Five years after Congress passed a law to reduce unnecessary MRIs, CT scans and other expensive diagnostic imaging tests that could harm patients and waste money, federal officials have yet to implement it.
The law requires that doctors consult clinical guidelines set by the medical industry before Medicare will pay for many common medical scans for enrollees. Health care providers who go way beyond clinical guidelines in ordering these scans (the 5 percent who order the most tests that are inappropriate) will, under the law, be required after that to get prior approval from Medicare for their diagnostic imaging.
But after physicians argued the provision would interfere with their practices, the Trump administration delayed putting the 2014 law in place until January 2020 — two years later than originally planned.
And even then, the Centers for Medicare & Medicaid Services has slated next year as a "testing" period, which means even if a physician doesn't check the guidelines, Medicare will still pay for the scan. CMS also said it won't decide until 2022 or 2023 when exactly physician penalties will begin.
Critics worry the delays come at a steep cost: Medicare is continuing to pay for millions of unnecessary exams, and patients are being subjected to radiation for no medical benefit.
A Harvard study published in 2011 in the Journal of Urology found "widespread overuse" of imaging tests for men on Medicare who were at low risk of getting prostate cancer. And a University of Washington study in the Journal of the American College of Radiology that reviewed 459 CT and MRI exams at a large academic medical center found 26% of the tests were inappropriate.
"These delays mean that many more inappropriate imaging procedures will be performed, wasting financial resources and subjecting patients to services they do not need," says Gary Young, director of the Northeastern University Center for Health Policy and Healthcare Research in Boston. "If this program were implemented stringently, you would certainly reduce inappropriate imaging to some degree."
Doctors order unnecessary tests for a variety of reasons: to seize a potential financial advantage for them or their health system, to ease fears of malpractice suits or to appease patients who insist on the tests.
The law applies to doctors treating patients who are enrolled in the traditional fee-for-service Medicare system. Health insurers, including those that operate the private Medicare Advantage plans, have for many years refused to pay for the exams unless doctors get authorization from them beforehand. That process can take days or weeks, which irks physicians and patients.
CMS Administrator Seema Verma has sought to reduce administrative burdens on doctors with her "patients over paperwork" initiative.
CMS would not make Verma or other officials available for an interview for this story and answered questions only by email.
A spokeswoman says CMS has no idea how many unnecessary imaging tests are ordered for Medicare beneficiaries.
"CMS expects to learn more about the prevalence of imaging orders identified as 'not appropriate' under this program when we begin to identify outlier ordering professionals," she says.
"It takes four clicks on a computer"
An influential congressional advisory board in 2011 cited the rapid growth of MRIs, CT scans and other imaging and recommended requiring doctors who order more tests than their peers to be forced to get authorization from Medicare before sending patients for such exams. In the 2014 law, Congress tried to soften that recommendation's effect by asking doctors billing Medicare to follow protocols to confirm that imaging would be appropriate for the patient.
Studies show a growing number of health systems have used clinical guidelines to better manage imaging services. The University of Virginia Health System found that unnecessary testing fell by between 5% and 11% after implementing such recommendations.
Virginia Mason Health System in Seattle in 2011 set up a system requiring its physicians — most of whom are on salary — to consult imaging guidelines. It would deny claims for any tests that did not meet appropriate criteria, except in rare circumstances. A study found the intervention led to a 23% drop in MRIs for lower back issues and headaches.
Dr. Craig Blackmore, a radiologist at Virginia Mason, says he worries that unlike the efforts at his hospital, many doctors could be confused by the Medicare program because they have not received proper training about the guidelines.
"My fear is that it will be a huge disruption in workflow and show no benefit," he says.
In 2014, AtlantiCare, a large New Jersey hospital system, began grading physicians on whether they consult its guidelines.
"Some doctors see this tool as additional work, but it takes four clicks on a computer — or less than a minute," says Ernesto Cerdena, director of radiology services at AtlantiCare.
Not all Medicare imaging tests will be subject to the requirements. Emergency patients are exempt, as well as patients admitted to hospitals. CMS has identified some of the most common conditions for which doctors will have to consult guidelines. Those include heart disease, headache and pain in the lower back, neck or shoulders.
Robert Tennant, director of health information technology for the Medical Group Management Association, which represents large physician groups, says the law will unfairly affect all doctors merely to identify the few who order inappropriately.
"For the most part, doctors are well trained and know exactly what tests to perform," Tennant says.
The association is one of several medical groups pushing Congress to repeal the provision.
American College of Radiology's role
The law required the federal government to designate health societies or health systems to develop guidelines and companies that would sell software to embed that guidance into doctors' electronic health record systems.
Among the leaders in that effort is the American College of Radiology, which lobbied for the 2014 law and has been issuing imaging guidelines since the 1990s. It is one of about 20 medical organizations and health systems certified by CMS to publish separate guidelines for doctors.
The college wanted "to get ahead of the train and come up with a policy that was preferable to prior authorization," says Cynthia Moran, an executive vice president of the radiology group. About 2,000 hospitals use the college's licensed guidelines — more than any others, she says. And the college profits from that use.
Moran says the licensing money helps the college mitigate the costs of developing the guidelines, which must be updated regularly, based on new research. She says the college gives away the guidelines to individual doctors upon request and sells them only to large institutions, although she notes they are not as easy to access that way, compared with being embedded in a doctor's medical records.
Kaiser Health News a nonprofit, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.