Revenue Increase following 2017 Multiple Procedures Payment Reduction Modification: Differential Impact on Neuroradiology—Report from an Academic Medical Center

Discussion

Our results show that depending on payer mix and procedure mix, some radiology practices may experience a major increase in reimbursement secondary to the rollback of the MPPR, with the neuroradiology portion of the practice receiving the most benefit. Those neuroradiology hospital-based practices with a higher rate of emergency department–combined trauma CT scans will likely receive a higher benefit than some outpatient imaging practices. However, neuroradiologists will also see improved revenue in MR imaging/MRA cases, complete spine MR imaging studies for metastatic disease, and neuroaxis (brain, cervical spine, thoracic spine MR) multiple sclerosis examinations.

The multiple procedures payment reduction of the CMS for the TC of certain advanced diagnostic imaging (CT, MR imaging, and ultrasound) had been justified on the basis of increased efficiency of simultaneous procedures in the same session.¹³ MPPR was basically saying that less work is done when multiple procedures are delivered to 1 patient at a single session. This concept was followed by adjusted reimbursement (ie, decreased payment).¹⁴

The MPPR has been one of the most challenging issues between radiology communities and the CMS. Since the early introduction of the TC of the MPPR in 2006, the concept was applied to other components of radiology reimbursement and was increased from 25% to 50% applied to the TC Medicare Physician Fee Schedule, including noncontiguous body parts across different modalities.¹⁵ Among different medical insurances, United Healthcare is the only major insurance company that implemented the MPPR besides the CMS.¹⁶

In 2011, the Medicare Payment Advisory Commission proposed a 50% PC MPPR inclusion in the Medicare Physician Fee Schedule, which caused stiff ACR and radiologist opposition. The Medicare Payment Advisory Commission justified this huge cut in revenue with the rationale that radiologists do not perform some reporting activities twice for multiple studies within 1 report, such as reviewing medical history, reviewing the final report, and following up with the ordering physician.¹⁵ While one might understand that a single injection of contrast to a person in a CT scanner that included chest, abdomen, and pelvis in 1 session should have some reduction in the TC, this amount of PC MPPR was undermining the independent interpretation of images by radiologists, particularly across subspecialties of radiology. The ACR and ASNR argued that sometimes 1 clinical history does not pertain to all body parts (eg, brain versus chest). If the radiology group had different subspecialized radiologists interpreting different imaging modalities that are not collocated, the rationale proposed by Medicare Payment Advisory Commission was lacking.

The idea that there were “efficiencies” to justify reducing the TC by 50% on an ultrasound study performed in one building from a CT scan performed in another site on the same day seemed unreasonable to most radiologists. The application of this logic to the professional component rather than restricting it to the technical component of a CPT code also rankled radiology and the ASNR leadership. The PC of the CPT code is supposed to reimburse physician work, practice expense, and professional liability insurance.¹⁷ It was unclear how multiple procedures in 1 day would have any effect on professional liability insurance costs and even on practice expenses.

However, the result was a 25% PC reduction as of January 1, 2012.^1,14,18 In 2013, this was further expanded, so the 25% PC MPPR would apply to all radiologists in the same group practice interpreting multiple imaging studies from the same patient on the same day, irrespective of practice setting.^1,4,18 The impact of this was not inconsequential. Chiao et al⁵ found that the PC MPPR unevenly affected different divisions of radiology, with thoracic imaging losing the most percentage and neuroradiology losing the most absolute revenue relative to other divisions.⁵

For >4 years the ACR and ASNR lobbied Congress and provided scientific data from well-performed peer-reviewed published studies regarding the impact of performing multiple studies on the same patient. Allen et al¹⁹ found that the maximum estimated percentage work reduction when multiple services were performed by the same physician in the same session was small, ranging from 4.3% to 8.2%, with a mean of 5.9% ± 1.5%, substantially less than the 25% PC MPPR that was in place at the time of the publication.

Duszak et al²⁰ found that the potential work reduction for same-session, same-technique services rendered by different physicians in the same group practice was even smaller, ranging from 1.4% to 2.7%, with a mean of 1.8% ± 0.6%.

Thus, after the initial series of unsuccessful negotiations in 2006 and 2011, the ACR, ASNR, and other radiology advocacy groups were able to convince the CMS in August 2016 to release a new decision, the MPPR rollback, which decreased the reduction in PC reimbursement from 25% to 5%.^21,22 The TC MPPR remained at the previous 50% level.

The impact of the 25% reductions on the field of neuroradiology was noted by the leaders in the profession. These consequences for neuroradiologists in private and academic settings included not just reduced revenue but downstream effects. First, divisional self-sufficiency was harmed. By sharply decreasing the revenue of certain divisions, the PC MPPR unintentionally but ominously impaired the financial health of these divisions. The revenue needed to support clinical fellows dropped. In academic medical centers, this impairment could have resulted in fewer dollars available for hiring new faculty, fellow support, research initiatives, and discretionary funds. Second, interdivisional relationships could be impaired. If certain divisions are seen as being subsidized by others, they may be perceived as “weak” or a drain on resources. Finally, the perception of “profitable” and “unprofitable” divisions may reach radiology residents, who are sensitive to issues of financial stability and well-being as they consider job prospects. Although the PC MPPR is certainly a minor factor overall, particularly now at a 5% reduction, it could conceivably have influenced resident decision-making regarding subspecialty fellowship training, resulting in fewer residents choosing to pursue certain subspecialty fellowships. In summary, the PC MPPR could have substantial unintended consequences on neuroradiology that were not considered by the CMS before the policy was adopted but were apparent to the neuroradiology community.⁵

On the basis of our categorization and the change in rate from 25% to 5% of MPPR, the impact on different divisions of radiology has decreased substantially. However, we have found that the revenue of the neuroradiology division and CT scanning as a technique are most affected.

During the study, 30.3% of patients who received radiology services were covered by Medicare at our institution. This MPPR policy will affect centers accordingly with more or less of a Medicare payer mix. Private insurance companies, such as United Healthcare, might mirror the changes regulated by Medicare and further decrease practice revenue.

Although we could not find a report to compare our institution count of modalities with those of other institutions, our estimates indicate that MPPR might impact a considerable portion of advanced diagnostic imaging studies for radiology practices across the United States.

There are certain limitations in this report. First, the study took place in a tertiary care academic medical center with a primary trauma center. Our study reflects the effect on an academic setting, with a high number of patients and many emergent requests for advanced diagnostic imaging, often leading to multiple studies per day. Also, it is more common in our hospital-dominated practice setting to have multiple procedures in the same day for a patient than in an outpatient center–dominated practice.

Another limitation in our results is that our numbers reflect the projected reimbursement amount, not the actual amount because the collection rate varies across CMS geographic areas and copay deductions. We also admit that since United Healthcare is not disclosing its Physician Fee Schedule the way CMS does, we could not analyze the revenue impact on United Healthcare patients.