rather than a scalpel." Congress hopes to stem the tide of overutilization, which has been on the rise with non-radiologists as well, by putting up this reimbursement roadblock. The provision, however, discounts the efforts of the ACR and the Practice Expense Advisory Committee to reduce Medicare costs by clearly defining appropriateness criteria for imaging. Instead of looking into the utilization issue and finding ways to reduce costs and discourage economically motivated self-referral, Congress has created cuts across the board. In February when the cuts were first introduced into the DRA, Borgstede commented: "The ACR maintained a constant dialogue with the appropriate jurisdictional committees regarding an imaging policy based on the implementation of quality and safety standards that would have curbed inappropriate utilization growth, raised quality of care and saved Medicare $5 billion over 10 years." Since then the ACR has worked diligently to educate radiologists and lawmakers on what they perceive will be the severe consequences of these imaging reimbursement cuts. If physicians are forced to reduce imaging in their office settings, then hospitals will have to absorb an increased influx of Medicare patients needing imaging. This will increase hospital utilization costs and create longer waiting time for patients when critical imaging is necessary for their disease management. One example of how these cuts could produce unintended consequences is with mammography screening, which has been exempted from the cuts. Borgstede explains, the problem could arise from the fact that mammography in many offices is a cost leader while the more profitable modalities subsidize mammography. "If they (CT, MRI, PET) are not profitable anymore, what some people may do is jettison mammography, and that would not be good for any of our patients," says Borgstede. "Other physicians will move away from imaging, but radiologists' offices won't be able to do imaging either … so therefore nobody's going to buy any equipment. If the vendors can't sell their equipment, they're not going into research and development," he continues. "And while everybody else can move on (sub-referrers, other physicians, hospitals and vendors), the only thing radiologists do is imaging, so we're going to be the ones … and our patients … who are going to be left with the shambles here." Efforts to determine a logical reimbursement plan involve defining both general and imaging practice expenses. Borgstede says the Practice Expense Advisory Committee, a sub-committee that advises CMS on appropriate reimbursement, has been refining expenses on imaging and other practice expenses, but this refinement has not yet been implemented. Additionally, the ACR along with other organizations has developed a supplemental survey, validated by CMS, that looks at physician practice expenses, which has also not yet been implemented. By applying this data, recommends Borgstede, CMS can develop accurate reimbursement for services spent. "If you did all those things, and then brought imaging out of this non-physicians work group which is how we're compensated right now, I think you would reimburse accurately for the technical component of imaging, which is all we're really asking for, but which doesn't occur in the Deficit Reduction Act. We're encouraging them to seriously look at the technical component reimbursement and adequately reimburse people who should be reimbursed." Currently, the ACR is working with its members, other patient advocacy groups and medical organizations to keep a dialogue open with Congress and CMS through impact statements, letters and meetings. On the ACR website, member radiologists can download a formula based on DRA information to plug in their own practice expenses and assess any impact the cuts may have. In order to raise awareness and ultimately reduce or repeal the cuts proposed in the DRA while there is still time, Borgstede recommends practicing radiologists and other imaging physicians become members of the ACR and contribute to their political action committee (RADPAC) to help the ACR articulate its position to members of Congress.