Cheryl Proval

Why is the American Medical Association declining to weigh in on the last-minute surreptitious addition to the budget bill that cut reimbursement for the outpatient diagnostic imaging technical component to the quick for some procedures? Why has the AMA failed to object that Congress ignored an established methodology for pricing all medical services paid under the Medicare Physician Fee Schedule?

Ironically, the resource-based relative value scale (RBRVS) was introduced 18 years ago as a response to a Congressional mandate to slow Medicare Part B spending. CMS, then HCFA, contracted with the Harvard School of Public Health to formulate a relative value scale for 32 medical specialties, in cooperation with the AMA, which ultimatedly endorsed the scale.

The RBRVS ranks medical procedures according to the relative resources required, including time spent with the patient, mental effort and judgement, the amount of technical and physician skill and stress, and the cost of doing business. The Ambulatory Payment Classifications were introduced in August 2000 for the purpose of reimbursing outpatient services, including hospital-based outpatient radiology. Costs are averaged over the range of services grouped under a single APC, and hospital-specific, department-specific cost-to-charge ratios are used to arrive at a payment rate. Not all institutions understand the importance of accurate cost reporting, and some of the overhead costs are allocated to the inpatient system. Therefore, the APCs do not represent the actual cost of performing a procedure on a freestanding outpatient basis.

Many organizations representing radiology have gathered together for what is referred to as the Big Tent effort to get a Medicare bill on the agenda. The American College of Radiology is under the Big Tent. The National Association for Quality Diagnostic Imaging Services is under the tent. The National Electrical Manufacturers Association representing the vendor community is under the tent, and reportedly even the American College of Cardiology. But without the support of the AMA, the Big Tent has the dimensions of a pup tent, and radiology will have difficulty raising itself out of the basement of relative self-interest.

There is no doubt that the DRA of 2005 will change the landscape. By the calculations of MRI expert Robert A. Bell, PhD, there will be casualties. But there also will be beneficiaries, as the growing demand for imaging is not in question...just its profitability in the freestanding outpatient setting.

Not all radiologists are concerned, including those without a technology ownership stake and many academics who have watched entrepreneurial outpatient imaging sites siphon off CT and MRI for years. A clear town-gown divide has emerged on this issue, short-sighted considering that what is at stake is the integrity of the RBRVS. Secretary of Health and Human Services Mark McClellan has made devising a replacement for the MPFS one of his priorities this year. But how can the AMA stand by and watch the government dismantle the Physician Fee Schedule before there is something to replace it?

Where is the AMA on this? It is nowhere to be found and unwilling to comment on issues on which it has no policy.

Cheryl Proval