Panel: Medicare should give prior approval for imaging tests

Physicians who order lots of diagnostic imaging tests should be required to get prior approval if they want to get paid under Medicare, the panel of experts who recommend payment policies urged Congress.

The near unanimous recommendation from the 17-member Medicare Payment Advisory Commission immediately provoked rationing accusations from industry. The recommendation is part of a semi-annual report to Congress, released Wednesday. 


"While MedPAC has confirmed that the growth in utilization of advanced imaging services was flat from 2008 to 2009, it continues to recommend dramatic reimbursement cuts as well as a prior authorization program that would result in reducing seniors' access to imaging services," said Dave Fisher, executive director of the Medical Imaging and Technology Alliance. "MedPAC has chosen to disregard the very imaging use data it confirms.  Deep cuts to imaging services that are not growing will impede patients' access to imaging services which are central to the standard of medical care."

Mark Miller, MedPAC's executive director, told reporters on Wednesday that imaging has been growing steadily over the past decade. The commission recommends cutting back on payments and subjecting providers who order the most imaging tests to a dual process: they would have to submit data on the tests they order, which would then be compared to clinical guidelines (prior notification); if the tests were ordered inappropriately, federal regulators or contractors would have to approve future tests (prior authorization).

Asked about other services where MedPAC has concerns about overuse, Miller mentioned pathology, radiation therapy and physical therapy. Still, he made it clear that the commission isn't considering prior authorization for those services — or at least not yet.

He added that prior authorization isn't a preferred solution, but rather a last resort. Far better, he said, would be to restructure Medicare so that it rewards quality of care rather than the current system of paying for individual procedures.

"It's not like this is excellent, this is a great, perfect idea," Miller said. "It's that we're in a suboptimal payment system — fee for service  these are the kinds of things you end up having to do. Really, the push in the commission is how do you get out of these systems so that you don't have to entertain these kinds of options."

To that end, the report is also recommending changes to Medicare's Quality Improvement Organization program to better target technical assistance to providers who lag behind in quality of care. The report also urges that Congress act on the Sustainable Growth Rate formula to avoid a 30 percent cut to physician payments in 2012.